Evidence for overuse of medical services around the world

Regional Supply of Medical Resources and Systemic Overuse of Health Care Among Medicare Beneficiaries

BACKGROUND

Overuse of health care resources has been identified as the leading contributor to waste in the US health care system.

OBJECTIVE

To explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services.

DESIGN

Using Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas.

KEY RESULTS

Regions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P < 0.001). Regional characteristics associated with higher JHOI scores, indicating more systemic overuse, included number per 1000 residents of acute care hospital beds (P = 0.002) and of hospital-based anesthesiologists, pathologists, and radiologists (P = 0.02).

CONCLUSIONS

Regional variations in health care resources including the clinician workforce are associated with the intensity of systemic overuse of health care. The role of primary care doctors in reducing health care overuse deserves further attention.

Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests

OBJECTIVES

To assess the temporal change in test use in UK primary care and to identify tests with the greatest increase in use.

DESIGN

Retrospective cohort study.

SETTING

UK primary care.

PARTICIPANTS

All patients registered to UK General Practices in the Clinical Practice Research Datalink, 2000/1 to 2015/16.

MAIN OUTCOME MEASURES

Temporal trends in test use, and crude and age and sex standardised rates of total test use and of 44 specific tests.

RESULTS

262 974 099 tests were analysed over 71 436 331 person years. Age and sex adjusted use increased by 8.5% annually (95% confidence interval 7.6% to 9.4%); from 14 869 tests per 10 000 person years in 2000/1 to 49 267 in 2015/16, a 3.3-fold increase. Patients in 2015/16 had on average five tests per year, compared with 1.5 in 2000/1. Test use also increased statistically significantly across all age groups, in both sexes, across all test types (laboratory, imaging, and miscellaneous), and 40 of the 44 tests that were studied specifically.

CONCLUSION

Total test use has increased markedly over time, in both sexes, and across all age groups, test types (laboratory, imaging, and miscellaneous) and for 40 of 44 tests specifically studied. Of the patients who underwent at least one test annually, the proportion who had more than one test increased significantly over time.

Current evidence for spinal X-ray use in the chiropractic profession: a narrative review

The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.

Key Concepts for assessing claims about treatment effects and making well-informed treatment choices

Background: The Informed Health Choices (IHC) Key Concepts are standards for judgement, or principles for evaluating the trustworthiness of treatment claims and treatment comparisons (evidence) used to support claims, and for making treatment choices. The list of concepts provides a framework, or starting point, for teachers, journalists and other intermediaries for identifying and developing resources (such as longer explanations, examples, games and interactive applications) to help people to understand and apply the concepts. The first version of the list was published in 2015 and has been updated yearly since then. We report here the changes that have been made from when the list was first published up to the current (2018) version. Methods: We developed the IHC Key Concepts by searching the literature and checklists written for the public, journalists, and health professionals; and by considering concepts related to assessing the certainty of evidence about the effects of treatments. We have revised the Key Concepts yearly, based on feedback and suggestions; and learning from using the IHC Key Concepts, other relevant frameworks, and adaptation of the IHC Key Concepts to other types of interventions besides treatments. Results: We have made many changes since the Key Concepts were first published in 2015. There are now 44 Key Concepts compared to the original 32; the concepts have been reorganised from six to three groups; we have added higher-level concepts in each of those groups; we have added short titles; and we have made changes to many of the concepts. Conclusions: We will continue to revise the IHC Key Concepts in response to feedback. Although we and others have found them helpful since they were first published, we anticipate that there are still ways in which they can be further improved. We welcome suggestions for how to do this.

Key Concepts for assessing claims about treatment effects and making well-informed treatment choices

Background: The Informed Health Choices (IHC) Key Concepts are standards for judgement, or principles for evaluating the trustworthiness of treatment claims and treatment comparisons (evidence) used to support claims, and for making treatment choices. The list of concepts provides a framework, or starting point, for teachers, journalists and other intermediaries for identifying and developing resources (such as longer explanations, examples, games and interactive applications) to help people to understand and apply the concepts. The first version of the list was published in 2015 and has been updated yearly since then. We report here the changes that have been made from when the list was first published up to the current (2018) version. Methods: We developed the IHC Key Concepts by searching the literature and checklists written for the public, journalists, and health professionals; and by considering concepts related to assessing the certainty of evidence about the effects of treatments. We have revised the Key Concepts yearly, based on feedback and suggestions; and learning from using the IHC Key Concepts, other relevant frameworks, and adaptation of the IHC Key Concepts to other types of interventions besides treatments. Results: We have made many changes since the Key Concepts were first published in 2015. There are now 44 Key Concepts compared to the original 32; the concepts have been reorganised from six to three groups; we have added higher-level concepts in each of those groups; we have added short titles; and we have made changes to many of the concepts. Conclusions: The IHC Key Concepts have proven useful in designing learning resources, evaluating them, and organising them. We will continue to revise the IHC Key Concepts in response to feedback. We welcome suggestions for how to do this.

Key Concepts for assessing claims about treatment effects and making well-informed treatment choices

Background: The Informed Health Choices (IHC) Key Concepts are standards for judgement, or principles for evaluating the trustworthiness of treatment claims and treatment comparisons (evidence) used to support claims, and for making treatment choices. The list of concepts provides a framework, or starting point, for teachers, journalists and other intermediaries for identifying and developing resources (such as longer explanations, examples, games and interactive applications) to help people to understand and apply the concepts. The first version of the list was published in 2015 and has been updated yearly since then. We report here the changes that have been made from when the list was first published up to the current (2018) version. Methods: We developed the IHC Key Concepts by searching the literature and checklists written for the public, journalists, and health professionals; and by considering concepts related to assessing the certainty of evidence about the effects of treatments. We have revised the Key Concepts yearly, based on feedback and suggestions; and learning from using the IHC Key Concepts, other relevant frameworks, and adaptation of the IHC Key Concepts to other types of interventions besides treatments. Results: We have made many changes since the Key Concepts were first published in 2015. There are now 44 Key Concepts compared to the original 32; the concepts have been reorganised from six to three groups; we have added higher-level concepts in each of those groups; we have added short titles; and we have made changes to many of the concepts. Conclusions: The IHC Key Concepts have proven useful in designing learning resources, evaluating them, and organising them. We will continue to revise the IHC Key Concepts in response to feedback. We welcome suggestions for how to do this.

A UK survey exploring the assistant practitioner role across diagnostic imaging: current practice, relationships and challenges to progression

OBJECTIVE:

Skill mix has been established as one method of maintaining imaging service delivery, with vertical and horizontal substitution of roles and tasks. Assistant practitioners (APs) have been undertaking limited imaging practice for almost two decades, but there remains a paucity of evidence related to the impact of their roles.

METHODS:

This article reports on an electronic survey of individual APs within the NHS in the UK to explore utilisation, role scope and aspirations.

RESULTS:

Responses were analysed from APs (n = 193) employed in 97 different organisations across the UK. The majority work in general radiography or mammography, with very few responses from other imaging modalities. Training routes varied across modalities, with most achieving Band 4 under Agenda for Change on completion of education. Limitations on practice vary between organisations and modalities, with many reporting blurring of the radiographer-AP boundary. Many aspire to continue their training to achieve registrant radiographer status, although there were clear frustrations from respondents over the lack of overt career prospects.

CONCLUSION:

Integration of the role into imaging department practice does not appear to be universal or consistent and further research is required to examine the optimal skill mix composition.

ADVANCES IN KNOWLEDGE:

Skill mix implementation is inconsistent across modalities and geography in the UK. Opportunities for further workforce utilisation and expansion are evident.

Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review

OBJECTIVE

Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system.

DESIGN

Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded.

RESULTS

47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data.

CONCLUSIONS

We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.

Human and veterinary antibiotics induce hormesis in plants: Scientific and regulatory issues and an environmental perspective

Veterinary and human pharmaceuticals have been widely used in the developed world, thus increasing their accumulation in the environment and thereby posing ecological risks. Earlier studies report that active pharmaceutical ingredients induce hormesis in plants, i.e. at low doses may enhance plant health whereas at high doses may suppress plant vigor. There is hitherto no study critically reviewing the effects of antibiotics on plants within a hormetic context despite effects of low doses on plants can have implications to animals, including humans, and to ecological processes. This study critically reviews for first time antibiotic-induced hormesis in plants, both quantitatively and qualitatively. Hormesis was induced by several antibiotics in a variety of species and endpoints. The maximum stimulatory response (MAX) was commonly <1.5-fold the control response and the distance from MAX to no-observed-adverse-effect level (NOAEL) was commonly up to 10-fold. Further quantitative and qualitative evaluations are provided and discussed in relation to scientific and regulatory aspects. Low doses of antibiotics are equally important as high doses as they can negatively affect plants, depending on plant tissues and the time tissues are subject to exposure. Antibiotic-induced hormesis in plants provides a significant environmental perspective and should be incorporated into the hazard and risk assessment process.

CAPSULE

Common antibiotics released in the environment induce hormesis in plants, urging for re-examination of the risk assessment practices by worldwide regulatory agencies.

Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

OBJECTIVES

To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.

DESIGN

A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance.

SETTING

Medical, surgical and intensive care units of a district general hospital.

OUTCOMES

The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method.

RESULTS

289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).

CONCLUSIONS

The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.

Short-term and long-term effects of caesarean section on the health of women and children

A caesarean section (CS) can be a life-saving intervention when medically indicated, but this procedure can also lead to short-term and long-term health effects for women and children. Given the increasing use of CS, particularly without medical indication, an increased understanding of its health effects on women and children has become crucial, which we discuss in this Series paper. The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose-response manner. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. The persistence of these risks into later life is less well investigated, although an association between CS use and greater incidence of late childhood obesity and asthma are frequently reported. There are few studies that focus on the effects of CS on cognitive and educational outcomes. Understanding potential mechanisms that link CS with childhood outcomes, such as the role of the developing neonatal microbiome, has potential to inform novel strategies and research for optimising CS use and promote optimal physiological processes and development.

Protection against the overuse and underuse of health care - methodological considerations for establishing prioritization criteria and recommendations in general practice

BACKGROUND

Initiatives such as "Choosing Wisely" in the USA and "Smarter Medicine" in Switzerland have published lists of widely overused health care services. The German initiative "Choosing Wisely Together (Gemeinsam Klug Entscheiden)" follows this example. The goal of our study was to prioritize important recommendations against the overuse and underuse of health care services. The final list of recommendations will be published in the German guideline "Protection against the overuse and underuse of health care".

METHODS

First, a multidisciplinary expert panel established a catalogue of prioritization criteria. Second, we extracted all the recommendations from evidence- and consensus-based German College of General Practice and Family Medicine (DEGAM) guidelines and National Health Care Guidelines (NVL). Third, the recommendations were rated by two independent panels (general practitioners and other health care professionals involved/not involved in guideline development). The prioritization process was finalized in a consensus conference held by DEGAM's Standing Guideline Committee (SLK).

RESULTS

Eleven prioritization criteria were established. A total of 782 recommendations were extracted and rated by 98 physicians and other health care professionals in a survey. In the voting process, more than 80% of the recommendations were eliminated. After the final consensus conference, twelve recommendations from DEGAM guidelines, nine DEGAM addenda and 17 NVL recommendations were chosen for inclusion in the guideline, for a total of 38 recommendations.

CONCLUSION

The selection procedure proved helpful in identifying the highest priority recommendations with which to combat the overuse and underuse of health care services. To date, in Germany there has been no attempt to compile such a list by using a systematic and transparent methodology. Hence, the guideline that results from this process can fill an important gap.

Medicare savings from conservative management of low back pain

OBJECTIVES

Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. We estimated 1-year medical costs associated with early imaging of Medicare beneficiaries with idiopathic LBP.

STUDY DESIGN

We used a 5% random sample of Medicare fee-for-service enrollees between 2006 and 2010 to determine 12-month costs following a diagnosis of idiopathic LBP. We analyzed costs of care and patient outcomes according to whether or not the patients had been referred for early imaging following their initial diagnosis.

METHODS

We employed an instrumental variables analysis using risk-adjusted physician-level propensity to order imaging for patients without LBP as an instrument for imaging use among patients with LBP. We selected this approach to adjust for confounding by indication when estimating the relative costs of early imaging of LBP compared with conservative management.

RESULTS

Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis. Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more.

CONCLUSIONS

Medicare beneficiaries with low-risk LBP frequently receive early imaging studies. Early imaging was associated with greater long-term costs than a conservative diagnostic strategy; Medicare expenditures could be reduced by $362 million annually by managing newly diagnosed LBP in accordance with clinical guidelines.

Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments

IMPORTANCE

Overuse of medical tests and treatments is an increasingly recognized problem across health systems; best practices for reducing overuse are not clear. Framing the problem in terms of the spectrum of potential patient harm is likely to be an effective strategy for clinician and patient engagement in efforts to reduce overuse, but the scope of negative consequences of overuse for patients has not been well described.

OBSERVATIONS

We sought to generate a comprehensive conceptual map documenting the processes through which overused tests and treatments lead to multiple domains of negative consequences for patients. For map development, an iterative consensus process was informed by structured review of the literature on overuse using PubMed and input from a panel of 6 international experts. For map verification, a systematic review was performed of case reports involving overused services, identified through literature review and manual review of relevant article collections. The conceptual map documents that overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop. Case reports on overuse confirmed the processes and domains of the conceptual map. Cases also revealed strengths and weaknesses in published communication about overuse: they were dominated by physical harms, with other negative consequences receiving far less attention.

CONCLUSIONS AND RELEVANCE

This evidence-based conceptual map clarifies the processes by which overused tests and treatments result in negative consequences for patients; it also documents multiple domains of negative consequences experienced by patients. The map will be useful for facilitating comprehensive communication about overuse, estimating harms and costs associated with overused services, and informing health system efforts to reduce overuse.

Looking for trouble? Diagnostics expanding disease and producing patients

Novel tests give great opportunities for earlier and more precise diagnostics. At the same time, new tests expand disease, produce patients, and cause unnecessary harm in overdiagnosis and overtreatment. How can we evaluate diagnostics to obtain the benefits and avoid harm? One way is to pay close attention to the diagnostic process and its core concepts. Doing so reveals 3 errors that expand disease and increase overdiagnosis. The first error is to decouple diagnostics from harm, eg, by diagnosing insignificant conditions. The second error is to bypass proper validation of the relationship between test indicator and disease, eg, by introducing biomarkers for Alzheimer's disease before the tests are properly validated. The third error is to couple the name of disease to insignificant or indecisive indicators, eg, by lending the cancer name to preconditions, such as ductal carcinoma in situ. We need to avoid these errors to promote beneficial testing, bar harmful diagnostics, and evade unwarranted expansion of disease. Accordingly, we must stop identifying and testing for conditions that are only remotely associated with harm. We need more stringent verification of tests, and we must avoid naming indicators and indicative conditions after diseases. If not, we will end like ancient tragic heroes, succumbing because of our very best abilities.

Too much medicine: overdiagnosis and overtreatment of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease. This remarkable rise in prevalence over the past 20 years is largely through the recognition of fatty liver in the absence of excessive alcohol consumption as a disease. The natural history of NAFLD is incompletely understood, and although a small proportion of individuals with NAFLD will develop complications of liver disease, most will not. This raises the prospect of widespread overdiagnosis of NAFLD. Clinical practice guidelines from the European specialist societies representing hepatology, endocrinology, and obesity endorse screening for NAFLD in at-risk groups, and this further increases the likelihood of overdiagnosis and consequent overtreatment through false-positive testing. Predictable outcomes of overdiagnosis include physical harms through investigation and treatment, and psychosocial harms through disease labelling. Prospective studies are required to better understand both the benefits and risks associated with an early diagnosis of NAFLD.

Quality appraisal of clinical guidelines for surgical site infection prevention: A systematic review

Background

Surgical site infections (SSI) occur in up to 10% of surgeries. Wound care practices to prevent infections are guided by Clinical Practice Guidelines (CPGs), yet their contribution to improving patient outcomes relies on their quality and adoption in practice. We critically evaluated the quality of CPGs for SSI prevention during pre-, intra- and post-operative phases of care.

Methods

We systematically reviewed the literature from 1990–2018 using the Cochrane Library, CINAHL, EMBASE, MEDLINE, ProQuest databases and five guidelines repositories. We extracted characteristics of each guideline using purposely-developed data collection tools. We assessed overall quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

Results

Combined searches of databases and repositories yielded 5,910 citations. Of these, we reviewed 215 full text documents. The final sample included 15 documents: 6 complete CPGs, 3 CPG updates, and 6 supplementary documents. The overall %mean scores across AGREE II domains for CPGs were: 1) scope and purpose (%mean ± SD = 86.3±23.5); 2) stakeholder involvement (%mean ± SD = 64±31.0); 3) rigour of development (%mean ± SD = 68.7±30.6); 4) clarity and presentation (%mean ± SD = 88.5±16.7); 5) applicability (%mean ± SD = 44±30.2); and, 5) editorial independence (%mean ± SD = 61±37.6). Based on individual AGREE II domains and overall scores, we appraised 4 out of 6 CPGs (inclusive of updates) as “recommended” for use in practice. Overall agreement among appraisers was excellent (ICC 0.86 [95%CI 0.73–0.94] - 0.98 [95%CI 0.96–0.99]; p <0.001).

Discussion

International interest in CPG development has resulted in refinements to methodologies, which has led to improvements in the overall quality of the product.

Implications for translation

Given the domains that received the lowest scores, it is clear that we need more consumer involvement and better consideration of the implementation challenges with CPG uptake and sustainability.

Cost Analysis of a Digital Health Care Model in Sweden

BACKGROUND

Digital technologies in health care are expected to increase in scope and to affect ever more parts of the health care system. It is important to enhance the knowledge of whether new digital methods and innovations provide value for money compared with traditional models of care.

OBJECTIVE

The objective of the study was to evaluate whether a digital health care model for primary care is a less costly alternative compared with traditional in-office primary care in Sweden.

METHODS

Cost data for the two care models were collected and analyzed to obtain a measure in local currency per care contact.

RESULTS

The comparison showed that the total economic cost of a digital consultation is 1960 Swedish krona (SEK) (SEK100 = US$11.29; February 2017) compared with SEK3348 for a traditional consultation at a health care clinic. Cost differences arose on both the provider side and on the user side.

CONCLUSION

The digital health care model may be a less costly alternative to the traditional health care model. Depending on the rate of digital substitution, gross economic cost savings of between SEK1 billion and SEK10 billion per year could be realized if more digital consultations were made. Further studies are needed to validate the findings, assess the types of care most suitable for digital care, and also to obtain various quality-adjusted outcome measures.

Reframing Global Palliative Care Advocacy for the Sustainable Development Goal Era: A Qualitative Study of the Views of International Palliative Care Experts

CONTEXT

The World Health Assembly Palliative Care Resolution in 2014 and the inclusion of palliative care within the sustainable development goals raised optimism that palliative care would no longer be a peripheral aspect of global health. However, no funding, accountability measures, or indicators for palliative care development accompanied these policy developments. This risks health actors continuing to prioritize the attainment of better known target-driven aspects of health care.

OBJECTIVES

To explore the attitudes of international palliative care experts regarding how the future development of palliative care can be accelerated.

METHODS

About 16 international palliative care experts were interviewed for their epistemic expertise. Participants were interviewed face to face or via Skype. Interviews were recorded, transcribed nonverbatim, and analyzed using a thematic approach (NVivo).

RESULTS

Participants strongly supported the rollout of national palliative care policies around the world for two reasons: to ensure palliative care attracts national funding streams and to attract global funding for palliative care. The absence of a global indicator for palliative care development was considered a severe impediment to the inclusion of palliative care within global efforts toward universal health care. Advocacy partnerships, using human rights approaches with economic frames, were considered the most effective methods of influencing policymakers.

CONCLUSION

Palliative care represents a value proposition that is not currently being maximized by advocacy. Advocates should consider palliative care developmentally, focusing on key asks for development and consider how palliative care can contribute to other international development priorities, in particular poverty reduction.

Moving low value care lists into action: prioritizing candidate health technologies for reassessment using administrative data

Background

Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR).

Methods

An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC).

Results

The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] “do not do” recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely “Top 5” lists) were identified. Using appropriate coding systems for BC’s administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment.

Conclusions

This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3459-1) contains supplementary material, which is available to authorized users.

Low-value care in Australian public hospitals: prevalence and trends over time

Objective

To examine 27 low-value procedures, as defined by international recommendations, in New South Wales public hospitals.

Design

Analysis of admitted patient data for financial years 2010–2011 to 2016–2017.

Main outcome measures

Number and proportion of episodes identified as low value by two definitions (narrower and broader), associated costs and bed-days, and variation between hospitals in financial year 2016–2017; trends in numbers of low-value episodes from 2010–2011 to 2016–2017.

Results

For 27 procedures in 2016–2017, we identified 5079 (narrower definition) to 8855 (broader definition) episodes involving low-value care (11.00%–19.18% of all 46 169 episodes involving these services). These episodes were associated with total inpatient costs of $A49.9 million (narrower) to $A99.3 million (broader), which was 7.4% (narrower) to 14.7% (broader) of the total $A674.6 million costs for all episodes involving these procedures in 2016–2017, and involved 14 348 (narrower) to 29 705 (broader) bed-days. Half the procedures accounted for less than 2% of all low-value episodes identified; three of these had no low-value episodes in 2016–2017. The proportion of low-value care varied widely between hospitals. Of the 14 procedures accounting for most low-value care, seven showed decreasing trends from 2010–2011 to 2016–2017, while three (colonoscopy for constipation, endoscopy for dyspepsia, sentinel lymph node biopsy for melanoma in situ) showed increasing trends.

Conclusions

Low-value care in this Australian public hospital setting is not common for most of the measured procedures, but colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopys for melanoma in situ require further investigation and action to reverse increasing trends. The variation between procedures and hospitals may imply different drivers and potential remedies.

Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial

BACKGROUND

Two billion peripheral intravenous catheters (PIVCs) are used globally each year, but optimal dressing and securement methods are not well established. We aimed to compare the efficacy and costs of three alternative approaches to standard non-bordered polyurethane dressings.

METHODS

We did a pragmatic, randomised controlled, parallel-group superiority trial at two hospitals in Queensland, Australia. Eligible patients were aged 18 years or older and required PIVC insertion for clinical treatment, which was expected to be required for longer than 24 h. Patients were randomly assigned (1:1:1:1) via a centralised web-based randomisation service using random block sizes, stratified by hospital, to receive tissue adhesive with polyurethane dressing, bordered polyurethane dressing, a securement device with polyurethane dressing, or polyurethane dressing (control). Randomisation was concealed before allocation. Patients, clinicians, and research staff were not masked because of the nature of the intervention, but infections were adjudicated by a physician who was masked to treatment allocation. The primary outcome was all-cause PIVC failure (as a composite of complete dislodgement, occlusion, phlebitis, and infection [primary bloodstream infection or local infection]). Analysis was by modified intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000769987.

FINDINGS

Between March 18, 2013, and Sept 9, 2014, we randomly assigned 1807 patients to receive tissue adhesive with polyurethane (n=446), bordered polyurethane (n=454), securement device with polyurethane (n=453), or polyurethane (n=454); 1697 patients comprised the modified intention-to-treat population. 163 (38%) of 427 patients in the tissue adhesive with polyurethane group (absolute risk difference -4·5% [95% CI -11·1 to 2·1%], p=0·19), 169 (40%) of 423 of patients in the bordered polyurethane group (-2·7% [-9·3 to 3·9%] p=0·44), 176 (41%) of 425 patients in the securement device with poplyurethane group (-1·2% [-7·9% to 5·4%], p=0·73), and 180 (43%) of 422 patients in the polyurethane group had PIVC failure. 17 patients in the tissue adhesive with polyurethane group, two patients in the bordered polyurethane group, eight patients in the securement device with polyurethane group, and seven patients in the polyurethane group had skin adverse events. Total costs of the trial interventions did not differ significantly between groups.

INTERPRETATION

Current dressing and securement methods are commonly associated with PIVC failure and poor durability, with simultaneous use of multiple products commonly required. Cost is currently the main factor that determines product choice. Innovations to achieve effective, durable dressings and securements, and randomised controlled trials assessing their effectiveness are urgently needed.

FUNDING

Australian National Health and Medical Research Council.

Long-term prognosis of unheralded myocardial infarction vs chronic angina; role of sex and coronary atherosclerosis burden

Background

Angina pectoris (AP) and unheralded myocardial infarction (MI) are considered random clinical equivalents of ischemic heart disease (IHD). Aim of the study was to evaluate the long-term progression of AP as opposed to unheralded MI as alternative first clinical presentations of IHD and the effect of sex on prognosis.

Methods

The study included 2272 consecutive patients, 1419 MI and 1353 AP, hospitalized from 1995 to 2007 at CNR Clinical Physiology Institute, Pisa, Italy and followed up to December 2013, who fulfilled the following criteria: unheralded MI or AP as first manifestation of IHD; age < = 70 years; known coronary anatomy; at least 10-year follow-up. Fatal and non fatal MI, all-cause, and cardiac deaths were the end-points.

Results

Males were predominant in MI (86%) as compared to AP (77%). Females were predominantly affected by AP (61%, MI 39%), and older than men (61 ± 7 vs 59 ± 8 years, p < 0.001). Coronary stenoses were prevalent in MI. During 115 ± 58 months follow-up, 628 deaths (23%) were observed, including 269 cardiac (43%), and 149 cancer deaths (24%). Long-term prognosis was significantly better in AP than MI group. The lowest prevalence of future MI was recorded in female AP (p < 0.001).

Conclusions

MI as first clinical manifestation of IHD implies a more adverse prognosis than AP; future MI is a rare event in AP; sex influences the first presentation of IHD and its course with possible implications for preventive strategy.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0890-5) contains supplementary material, which is available to authorized users.

Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment

INTRODUCTION

Precision medicine aims to focus on meeting patient requirements accurately, optimizing patient outcomes, and reducing under-/overdiagnosis and therapy. We aim to offer a fresh perspective on accuracy driven “age-old precision medicine” and illustrate how newer case-based blended learning ecosystems (CBBLE) can strengthen the bridge between age-old precision approaches with modern technology and omics-driven approaches.

METHODOLOGY

We present a series of cases and examine the role of precision medicine within a “case-based blended learning ecosystem” (CBBLE) as a practicable tool to reduce overdiagnosis and overtreatment. We illustrated the workflow of our CBBLE through case-based narratives from global students of CBBLE in high and low resource settings as is reflected in global health.

RESULTS

Four micro-narratives based on collective past experiences were generated to explain concepts of age-old patient-centered scientific accuracy and precision and four macro-narratives were collected from individual learners in our CBBLE. Insights gathered from a critical appraisal and thematic analysis of the narratives were discussed.

DISCUSSION AND CONCLUSION

Case-based narratives from the individual learners in our CBBLE amply illustrate their journeys beginning with “age-old precision thinking” in low-resource settings and progressing to “omics-driven” high-resource precision medicine setups to demonstrate how the approaches, used judiciously, might reduce the current pandemic of over-/underdiagnosis and over-/undertreatment.

Public health implications of overscreening for carotid artery stenosis, prediabetes, and thyroid cancer

Background

Overscreening occurs when people without symptoms undergo tests for diseases and the results will not improve their health. In this commentary, we examine three examples of how campaigns to screen and treat specific vascular, metabolic, and oncologic diseases in asymptomatic individuals have produced substantial overdiagnosis and may well have contributed to more harm than good. These conditions were chosen because they may not be as well known as other cases such as screening for breast or prostate cancer.

Main text

Screening for carotid artery stenosis can be a lucrative business using portable equipment and mobile vans. While this fatty buildup of plaque in the arteries of the neck is one risk factor for ischemic stroke, current evidence does not suggest that performing carotid dopplers to screen for CAS reduces the incidence of stroke or provide long-term benefits. After a positive screening, the follow-up procedures can lead to heart attacks, bleeding, strokes, and even death. Similarly, many organizations have launched campaigns for “prediabetes awareness.” Screening for prediabetes with a blood sugar test does not decrease mortality or cardiovascular events. Identifying people with prediabetes could lead to psychological stress and starting medication that may have significant side effects. Finally, palpating people’s necks or examining them with ultrasounds for thyroid cancer is common in many countries but ineffective in reducing mortality. Deadly forms of thyroid cancer are rare, and the overall 5-year survival rate is excellent. Interventions from treatment for more prevalent, less aggressive forms of thyroid cancer can lead to surgical complications, radiation side effects, or require lifelong thyroid replacement therapy.

Conclusions

Screening for carotid artery stenosis, prediabetes, and thyroid cancer in an asymptomatic population can result in unnecessary, harmful, and costly care. Systemic challenges to lowering overscreening include lack of clinician awareness, examination of conflicts of interests, perverse financial incentives, and communication with the general public.

How to Uncover Sources of Unwarranted Practice Variation: A Case Study in Emergency Medicine

Forty years of statistical database analyses have demonstrated the existence of unwarranted practice variation in care delivery, that is, variations independent of medical need, evidence, or patient preference. Alas, little is known about the underlying mechanisms and thus finding interventions to reduce unwarranted variations remains difficult, hampering quality, equity, and efficiency of care. Whereas statistical analyses describe deviations from ideal patterns, ethnographically inspired analyses aim at understanding when, how, and why variations occur in practice. Based on case studies derived from shadowing emergency physicians, I demonstrate that analyzing practice variation in practice helps to (a) advance the understanding of mechanisms and (b) evaluate/expand the existing repertoire of interventions. Results revealed unmet expectations and new sources of known variations as well as interventions complementing systemic changes with those that empower individuals to better cope with the existing system. These findings highlight the benefits of mixed-methods for understanding and tackling practice variation.

The GUIDES checklist: development of a tool to improve the successful use of guideline-based computerised clinical decision support

Background

Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed.

Multifaceted context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully.

Methods

We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist.

Results

We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy.

Conclusions

The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0772-3) contains supplementary material, which is available to authorized users.

Enhancing the uptake of systematic reviews of effects: what is the best format for health care managers and policy-makers? A mixed-methods study

BACKGROUND

Systematic reviews are infrequently used by health care managers (HCMs) and policy-makers (PMs) in decision-making. HCMs and PMs co-developed and tested novel systematic review of effects formats to increase their use.

METHODS

A three-phased approach was used to evaluate the determinants to uptake of systematic reviews of effects and the usability of an innovative and a traditional systematic review of effects format. In phase 1, survey and interviews were conducted with HCMs and PMs in four Canadian provinces to determine perceptions of a traditional systematic review format. In phase 2, systematic review format prototypes were created by HCMs and PMs via Conceptboard©. In phase 3, prototypes underwent usability testing by HCMs and PMs.

RESULTS

Two hundred two participants (80 HCMs, 122 PMs) completed the phase 1 survey. Respondents reported that inadequate format (Mdn = 4; IQR = 4; range = 1-7) and content (Mdn = 4; IQR = 3; range = 1-7) influenced their use of systematic reviews. Most respondents (76%; n = 136/180) reported they would be more likely to use systematic reviews if the format was modified. Findings from 11 interviews (5 HCMs, 6 PMs) revealed that participants preferred systematic reviews of effects that were easy to access and read and provided more information on intervention effectiveness and less information on review methodology. The mean System Usability Scale (SUS) score was 55.7 (standard deviation [SD] 17.2) for the traditional format; a SUS score < 68 is below average usability. In phase 2, 14 HCMs and 20 PMs co-created prototypes, one for HCMs and one for PMs. HCMs preferred a traditional information order (i.e., methods, study flow diagram, forest plots) whereas PMs preferred an alternative order (i.e., background and key messages on one page; methods and limitations on another). In phase 3, the prototypes underwent usability testing with 5 HCMs and 7 PMs, 11 out of 12 participants co-created the prototypes (mean SUS score 86 [SD 9.3]).

CONCLUSIONS

HCMs and PMs co-created prototypes for systematic review of effects formats based on their needs. The prototypes will be compared to a traditional format in a randomized trial.

Drivers and strategies for avoiding overuse. A cross-sectional study to explore the experience of Spanish primary care providers handling uncertainty and patients' requests

OBJECTIVES

Identify the sources of overuse from the point of view of the Spanish primary care professionals, and analyse the frequency of overuse due to pressure from patients in addition to the responses when professionals face these demands.

DESIGN

A cross-sectional study.

SETTING

Primary care in Spain.

PARTICIPANTS

A non-randomised sample of 2201 providers (general practitioners, paediatricians and nurses) was recruited during the survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

The frequency, causes and responsibility for overuse, the frequency that patients demand unnecessary tests or procedures, the profile of the most demanding patients, and arguments for dissuading the patient.

RESULTS

In all, 936 general practitioners, 682 paediatricians and 286 nurses replied (response rate 18.6%). Patient requests (67%) and defensive medicine (40%) were the most cited causes of overuse. Five hundred and twenty-two (27%) received requests from their patients almost every day for unnecessary tests or procedures, and 132 (7%) recognised granting the requests. The lack of time in consultation, and information about new medical advances and treatments that patients could find on printed and digital media, contributed to the professional's inability to adequately counter this pressure by patients. Clinical safety (49.9%) and evidence (39.4%) were the arguments that dissuaded patients from their requests the most. Cost savings was not a convincing argument (6.8%), above all for paediatricians (4.3%). General practitioners resisted more pressure from their patients (x²=88.8, P<0.001, percentage difference (PD)=17.0), while nurses admitted to carrying out more unnecessary procedures (x²=175.7, P<0.001, PD=12.3).

CONCLUSION

Satisfying the patient and patient uncertainty about what should be done and defensive medicine practices explains some of the frequent causes of overuse. Safety arguments are useful to dissuade patients from their requests.

Regional variations in childbirth interventions in the Netherlands: a nationwide explorative study

BACKGROUND

Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics.

METHODS

Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37 weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients.

RESULTS

Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage.

CONCLUSIONS

Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

Rational decision making in medicine: Implications for overuse and underuse

In spite of substantial spending and resource utilization, today's health care remains characterized by poor outcomes, largely due to overuse (overtesting/overtreatment) or underuse (undertesting/undertreatment) of health services. To a significant extent, this is a consequence of low-quality decision making that appears to violate various rationality criteria. Such suboptimal decision making is considered a leading cause of death and is responsible for more than 80% of health expenses. In this paper, we address the issue of overuse or underuse of health care interventions from the perspective of rational choice theory. We show that what is considered rational under one decision theory may not be considered rational under a different theory. We posit that the questions and concerns regarding both underuse and overuse have to be addressed within a specific theoretical framework. The applicable rationality criterion, and thus the "appropriateness" of health care delivery choices, depends on theory selection that is appropriate to specific clinical situations. We provide a number of illustrations showing how the choice of theoretical framework influences both our policy and individual decision making. We also highlight the practical implications of our analysis for the current efforts to measure the quality of care and link such measurements to the financing of health care services.

Medical overuse in the Iranian healthcare system: a systematic review protocol

INTRODUCTION

Lack of resources is one of the main problems of all healthcare systems. Recent studies have shown that reducing the overuse of medical services plays an important role in reducing healthcare system costs. Overuse of medical services is a major problem in the healthcare system, and it threatens the quality of the services, can harm patients and create excess costs for patients. So far, few studies have been conducted in this regard in Iran. The main objective of this systematic review is to perform an inclusive search for studies that report overuse of medical services in the Iranian healthcare system.

METHOD AND ANALYSIS

An extensive search of the literature will be conducted in six databases including PubMed, Embase, Scopus, Web of Science, Cochrane and Scientific Information Database using a comprehensive search strategy to identify studies on overuse of medical care. The search will be done without time limit until the end of 2017, completed by reference tracking, author tracking and expert consultation. The search will be conducted on 1 February 2018. Any study that reports an overuse in a service based on a specific standard will be included in the study. Two reviewers will screen the articles based on the title, abstract and full text, and extract data about type of service, clinical area and overuse rate. Quality appraisal will be assessed using the Joanna Briggs Institute checklist. Potential discrepancies will be resolved by consulting a third author.

ETHICS AND DISSEMINATION

Recommendations will be made to the Iranian MOHME (Ministry of Health and Medical Education) in order to make better evidence-based decisions about medical services in the future.

PROSPERO REGISTRATION NUMBER

CRD42017075481.

How should we monitor patients with acute respiratory failure treated with noninvasive ventilation?

Noninvasive ventilation (NIV) is currently one of the most commonly used support methods in hypoxaemic and hypercapnic acute respiratory failure (ARF). With advancing technology and increasing experience, not only are indications for NIV getting broader, but more severe patients are treated with NIV. Depending on disease type and clinical status, NIV can be applied both in the general ward and in high-dependency/intensive care unit settings with different environmental opportunities. However, it is important to remember that patients with ARF are always very fragile with possible high mortality risk. The delay in recognition of unresponsiveness to NIV, progression of respiratory failure or new-onset complications may result in devastating and fatal outcomes. Therefore, it is crucial to understand that timely action taken according to monitoring variables is one of the key elements for NIV success. The purpose of this review is to outline basic and advanced monitoring techniques for NIV during an ARF episode.

Opportunities for better value wound care: a multiservice, cross-sectional survey of complex wounds and their care in a UK community population

BACKGROUND

Complex wounds impose a substantial health economic burden worldwide. As wound care is managed across multiple settings by a range of healthcare professionals with varying levels of expertise, the actual care delivered can vary considerably and result in the underuse of evidence-based interventions, the overuse of interventions supported by limited evidence and low value healthcare.

OBJECTIVES

To quantify the number, type and management of complex wounds being treated over a two-week period and to explore variations in care by comparing current practices in wound assessment, prevention and treatment.

DESIGN

A multiservice cross-sectional survey.

SETTING

This survey spanned eight community services within five Northern England NHS Trusts.

RESULTS

The point prevalence of complex wounds in this community-based population was 16.4 per 10 000 (95% CI 15.9 to 17.0). Based on data from 3179 patients, antimicrobial dressings were being used as the primary dressing for 36% of patients with complex wounds. Forty per cent of people with leg ulcers either had not received the recommended Doppler-aided Ankle Brachial Pressure Index assessment or it was unclear whether a recording had been taken. Thirty-one per cent of patients whose most severe wound was a venous leg ulcer were not receiving compression therapy, and there was limited use of two-layer compression hosiery. Of patients with a pressure ulcer, 39% were not using a pressure-relieving cushion or mattress.

CONCLUSIONS

Marked variations were found in care, underuse of evidence-based practices and overuse of practices that are not supported by robust research evidence. Significant opportunities for delivering better value wound care therefore exist. Efforts should now focus on developing strategies to identify, assess and disinvest from products and practices supported by little or no evidence and enhance the uptake of those that are.

Appropriate use of medical imaging in two Spanish public hospitals: a cross-sectional analysis

OBJECTIVES

To determine the appropriateness of medical imaging examinations involving radiation and to estimate the effective radiation dose and costs associated.

DESIGN

Cross-sectional retrospective study.

SETTING

Two Spanish public tertiary hospitals.

PARTICIPANTS

2022 medical imaging tests were extracted from the radiology information system in February and March of 2014. MRI and ultrasound examinations were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Five outcomes were set independently by at least two researchers according to four guidelines: (1) appropriate; (2) inappropriate; (3) inappropriate due to repetition, if the timing to carry out next diagnostic tests was incorrect according to guidelines; (4) not adequately justified, if the referral form did not include enough clinical information to allow us to understand the patient's clinical condition; and (5) not included in the guidelines, if the referral could not be matched to a clinical scenario described in the guidelines. We estimated the prevalence of the five categories according to relevant clinical and sociodemographic variables and the effective radiation dose and costs for each category.

RESULTS

Approximately half of the imaging tests were deemed as appropriate (967, 47.8%) while one-third (634, 31.4%) were considered inappropriate. 19.6% of the effective dose and 25.2% of the cost were associated with inappropriate tests. Women were less likely than men to have an imaging test classified as appropriate (adjusted OR 0.70,95% CI 0.57 to 0.86). Imaging tests requested by general practitioners were less likely to be considered appropriate than those requested by central services (adjusted OR 0.60, 95% CI 0.38 to 0.93). Mammography and CT were more likely to be appropriate than conventional X-rays.

CONCLUSION

There was a significant frequency of inappropriateness, which resulted in a high percentage of associated effective radiation dose. Percentage of inappropriateness depends on sociodemographic and clinical characteristics such as sex, age, referral physician and medical imaging test.

Intensity of treatment in Swiss cancer patients at the end-of-life

Purpose

Current evidence on the care-delivering process and the intensity of treatment at the end-of-life of cancer patients is limited and remains unclear. Our objective was to examine the care-delivering processes in health care during the last months of life with real-life data of Swiss cancer patients.

Patients and methods

The study population consisted of adult decedents in 2014 who were insured at Helsana Group. Data on the final cause of death were provided additionally by the Swiss Federal Statistical Office. Of the 10,275 decedents, 2,710 (26.4%) died of cancer. Intensity of treatment and health care utilization (including transitions) at their end-of-life were examined. Intensity measures included the following: last dose of chemotherapy within 14 days of death, a new chemotherapy regimen starting <30 days before death, more than one hospital admission or spending >14 days in hospital in the last month, death in an acute care hospital, more than one emergency visit and ≥1 intensive care unit admission in the last month of life.

Results

In the last 6 months of life, 89.5% of cancer patients had ≥1 transition, with 87.2% being hospitalized. Within 30 days before death, 64.2% of the decedents had ≥1 intensive treatment, whereby 8.9% started a new chemotherapy. In the multinomial logistic regression model, older age, higher density of nursing home beds and home care nurses were associated with a decrease, while living in the Italian- or French-speaking part of Switzerland was associated with an increase in intensive care.

Conclusion

Swiss cancer patients insured by Helsana Group experience a considerable number of transitions and intensive treatments at the end-of-life, whereby treatment intensity declines with increasing age. Among others, increased home care nursing might be helpful to reduce unwarranted treatments and transitions, therefore leading to better care at the end-of-life.