Inappropriate laboratory test utilization in outpatient tertiary care: Implications for value-based healthcare

OBJECTIVES

To assess the rate of inappropriate repetition of laboratory testing and estimate the cost of such testing for thyroid stimulating hormone (TSH), total cholesterol, vitamin D, and vitamin B12 tests.

METHODS

A retrospective cohort study was carried out in the Family Medicine and Polyclinic Department at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. Clinical and laboratory data were collected between 2018-2021 for the 4 laboratory tests. The inappropriate repetition of tests was defined according to international guidelines and the costs were calculated using the hospital prices.

RESULTS

A total of 109,929 laboratory tests carried out on 23,280 patients were included in this study. The percentage of inappropriate tests, as per the study criteria, was estimated to be 6.1% of all repeated tests. Additionally, the estimated total cost wasted amounted to 2,364,410 Saudi Riyals. Age exhibited a weak positive correlation with the total number of inappropriate tests (r=0.196, p=0.001). Furthermore, significant differences were observed in the medians of the total number of inappropriate tests among genders and nationalities (p<0.001).

CONCLUSION

The study identified significantly high rates of inadequate repetitions of frequently requested laboratory tests. Urgent action is therefore crucial to overcoming such an issue.

Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review

PURPOSE

The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients.

METHODS

A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal.

RESULTS

Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention.

CONCLUSION

In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed.

LEVEL OF EVIDENCE

Systematic review study, level IV.

[Implementation of the Choosing Wisely Program in the General Surgery Residency]

INTRODUCTION

The practice of unnecessary conduct and waste in Health is an important topic, not often addressed during undergraduate training. Medical education has a fundamental role in student and doctors' training concerning cost-conscious attitudes for good health care. The aim of this study was to describe and assess the implementation of the Choosing Wisely campaign within a General Surgery residency program.

MATERIAL AND METHODS

This was an interventional study involving residency advisors and specialty residents. Recommendations based on three procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients were identified by residency advisors with the use of the Delphi method and were grouped by frequency and by nature according to the Choosing Wisely layout. Educational actions such as workshops and banner advertising in addition to training activities regarding cost-conscious healthcare were carried out. This subject was also included in the theoretical evaluation of the residency program.

RESULTS

The leading five recommendations were related to (i) computed tomography overuse (versus ultrasound imaging) in patients with suspected acute appendicitis, (ii) multithreaded computed tomography overuse in patients with low-risk trauma, (iii) longer than recommended antibiotic prophylaxis in surgical patients, (iv) longer than recommended preoperative fasting period and (v) upper gastrointestinal endoscopy overuse in surgical patients without an adequate clinical evidence or without the presence of warning signs. Awareness and reflection among participants were improved, leading to high grades in final evaluation.

DISCUSSION

Changes in training regarding quality of care and cost awareness should start throughout undergraduate training, within a learning environment focused on a reflective and evidence-based practice. All the benefits and harms to patients were taken into account in the recommendations that emerged from this study.

CONCLUSION

The inclusion of this initiative in the General Surgery residency, involving reflective discussions on campaign recommendations regarding procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients may lead to more cost-conscious procedures.

Patient-Provider Discussion About Cancer Treatment Costs and Out-of-Pocket Spending: Implications for Shared Decision Making in Cancer Care

OBJECTIVES

Patient-provider discussion about treatment costs has been recognized as a key component of shared clinical decision making in cancer care. This study examined the association of patient-provider cost discussion with out-of-pocket spending among cancer survivors.

METHODS

Using data from the 2016-2017 Medical Expenditure Panel Survey-Experiences with Cancer Survivorship Supplement, cancer survivors in the United States who reported having a detailed discussion about treatment costs were identified. Multivariable generalized linear model with gamma distribution and log-link was fitted to analyze average total out-of-pocket spending between those who had the discussion and those who did not. We also examined whether having the cost discussion is associated with the likelihood of reporting receipt of all cancer care they believed was necessary using a multivariable logistic regression model. All analyses controlled for patient socioeconomic and health-related characteristics.

RESULTS

Among 1525 individuals, representing 14.6 million cancer survivors in the United States (mean age, 65.5 years; 59% women; 80.4% white), only 10.4% (95% confidence interval [CI], 8.7%-12.1%) reported having the detailed cost discussion with their providers during their cancer care. Having a cost discussion was associated with a -33.8% reduction in (95% CI, -38.2% to -29.6%; an absolute difference of -$478) average total out-of-pocket spending. The probability of receiving all necessary patient-reported cancer care was not different between those who had the discussion and those who did not.

CONCLUSION

Detailed patient-provider cost discussions were associated with lower average total out-of-pocket spending. Patients who had detailed cost discussions with providers did not seem to sacrifice the appropriate utilization of necessary cancer treatments.

Follow-up of guidelines and impact on the management of suspected deep vein thrombosis in emergency departments

AIMS

To evaluate the implementation of the European Society of Cardiology (ESC) guidelines concerning the diagnostic management of deep vein thrombosis (DVT) in emergency departments (ED); and to estimate the additional financial cost and the increase in the time spent in the ED if the guidelines are not followed.

PATIENTS AND METHODS

Retrospective, bi-centric study including all patients directly admitted or referred to the ED for a suspected isolated DVT, between April 1, 2019, and July 30, 2019. The diagnostic management was compared to the 2017 ESC's guidelines.

RESULTS

107 patients were included, 13 had DVT (12%) and three had superficial venous thrombosis (3%). A total of 26 patients (24%) had a diagnostic management according to guidelines. In 72 patients (67%), no assessment of clinical probability score was found. Among the 35 patients in whom a clinical probability score was calculated, 5 patients had an unnecessary D-dimer assay and 2 patients had unjustified imaging. The median time spent in the ED was 185minutes when the recommendations were followed, and 250minutes when they were not (P=0.317). The total estimated additional cost was €232.20.

CONCLUSION

The rate of adherence to the guidelines is low, mainly due to the absence of calculation of a clinical probability. This leads, in addition to the risk of diagnostic error, to an increase in the time spent in the EDs and inappropriate use of the technical platform, resulting in additional costs of care.

Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit

IMPORTANCE

For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care.

OBJECTIVE

To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020.

EXPOSURE

Receipt of a given test within 1 week before or after the AWV.

MAIN OUTCOMES AND MEASURES

Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed.

RESULTS

Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests.

CONCLUSIONS AND RELEVANCE

In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.

Skin Cancer Excision Is More Efficient and Cost Effectivein a Specialist Secondary Care Service

Aim To compare the relative efficiencies of skin excisions in primary and secondary care. Methods We compared the benign: malignant ratio for specimens referred by General Practice, General Surgery and the Skin Cancer Service to the regional pathology laboratory over one month. We used cost minimization analysis to compare the relative efficiencies of the services. Results 620 excisions were received: 139 from General Practice, 118 from General Surgery and 363 from the Skin Cancer Service. The number (%) of malignant lesions was 13 (9.4%) from General Practice, 18 (15.2%) from General Surgery and 137 (37.7%) from the Skin Cancer Service. Excision was cheaper in General Practice at €84.58 as compared to €97.49 in the hospital day surgical unit. However, the cost per malignant lesion excised was €1779.80 in general practice versus €381.78 in the Skin Cancer Service. Conclusion Our results indicate that moving skin cancer treatment to General Practice may result in an excess of benign excisions and therefore be both less efficient and less cost effective.

Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department

IMPORTANCE

Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed.

OBJECTIVE

To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019.

MAIN OUTCOMES AND MEASURES

Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care.

RESULTS

Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03).

CONCLUSIONS AND RELEVANCE

The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

A national intervention to reduce imaging for low back pain by general practitioners: a retrospective economic program evaluation using Medicare Benefits Schedule data

BACKGROUND

The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder.

METHODS

The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS.

RESULTS

The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed.

CONCLUSIONS

The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.

From Evidence to Practice: Are Low-Risk Breast Cancer Patients still Enduring Unnecessary Costs of Radiation?

Radiation is routinely recommended after conservative surgery for breast cancer, despite long-standing Level I evidence showing no survival benefit for elderly patients with favorable disease using endocrine therapy. We sought to evaluate radiation use and costs in patients eligible for omission of radiation. A retrospective single-institution review from 2005 to 2017 was performed of women aged ≥70 years, with cT1N0M0, who were ER/PR positive and HER-2 negative, and receiving breast-conserving surgery. Patient, tumor, and treatment characteristics were compared by use of radiation. Cost estimates used Medicare's 2019 fee schedule. Of 84 patients meeting the study criteria, 72.6 per cent received radiation and 56 per cent received endocrine therapy, with four recurrences (4.9% radiated and 4.4% not radiated, P = 0.9). Early and late grade I radiation toxicities occurred in 67.2 per cent and 26.2 per cent of radiated patients, respectively. Younger age (P = 0.01), receipt of endocrine therapy (P < 0.0001), and axillary surgery (P < 0.0001) were significantly associated with radiation use. There were no significant differences in radiation use based on race/ethnicity, language, comorbidities, BMI, or pathologic tumor size. Estimated total radiation cost was $646,426. Radiation remains overused and endocrine therapy, underused in breast cancer patients eligible to avoid radiation. As gatekeepers for radiation oncology referrals, surgeons can diminish both physical and financial costs of radiation in eligible patients.

Waste in the US Health Care System: Estimated Costs and Potential for Savings

IMPORTANCE

The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains.

OBJECTIVES

To estimate current levels of waste in the US health care system in 6 previously developed domains and to report estimates of potential savings for each domain.

EVIDENCE

A search of peer-reviewed and "gray" literature from January 2012 to May 2019 focused on the 6 waste domains previously identified by the Institute of Medicine and Berwick and Hackbarth: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. For each domain, available estimates of waste-related costs and data from interventions shown to reduce waste-related costs were recorded, converted to annual estimates in 2019 dollars for national populations when necessary, and combined into ranges or summed as appropriate.

FINDINGS

The review yielded 71 estimates from 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature. Computations yielded the following estimated ranges of total annual cost of waste: failure of care delivery, $102.4 billion to $165.7 billion; failure of care coordination, $27.2 billion to $78.2 billion; overtreatment or low-value care, $75.7 billion to $101.2 billion; pricing failure, $230.7 billion to $240.5 billion; fraud and abuse, $58.5 billion to $83.9 billion; and administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: failure of care delivery, $44.4 billion to $97.3 billion; failure of care coordination, $29.6 billion to $38.2 billion; overtreatment or low-value care, $12.8 billion to $28.6 billion; pricing failure, $81.4 billion to $91.2 billion; and fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion.

CONCLUSIONS AND RELEVANCE

In this review based on 6 previously identified domains of health care waste, the estimated cost of waste in the US health care system ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste, excluding savings from administrative complexity, ranged from $191 billion to $286 billion, representing a potential 25% reduction in the total cost of waste. Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in US health care expenditures.

Reducing unnecessary vitamin testing in general practice: barriers and facilitators according to general practitioners and patients

OBJECTIVE

There has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of patients. So far, there is little evidence of effective strategies to reduce this overtesting in general practice. Therefore, the aim of this qualitative study was to explore the barriers and facilitators for reducing the number of (unnecessary) vitamin D and B12 laboratory tests ordered.

DESIGN AND SETTING

This qualitative study, based on a grounded theory design, used semistructured interviews among general practitioners (GPs) and patients from two primary care networks (147 GPs, 195 000 patients). These networks participated in the Reducing Vitamin Testing in Primary Care Practice (REVERT) study, a clustered randomized trial comparing two de-implementation strategies to reduce test ordering in primary care in the Netherlands.

PARTICIPANTS

Twenty-one GPs, with a maximum of 1 GP per practice who took part in the REVERT study, and 22 patients (who were invited by their GP during vitamin-related consultations) were recruited, from which 20 GPs and 19 patients agreed to participate in this study.

RESULTS

The most important factor hampering vitamin-test reduction programmes is the mismatch between patients and medical professionals regarding the presumed appropriate indications for testing for vitamin D and B12. In contrast, the most important facilitator for vitamin-test reduction may be updating GPs' knowledge about test indications and their awareness of their own testing behaviour.

CONCLUSION

To achieve a sustainable reduction in vitamin testing, guidelines with clear and uniform recommendations on evidence-based indications for vitamin testing, combined with regular (individual) feedback on test-ordering behaviour, are needed. Moreover, the general public needs access to clear and reliable information on vitamin testing. Further research is required to measure the effect of these strategies on the number of vitamin test requests.

TRIAL REGISTRATION NUMBER

WAG/mb/16/039555.

Cascades of Care After Incidental Findings in a US National Survey of Physicians

IMPORTANCE

Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally.

OBJECTIVE

To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians.

DESIGN, SETTING, AND PARTICIPANTS

Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019.

MAIN OUTCOMES AND MEASURES

Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades.

RESULTS

This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions.

CONCLUSIONS AND RELEVANCE

The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Payment models in primary health care: A driver of the quantity and quality of medical laboratory utilization

Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed-effects specification to address selection, it is estimated that the switch to capitation leads to a short-run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.

The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures

BACKGROUND

Patients treated with hip hemiarthroplasty for low energy femoral neck fractures routinely undergo hip radiographs at each postoperative clinic visit regardless of history and physical findings. No studies to date have evaluated the effectiveness of this accepted practice. The goal of this study was to identify the postoperative utility of both history and physical (H/P) and hip radiographs in the treatment course of patients treated with hip hemiarthroplasty for low energy femoral neck fractures.

METHODS

A retrospective chart review was performed on consecutive patients treated with hip hemiarthroplasty for low energy femoral neck fractures. An abnormal H/P and hip radiographs as well as a change in treatment course were recorded at each clinic or emergency department visit.

RESULTS

Five hundred and eighty-three patients met inclusion criteria, consisting of 1177 clinic and 50 emergency department (ED) visits. An abnormal radiograph in the presence of a normal H/P did not lead to a change in treatment course. An abnormal H/P alone changed treatment course in 28 (3%) clinic visits and 18 (36%) ED visits. An abnormal H/P and the presence of an abnormal hip radiograph changed the treatment course in 23 (2%) clinic visits and 18 (36%) ED visits. In only one case - 0.3% of abnormal radiographs or 0.08% of 1177 clinic visits - did an abnormal hip radiograph change treatment course in the setting of an abnormal H/P within 6 months from surgery. The average cost of a series of hip and pelvis radiographs was $242.

CONCLUSIONS

Abnormal radiographs do not change treatment course in the presence of a normal H/P. Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient.

Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses

BACKGROUND

Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts.

METHODS

We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing.

RESULTS

In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis.

CONCLUSIONS

Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.

Is it ethical to provide IVF add-ons when there is no evidence of a benefit if the patient requests it?

In vitro fertilisation (IVF) 'add-ons' are therapeutic or diagnostic tools developed in an endeavour to improve the success rate of infertility treatment. However, there is no conclusive evidence that these interventions are a beneficial or effective adjunct of assisted reproductive technologies. Additionally, IVF add-ons are often implemented in clinical practice before their safety can be thoroughly ascertained. Yet, patients continue to request and pay large sums for such additional IVF tools. Hence, this essay set out to examine if it is ethical to provide IVF add-ons when there is no evidence of a benefit if the patient requests it. In order to determine what is ethical-namely, morally good and righteous, the question was considered in relation to three key values of medical ethics-autonomy, beneficence and non-maleficence. It was determined that providing IVF add-ons might be morally acceptable in specific circumstances, if true informed consent can be given, there is a potential of cost-effective physiological or psychological benefit and the risk of harm is minimal, particularly with regard to the unborn child.

Is pelvis x-ray essential in stable trauma patients? Step towards lowering the treatment cost

OBJECTIVE

To determine the diagnostic accuracy of clinical examination in detecting pelvic fractures in patients with blunt trauma..

METHODS

The cross-sectional prospective study was conducted at Aga Khan University Hospital, Karachi, from January to June 2015, and comprised alert, awake blunt-trauma patients. Pelvis examination findings were compared to routine pelvic X-rays. SPSS 19 was used for data analysis..

RESULTS

Of the 133 patients, 122 (92%) were males. Overall mean age was 37 ±14.2 years. There were 14 (10%) patients who were true positives with pelvic fracture diagnosis on both clinical examination and pelvic X-ray, while 14 (10%) were false negative on examination. Clinical examination missed 2 patients with evidence of fracture on X-ray and were considered false positive. Besides, 103 (77.4%) patients were true negative as both clinical exam and X-ray showed no evidence of fracture.

CONCLUSION

Omitting pelvic X-ray in the recommended protocol can avoid unnecessary financial burden and reduce undesirable radiation exposure..

Reducing inappropriate urine testing at Hutt Valley District Health Board using Choosing Wisely principles

AIM

Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives.

METHODS

The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions.

RESULTS

There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134).

CONCLUSION

The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.

The Effectiveness of Cost Reduction with Charge Displays on Test Ordering under the Health Insurance System in Japan: A Study Using Paper-based Simulated Cases for Residents and Clinical Fellows

Objective To determine whether or not displaying the cost of tests can help reduce charges on test ordering in Japan. Methods This study was conducted under the setting of a simulated first visit of an outpatient for general internal medicine in a secondary medical institution in Japan. We randomly assigned 27 residents and clinical fellows to Team A or B. The first half, without charges displayed on the ordering system, was designated the "non-display group," and the participants of Team A selected tests for each paper-based simulated case (Q1-Q14), while the participants of Team B selected tests for Q15-Q28. The second half, which had charges displayed, was designated the "display group," and the participants of Team A selected tests for Q15-Q28, while the participants of Team B selected tests for Q1-Q14. The main outcome measure was the difference in the cost of tests per paper-based simulated case between the non-display and display groups. Results The median (interquartile range) cost of tests per paper-based simulated case was 12,255 yen (5,040-23,695 yen) in the non-display group versus 9,425 yen (2,320-21,700 yen) in the display group, showing a decrease of 2,830 yen with charges being displayed (p=0.002). Conclusion Displaying the charges when ordering tests in paper-based simulated cases resulted in cost reduction. The adoption of this intervention may reduce health insurance costs under the health insurance system in Japan, which has features such as universal health coverage and universal access to care.

Determining the Prevalence and Costs of Unnecessary Referrals in Adolescent Idiopathic Scoliosis

BACKGROUND

Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs.

METHODS

We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was "unnecessary," defined as a Cobb angle <20 degrees. Patient and provider costs were estimated. Patient costs included transportation expenses and parental lost wages. Provider costs included orthopaedic evaluation, diagnostic imaging, and overhead. Transportation costs were based on actual driving distances and the Internal Revenue Service standard mileage rate. Parental lost wages and the cost of evaluation by an orthopaedic surgeon were calculated with time-driven activity-based costing. Diagnostic imaging costs were calculated with a traditional activity-based costing methodology.

RESULTS

Three hundred thirty-seven patients were included. The prevalence of unnecessary referrals was 39% (n=131). 17% of patients had a Cobb angle <10 degrees and 22% had a Cobb angle between 10-20 degrees. Males were more likely to be referred unnecessarily than females, 49% to 35% (p=0.02) as were non-Caucasians (54% vs. 37%, p=0.04). No difference was noted related to source of insurance (private or public, p=0.18). The average total cost of an unnecessary referral was $782.13 USD, including $231.07 in patient costs and $551.06 in provider costs.

CONCLUSIONS

Nearly 40% of all referrals for AIS were deemed unnecessary. The average cost of an unnecessary referral is approximately $780, imposing significant costs on both patients and the healthcare system.Level of Evidence: III.

The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury

Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.

Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization

Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59-0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.