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Scott IA, Elshaug AG, Fox M. Low value care is a health hazard that calls for patient empowerment. Med J Aust 2021; 215:101-103.e1. [PMID: 34275155 DOI: 10.5694/mja2.51168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, Brisbane, QLD.,University of Queensland, Brisbane, QLD
| | - Adam G Elshaug
- Centre for Health Policy, University of Melbourne, Melbourne, VIC
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Yakusheva O, Bang JT, Hughes RG, Bobay KL, Costa L, Weiss ME. Nonlinear association of nurse staffing and readmissions uncovered in machine learning analysis. Health Serv Res 2021; 57:311-321. [PMID: 34195989 DOI: 10.1111/1475-6773.13695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/29/2021] [Accepted: 06/01/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Several studies of nurse staffing and patient outcomes found a curvilinear or U-shaped relationship, with benefits from additional nurse staffing diminishing or reversing at high staffing levels. This study examined potential diminishing returns to nurse staffing and the existence of a "tipping point" or the level of staffing after which higher nurse staffing no longer improves and may worsen readmissions. DATA SOURCES/STUDY SETTING The Readiness Evaluation And Discharge Interventions (READI) study database of over 130,000 adult (18+) inpatient discharges from 62 medical, surgical, and medical-surgical (noncritical care) units from 31 United States (US) hospitals during October 2014-March 2017. STUDY DESIGN Observational cross-sectional study using a fully nonparametric random forest machine learning method. Primary exposure was nurse hours per patient day (HPPD) broken down by registered nurses (nonovertime and overtime) and nonlicensed nursing personnel. The outcome was 30-day all-cause same-hospital readmission. Partial dependence plots were used to visualize the pattern of predicted patient readmission risk along a range of unit staffing levels, holding all other patient characteristics and hospital and unit structural variables constant. DATA COLLECTION/EXTRACTION METHODS Secondary analysis of the READI data. Missing values were imputed using the missing forest algorithm in R. PRINCIPAL FINDINGS Partial dependence plots were U-shaped, showing the readmission risk first declining and then rising with additional nurse staffing. The tipping points were at 6.95 and 0.21 HPPD for registered nurse staffing (nonovertime and overtime, respectively) and 2.91 HPPD of nonlicensed nursing personnel. CONCLUSIONS The U-shaped association was consistent with diminishing returns to nurse staffing suggesting that incremental gains in readmission reduction from additional nurse staffing taper off and could reverse at high staffing levels. If confirmed in future causal analyses across multiple outcomes, accompanying investments in infrastructure and human resources may be needed to maximize nursing performance outcomes at higher levels of nurse staffing.
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Affiliation(s)
- Olga Yakusheva
- Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA.,Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - James T Bang
- Department of Economics, St. Ambrose University, Davenport, Iowa, USA
| | - Ronda G Hughes
- Center for Nursing Leadership, College of Nursing, University of South Carolina, Columbia, South Carolina, USA
| | - Kathleen L Bobay
- Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Illinois, USA
| | - Linda Costa
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Marianne E Weiss
- College of Nursing, Marquette University, Milwaukee, Wisconsin, USA
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The Impact of a Standardized Pre-visit Laboratory Testing Panel in the Internal Medicine Outpatient Clinic: a Controlled "On-Off" Trial. J Gen Intern Med 2021; 36:1914-1920. [PMID: 33483828 PMCID: PMC8298644 DOI: 10.1007/s11606-020-06453-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/13/2020] [Indexed: 10/26/2022]
Abstract
BACKGROUND In several settings, a shorter time to diagnosis has been shown to lead to improved clinical outcomes. The implementation of a rapid laboratory testing allows for a pre-visit testing in the outpatient clinic, meaning that test results are available during the first outpatient visit. OBJECTIVE To determine whether the pre-visit laboratory testing leads to a shorter time to diagnosis in the general internal medicine outpatient clinic. DESIGN An "on-off" trial, allocating subjects to one of two treatment arms in consecutive alternating blocks. PARTICIPANTS All new referrals to the internal medicine outpatient clinic of a university hospital were included, excluding second opinions. A total of 595 patients were eligible; one person declined to participate, leaving data from 594 patients for analysis. INTERVENTION In the intervention group, patients had a standardized pre-visit laboratory testing before the first visit. MAIN MEASURES The primary outcome was the time to diagnosis. Secondary outcomes were the correctness of the preliminary diagnosis on the first day, health care utilization, and patient and physician satisfaction. KEY RESULTS There was no difference in time to diagnosis between the two groups (median 35 days vs 35 days; hazard ratio 1.03 [0.87-1.22]; p = .71). The pre-visit testing group had higher proportions of both correct preliminary diagnoses on day 1 (24% vs 14%; p = .003) and diagnostic workups being completed on day 1 (10% vs 3%; p < .001). The intervention group had more laboratory tests done (50.0 [interquartile range (IQR) 39.0-69.0] vs 43.0 [IQR 31.0-68.5]; p < .001). Otherwise, there were no differences between the groups. CONCLUSIONS Pre-visit testing did not lead to a shorter overall time to diagnosis. However, a greater proportion of patients had a correct diagnosis on the first day. Further studies should focus on customizing pre-visit laboratory panels, to improve their efficacy. TRIAL REGISTRATION NL5009.
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Korenstein D, Harris R, Elshaug AG, Ross JS, Morgan DJ, Cooper RJ, Cho HJ, Segal JB. To Expand the Evidence Base About Harms from Tests and Treatments. J Gen Intern Med 2021; 36:2105-2110. [PMID: 33479928 PMCID: PMC8298733 DOI: 10.1007/s11606-021-06597-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/01/2021] [Indexed: 12/19/2022]
Abstract
Rigorous evidence about the broad range of harms that might be experienced by a patient in the course of testing and treatment is sparse. We aimed to generate recommendations for how researchers might more comprehensively evaluate potential harms of healthcare interventions, to allow clinicians and patients to better include this evidence in clinical decision-making. We propose seven domains of harms of tests and treatments that are relevant to patients: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. These domains will include a range of severity of harms and variation in timing after testing or treatment, attributable to the service itself or a resulting care cascade. Although some new measures may be needed, diverse data and tools are available to allow the assessment of harms comprehensively across these domains. We encourage researchers to evaluate harms in sub-populations, since the harms experienced may differ importantly by demographics, social determinants, presence of comorbid illness, psychological state, and other characteristics. Regulators, funders, and editors might require either assessment or reporting of harms in each domain or require justification for inclusion and exclusion of different domains.
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Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | | | - Adam G Elshaug
- Melbourne School of Population and Global Health and Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- The Brookings Institution, Washington DC, USA
| | - Joseph S Ross
- Department of Medicine, Yale School of Medicine, New Haven, CT USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD USA
| | - Richelle J Cooper
- UCLA Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Hyung J Cho
- Department of Quality and Safety, NYC Health and Hospitals, New York, NY USA
| | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Qual 2021; 10:e001287. [PMID: 34215659 PMCID: PMC8256731 DOI: 10.1136/bmjoq-2020-001287] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 06/07/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety. METHODS Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation. RESULTS Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis. CONCLUSION Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Anand Parkunan
- Healthshare Community NHS Musculoskeletal Services, London, UK
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
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Shah NN, Mathew C, Brown TJ, Karam A, Das SR. A High-Value Care Initiative to Reduce the Use of Intravenous Magnesium Sulfate Through an Electronic Indication-Based Order Set. Jt Comm J Qual Patient Saf 2021; 47:802-808. [PMID: 34364798 DOI: 10.1016/j.jcjq.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Intravenous (IV) magnesium sulfate (MgSO4) supplementation is common despite limited indications. Oral magnesium oxide (MgO) is an effective, lower-cost alternative. This project aimed to reduce IV MgSO4 use by 20% among the Internal Medicine (IM) service. METHODS Electronic health record (EHR) orders for MgSO4 and MgO within the IM service were replaced with an indication-based EHR order panel. The project team educated clinicians regarding indications for IV MgSO4 and relative costs. The mean of daily 2 g MgSO4 administrations per week and the mean of weekly proportion of 2 g MgSO4 administrations nine months before and after intervention were compared between IM and Emergency Medicine (EM) (control group). Statistical process control analysis was used to assess for special cause variation in daily MgSO4 per week and weekly proportion of MgSO4 administrations. RESULTS The mean of daily 2 g IV MgSO4 administrations per week decreased among IM (19.3 vs. 12.1, p < 0.0001) but not EM (3.1 vs. 4.8, p < 0.0001). The mean of weekly proportions of IV MgSO4 administrations decreased among both IM (83.6% vs. 60.7%, p < 0.0001) and EM (97.0% vs. 93.1%, p = 0.0004). For IM, the change in daily MgSO4 per week and weekly proportion of MgSO4 occurred as a discrete initial decline consistent with special cause variation; for EM, changes in both measures were not consistent with special cause variation. CONCLUSION Replacing stand-alone IV MgSO4 orders with an indication-based order panel along with clinician education reduced IV MgSO4 administrations and may offer a significant opportunity to reduce low-value care.
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Affiliation(s)
| | - Deborah Korenstein
- Lown Institute, 21 Longwood Ave, Brookline, MA 02446, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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Fenton JJ, Jerant A, Franks P, Gosdin M, Fridman I, Cipri C, Weinberg G, Hudnut A, Tancredi DJ. Watchful waiting as a strategy to reduce low-value spinal imaging: study protocol for a randomized trial. Trials 2021; 22:167. [PMID: 33639993 PMCID: PMC7910785 DOI: 10.1186/s13063-021-05106-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background Patients with acute low back pain frequently request diagnostic imaging, and clinicians feel pressure to acquiesce to such requests to sustain patient trust and satisfaction. Spinal imaging in patients with acute low back pain poses risks from diagnostic evaluation of false-positive findings, patient labeling and anxiety, and unnecessary treatment (including spinal surgery). Watchful waiting advice has been an effective strategy to reduce some low-value treatments, and some evidence suggests a watchful waiting approach would be acceptable to many patients requesting diagnostic tests. Methods We will use key informant interviews of clinicians and focus groups with primary care patients to refine a theory-informed standardized patient-based intervention designed to teach clinicians how to advise watchful waiting when patients request low-value spinal imaging for low back pain. We will test the effectiveness of the intervention in a randomized clinical trial. We will recruit 8–10 primary care and urgent care clinics (~ 55 clinicians) in Sacramento, CA; clinicians will be randomized 1:1 to intervention and control groups. Over a 3- to 6-month period, clinicians in the intervention group will receive 3 visits with standardized patient instructors (SPIs) portraying patients with acute back pain; SPIs will instruct clinicians in a three-step model emphasizing establishing trust, empathic communication, and negotiation of a watchful waiting approach. Control physicians will receive no intervention. The primary outcome is the post-intervention rate of spinal imaging among actual patients with acute back pain seen by the clinicians adjusted for rate of imaging during a baseline period. Secondary outcomes are use of targeted communication techniques during a follow-up visit with an SP, clinician self-reported use of watchful waiting with actual low back pain patients, post-intervention rates of diagnostic imaging for other musculoskeletal pain syndromes (to test for generalization of intervention effects beyond back pain), and patient trust and satisfaction with physicians. Discussion This trial will determine whether standardized patient instructors can help clinicians develop skill in negotiating a watchful waiting approach with patients with acute low back pain, thereby reducing rates of low-value spinal imaging. The trial will also examine the possibility that intervention effects generalize to other diagnostic tests. Trial registration ClinicalTrials.govNCT 04255199. Registered on January 20, 2020
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Affiliation(s)
- Joshua J Fenton
- Department of Family and Community Medicine, University of California, Davis, Davis, USA. .,Center for Healthcare Policy and Research, University of California, Davis, Davis, USA.
| | - Anthony Jerant
- Department of Family and Community Medicine, University of California, Davis, Davis, USA.,Center for Healthcare Policy and Research, University of California, Davis, Davis, USA
| | - Peter Franks
- Department of Family and Community Medicine, University of California, Davis, Davis, USA.,Center for Healthcare Policy and Research, University of California, Davis, Davis, USA
| | - Melissa Gosdin
- Center for Healthcare Policy and Research, University of California, Davis, Davis, USA
| | - Ilona Fridman
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Camille Cipri
- Center for Healthcare Policy and Research, University of California, Davis, Davis, USA
| | - Gary Weinberg
- Center for Healthcare Policy and Research, University of California, Davis, Davis, USA
| | - Andrew Hudnut
- Sutter Institute for Medical Research, Sacramento, CA, USA
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Davis, USA.,Department of Pediatrics, University of California, Davis, Davis, USA
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Gamstätter T. [The problem of medical overuse : Finding a definition and solutions]. Internist (Berl) 2021; 62:343-353. [PMID: 33580822 DOI: 10.1007/s00108-021-00957-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 11/30/2022]
Abstract
High-quality medical care including the concepts of "patient-centered medicine" and "precision medicine" imply medical awareness of measures that are "too much" and thus not appropriate for certain patients in a certain context. Physicians occupy a central role as stewards of limited social resources. Numerous influencing factors can cause a cascading into medical overuse. How to identify and avoid overuse? When is "less medicine" the better medicine for an individual patient?
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Affiliation(s)
- T Gamstätter
- Deutsche Gesellschaft für Innere Medizin e. V. (DGIM), Irenenstr. 1, 65189, Wiesbaden, Deutschland.
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Decreasing Admissions to the NICU: An Official Transition Bed for Neonates. Adv Neonatal Care 2021; 21:87-91. [PMID: 32384327 DOI: 10.1097/anc.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evidence supports the need to decrease healthcare costs. One approach may be minimizing use of low-value care by reducing the number of unnecessary neonatal intensive care unit (NICU) admissions through the use of official neonatal transition beds. PURPOSE To evaluate whether transition beds decrease unnecessary NICU admissions and estimate the cost savings of this practice change. METHODS This retrospective chart review examined the records of all neonates of 350/7 weeks' gestational age and greater with birth weights of 2000 g and more admitted to a neonatal transition bed from January 1, 2017, to December 31, 2017. Outcomes evaluated were number of neonates returned to their mothers and an estimate of dollars saved for a 1-year period. RESULTS A total of 194 neonates were admitted to transition beds, which resulted in 144 NICU admissions averted. Respiratory distress was the most common reason for admission to transition beds. There was a statistically significant difference in length of stay in transition beds between neonates admitted to the NICU and those returned to couplet care after admission to transition beds (135.92 minutes vs 159.27 minutes; P = .047). There was no difference in gestational age based on admission to NICU or returned to couplet care (37.9 weeks vs 38 weeks; P = .772). The estimated cost savings was $3000 per neonate returned to couplet care totaling $432,000 annually. IMPLICATIONS FOR PRACTICE The use of neonatal transition beds is a potential strategy to decrease unnecessary NICU admissions and reduce low value care. IMPLICATIONS FOR RESEARCH Research regarding potential benefits of transition beds including the effect on hospital resources and low-value care at other institutions is needed. Additional research regarding potential benefits to the family including parent satisfaction and the effect of transition beds on rates of breastfeeding and skin-to-skin care is important.
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Trevisiol C, Cani I, Fabricio ASC, Gion M, Giometto B, De Massis P. Serum Tumor Markers in Paraneoplastic Neurologic Syndromes: A Systematic Review of Guidelines. Front Neurol 2021; 11:607553. [PMID: 33536995 PMCID: PMC7848074 DOI: 10.3389/fneur.2020.607553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/09/2020] [Indexed: 01/22/2023] Open
Abstract
Purpose: Algorithms for the detection of a malignancy in patients with unclear neurologic symptoms of suspicious paraneoplastic origins are not universally applied. Frequently, circulating tumor markers (TMs) are considered a valuable tool for cancer diagnosis in patients with paraneoplastic neurologic syndromes (PNS). Our aim was to extract the recommendations on the use of TMs and onconeural antibodies (Abs) for the diagnosis of malignancies in PNS from clinical practice guidelines and put them forward as evidence in a common framework to facilitate diffusion, dissemination, and implementation. Methods: Systematic literature searches were performed for guidelines on both oncology and PNS published since 2007. Guidelines containing information and recommendations for clinical practice pertaining to the screening and diagnosis of PNS were selected. Information on circulating TMs and onconeural Abs was extracted and synthesized in consecutive steps of increasing simplification. Results: We retrieved 799 eligible guidelines on oncology for the potential presence of information on PNS but only six covered treated diagnosis or the screening of cancer in PNS, which were then selected. Seventy-nine potentially relevant guidelines on PNS were identified as eligible and 15 were selected. Synoptic tables were prepared showing that classical TMs are not recommended for the screening or the diagnosis of a malignancy in patients with a suspected PNS. Neither should onconeural Abs be considered to screen for the presence of a malignancy, although they could be helpful to define the probability of the paraneoplastic origin of a neurologic disorder. Conclusion: The present work of synthesis may be a useful tool in the diffusion, dissemination, and implementation of guideline recommendations, potentially facilitating the decrease of the inappropriate use of circulating biomarkers for cancer screening in the presence of PNS.
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Affiliation(s)
- Chiara Trevisiol
- Veneto Institute of Oncology IOV-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Ilaria Cani
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Aline S C Fabricio
- Regional Center for Biomarkers, Department of Clinical Pathology and Transfusion Medicine, Venice, Italy
| | - Massimo Gion
- Regional Center for Biomarkers, Department of Clinical Pathology and Transfusion Medicine, Venice, Italy
| | - Bruno Giometto
- U.O. Neurologia, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Ganguli I, Lupo C, Mainor AJ, Wang Q, Orav EJ, Rosenthal MB, Sequist TD, Colla CH. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit. JAMA Netw Open 2020; 3:e2029891. [PMID: 33306120 PMCID: PMC7733154 DOI: 10.1001/jamanetworkopen.2020.29891] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Sechtem U. Intramural haematoma of the ascending aorta – not so malignant after all? EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:S3-S4. [DOI: 10.1177/2048872618812397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Radomski TR, Feldman R, Huang Y, Sileanu FE, Thorpe CT, Thorpe JM, Fine MJ, Gellad WF. Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration. JAMA Netw Open 2020; 3:e2016445. [PMID: 32960278 PMCID: PMC7509631 DOI: 10.1001/jamanetworkopen.2020.16445] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration. OBJECTIVES To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020. EXPOSURES Continuous enrollment in Veterans Health Administration during fiscal year 2015. MAIN OUTCOMES AND MEASURES Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level. RESULTS Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.
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Affiliation(s)
- Thomas R. Radomski
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Robert Feldman
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Yan Huang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- UPMC Center for High-Value Health Care, UPMC Insurance Services Division Steel Tower, Pittsburgh, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Joshua M. Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Michael J. Fine
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Anderson TS, Leonard S, Zhang AJ, Madden E, Mowery D, Chapman WW, Keyhani S. Trends in Low-Value Carotid Imaging in the Veterans Health Administration From 2007 to 2016. JAMA Netw Open 2020; 3:e2015250. [PMID: 32886120 PMCID: PMC7489844 DOI: 10.1001/jamanetworkopen.2020.15250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE As part of the Choosing Wisely campaign, primary care, surgery, and neurology societies have identified carotid imaging ordered for screening, preoperative evaluation, and syncope as frequently low value. OBJECTIVE To determine the changes in overall and indication-specific rates of carotid imaging following Choosing Wisely recommendations. DESIGN, SETTING, AND PARTICIPANTS This serial cross-sectional study compared annual rates of carotid imaging before Choosing Wisely recommendations (ie, 2007 to 2012) and after (ie, 2013 to 2016) among adults receiving care in the Veterans Health Administration (VHA) national health system. Data analysis was performed from April 10, 2019, to November 27, 2019. EXPOSURES Release of the Choosing Wisely recommendations. MAIN OUTCOMES AND MEASURES Annual rates of overall imaging, imaging ordered for stroke workup, imaging ordered for low-value indications (ie, screening owing to carotid bruit, preoperative evaluation, and syncope). Indications were identified using a text lexicon algorithm based on electronic health record review of a stratified random sample of 1000 free-text imaging orders. The subsequent performance of carotid procedures within 6 months after carotid imaging was assessed. RESULTS Between 2007 and 2016, 809 071 carotid imaging examinations were identified (mean [SD] age of patients undergoing imaging, 69 [10] years; 776 632 [96%] men), of which 201 467 images (24.9%) were ordered for low-value indications (67 064 [8.2%] for carotid bruit, 25 032 [3.1%] for preoperative evaluation, and 109 400 [13.5%] for syncope), 257 369 (31.8%) for stroke workup, and 350 235 (43.3%) for other indications. Imaging for carotid bruits declined across the study period while there was no significant change in imaging for syncope or preoperative evaluation. Compared with the 6 years before, during the 4 years following Choosing Wisely recommendations, there was no change in the trend for syncope, a small decline in preoperative imaging (post-Choosing Wisely trend, -0.1 [95% CI, -0.1 to <-0.1] images per 10 000 veterans), and a continued but less steep decline in imaging for carotid bruits (post-Choosing Wisely trend, -0.3 [95% CI, -0.3 to -0.2] images per 10 000 veterans). During the study period, 17 689 carotid procedures were identified, of which 3232 (18.3%) were preceded by carotid imaging ordered for low-value indications. CONCLUSIONS AND RELEVANCE These findings suggest that Choosing Wisely recommendations were not associated with a meaningful change in low-value carotid imaging in a national integrated health system. To reduce low-value testing and utilization cascades, interventions targeting ordering clinicians are needed to augment the impact of public awareness campaigns.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samuel Leonard
- Northern California Institute of Research and Education, San Francisco
| | - Alysandra J. Zhang
- Northern California Institute of Research and Education, San Francisco
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, New York
| | - Erin Madden
- Northern California Institute of Research and Education, San Francisco
| | - Danielle Mowery
- Department of Bioinformatics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | | | - Salomeh Keyhani
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Richter A, Sierocinski E, Singer S, Bülow R, Hackmann C, Chenot JF, Schmidt CO. The effects of incidental findings from whole-body MRI on the frequency of biopsies and detected malignancies or benign conditions in a general population cohort study. Eur J Epidemiol 2020; 35:925-935. [PMID: 32860149 PMCID: PMC7524843 DOI: 10.1007/s10654-020-00679-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/19/2020] [Indexed: 12/12/2022]
Abstract
Magnetic resonance imaging (MRI) yields numerous tumor-related incidental findings (IFs) which may trigger diagnostics such as biopsies. To clarify these effects, we studied how whole-body MRI IF disclosure in a population-based cohort affected biopsy frequency and the detection of malignancies. Laboratory disclosures were also assessed. Data from 6753 participants in the Study of Health in Pomerania (SHIP) examined between 2008 and 2012 were utilized. All underwent laboratory examinations and 3371 (49.9%) a whole-body MRI. Electronic biopsy reports from 2002 to 2017 were linked to participants and assigned to outcome categories. Biopsy frequency 2 years pre- and post-SHIP was investigated using generalized estimating equations with a negative-binomial distribution. Overall 8208 IFs (laboratory findings outside reference limits: 6839; MRI: 1369) were disclosed to 4707 participants; 2271 biopsy reports belonged to 1200 participants (17.8%). Of these, 938 biopsies occurred pre-SHIP; 1333 post-SHIP (event rate/100 observation years = 6.9 [95% CI 6.5; 7.4]; 9.9 [9.3; 10.4]). Age, cancer history, recent hospitalization, female sex, and IF disclosure were associated with higher biopsy rates. Nonmalignant biopsy results increased more in participants with disclosures (post-/pre-SHIP rate ratio 1.39 [95% CI 1.22; 1.58]) than without (1.09 [95% CI 0.85; 1.38]). Malignant biopsy results were more frequent post-SHIP (rate ratio 1.74 [95% CI 1.27; 2.42]). Biopsies increased after participation in a population-based cohort study with MRI and laboratory IF disclosure. Most biopsies resulted in no findings and few malignancies were diagnosed, indicating potential overtesting and overdiagnosis. A more restrictive policy regarding IF disclosure from research findings is required.
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Affiliation(s)
- Adrian Richter
- Department SHIP-KEF, Institute for Community Medicine, Greifswald University Medical Center, Walther Rathenau Str. 48, 17475, Greifswald, Germany.
| | - Elizabeth Sierocinski
- Department SHIP-KEF, Institute for Community Medicine, Greifswald University Medical Center, Walther Rathenau Str. 48, 17475, Greifswald, Germany.,Department of Family Medicine, Institute for Community Medicine, Fleischmannstr. 42, 17475, Greifswald, Germany
| | - Stephan Singer
- Institute for Pathology, Greifswald University Medical Center, Friedrich-Loeffler-Str. 23e, 17487, Greifswald, Germany.,Institute of Pathology, University Hospital Tuebingen, Liebermeisterstrasse 8, 72076, Tuebingen, Germany
| | - Robin Bülow
- Department of Diagnostic Radiology and Neuroradiology, Greifswald University Medical Center Greifswald, 17475, Greifswald, Germany
| | - Carolin Hackmann
- Department SHIP-KEF, Institute for Community Medicine, Greifswald University Medical Center, Walther Rathenau Str. 48, 17475, Greifswald, Germany.,Institute for Hygiene and Environmental Medicine, Charité - University Medicine Berlin, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Jean-François Chenot
- Department of Family Medicine, Institute for Community Medicine, Fleischmannstr. 42, 17475, Greifswald, Germany
| | - Carsten Oliver Schmidt
- Department SHIP-KEF, Institute for Community Medicine, Greifswald University Medical Center, Walther Rathenau Str. 48, 17475, Greifswald, Germany
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Pezeshki MZ, Janati A, Arab-Zozani M. Medical Overuse in the Iranian Healthcare System: A Systematic Scoping Review and Practical Recommendations for Decreasing Medical Overuse During Unexpected COVID-19 Pandemic Opportunity. Risk Manag Healthc Policy 2020; 13:1103-1110. [PMID: 32848487 PMCID: PMC7429239 DOI: 10.2147/rmhp.s262908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/15/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose To perform an inclusive search for original studies that report medical overuse in the Iranian healthcare system and discovering the area of overuse. Patients and Methods A systematic search of the literature is conducted in bibliographic databases including PubMed, Embase, Scopus, Web of Sciences, Cochrane and Scientific Information Database using a comprehensive search strategy without time limit until the end of 2018, updated by 1 July 2020, accomplished by reference tracking, author contacting and expert consultation to identify studies on the overuse of medical care. Results We reviewed 4124 published articles based on predetermined inclusion criteria. The author’s consensus included a total of 41 articles. Of these, 32 were in English and 9 in Farsi, published between 1975–2019. The result categorized into two distinct clinical areas: treatment (18 articles) and diagnostic (23 articles) services. Almost all of the studies only described the magnitude of unnecessary overuse. Unnecessary overuse of antibiotics, MRI, and CT-scan were the most reported topics. The ranges of their overuse proportion were as follows: antibiotic (31 to 97%); MRI (33 to 88%), and CT-scan (19 to 50%). Conclusion Our review showed, even so, the magnitude of unnecessary overuse of medical services is high but there are only a few interventional studies in clinical and administrative level for finding effective methods for decreasing these unnecessary services. Researchers should be encouraged to conducting interventional studies. We suggest the ministry of health to use the golden opportunity of COVID-19 epidemic for designing Iran national policy and action plan for controlling and preventing unnecessary healthcare services and including a section for “Interventional Research” in the action plan.
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Affiliation(s)
- Mohammad Zakaria Pezeshki
- Social Determinants of Health Research Center, Department of Community and Family Medicine, Tabriz Medical School, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Janati
- Iranian Center of Excellence in Health Management, Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
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68
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Lee CS, Divi SN, Dirschl DR, Hynes KK. Financial Impact of Magnetic Resonance Imaging in the Surgical Treatment of Foot and Ankle Osteomyelitis. J Foot Ankle Surg 2020; 59:69-74. [PMID: 31882152 DOI: 10.1053/j.jfas.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/23/2019] [Accepted: 07/12/2019] [Indexed: 02/03/2023]
Abstract
Magnetic resonance imaging (MRI) is generally considered the most sensitive imaging for diagnosis of osteomyelitis; however, it is associated with significant cost and is at times ordered as initial screening imaging when a less resource-intensive test would suffice. The purpose of this retrospective cohort study was to examine the differences between patients with osteomyelitis of the foot and ankle, and their subsequent treatment course, who underwent MRI compared with those who did not. Financial impact of MRI as it relates to clinical decision-making was also calculated. Patients treated for a diagnosis of osteomyelitis of the foot and ankle from 2009 to 2015 were retrospectively identified. Demographics, imaging modalities, and operative procedures for each patient were collected. An "impact MRI" was defined as one that led to a subsequent operative procedure within the same admission. The impact cost of an MRI was estimated using the equation: (average MRI cost) × (total MRIs/impact MRIs). A total of 144 patients underwent 220 MRIs, and 399 patients did not have MRIs. The operative rate between the 2 groups was similar (70.8% versus 70.4%, p = .93). Multiple linear regression showed that MRI was not a significant predictor of operation (p = .50). However, we found a significant correlation between MRI use and operative intervention for patients with increased comorbidities. From 2011 to 2015, there was a significant increase in impact cost, while controlling for average MRI cost ($8172 to $15,292, p ≤ .05). Over the study period, the impact cost of an MRI significantly increased from 1.8 to 5.0 times the average cost.
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Affiliation(s)
- Cody S Lee
- Medical Student, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Srikanth N Divi
- Orthopaedic Resident, Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Douglas R Dirschl
- Chairman, Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL
| | - Kelly K Hynes
- Assistant Professor, Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL.
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Dietrich CF, Westerway S, Nolsøe C, Kim S, Jenssen C. Commentary on the World Federation for Ultrasound in Medicine and Biology Project "Incidental Findings". ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1815-1820. [PMID: 32409233 DOI: 10.1016/j.ultrasmedbio.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/25/2020] [Accepted: 02/03/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Hirslanden Klinik Beau-Site, Salem und Permanence, Bern, Switzerland; Sino-German Research Center of Ultrasound in Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sue Westerway
- Centre for Surgical Ultrasound, Dep of Surgery, Zealand University Hospital, Køge Asc Prof, Copenhagen Academy for Medical Education and Simulation (CAMES) University of Copenhagen Denmark
| | - Christian Nolsøe
- Copenhagen Academy for Medical Education and Simulation (CAMES), Ultrasound Section, Department of Gastroenterology, Division of Surgery, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Seung Kim
- Seoul National University, Seoul, South Korea
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen and Brandenburg Institute for Clinical Ultrasound, Neuruppin, Germany
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Roth CG, Huang W, Sekhon N, Caruso A, Kung D, Greely J, Purkiss J, Ismail N. Teaching Laboratory Stewardship in the Medical Student Core Clerkships Pathology-Teaches. Arch Pathol Lab Med 2020; 144:883-887. [PMID: 31825668 DOI: 10.5858/arpa.2019-0329-oa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Current health care spending is unsustainable, and there is a need to teach high-value care principles to future physicians. Pathology-Teaches is an educational intervention designed to teach laboratory stewardship early in clinical training, at the level of the medical student in their core clinical clerkships. OBJECTIVE.— To assess the pilot implementation of case-based educational modules in 5 required core clerkships at our institution. DESIGN.— The online cases were developed by using a multidisciplinary approach. In the Pathology-Teaches educational module, students make decisions regarding the ordering or interpretation of laboratory testing within the context of a clinical scenario and receive immediate feedback during the case. The intervention was assessed by using pretest and posttest. Student feedback was also collected from end-of-rotation evaluations. RESULTS.— A total of 203 students completed the Pathology-Teaches pilot, including 72 in Family Medicine, 72 in Emergency Medicine, 24 in Internal Medicine, 24 in Neurology, and 11 in Obstetrics-Gynecology (OB-GYN). Pathology-Teaches utility was demonstrated by significantly increased improvement between pretest and posttest scores (mean, 63.1% versus 83.5%; P < .001; Hedge g effect size = 0.93). Of the 494 students who completed the Pathology-Teaches questions on the end-of-rotation evaluation, 251 provided specific feedback, with 38.6% (97 of 251) rating the activity as "extremely valuable" or "very valuable," and 41.4% (104 of 251) as "some/moderate value." Qualitative feedback included 17 positive comments with 6 requests to scale up or include more cases, 16 constructive comments for improvement mainly regarding the technical aspects, and 5 negative comments. CONCLUSIONS.— Pathology-Teaches effectively teaches stewardship concepts, and most students perceived value in this educational intervention.
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Affiliation(s)
- Christine G Roth
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
| | - William Huang
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
| | - Navdeep Sekhon
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
| | - Andrew Caruso
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
| | - Doris Kung
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
| | - Jocelyn Greely
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
| | - Joel Purkiss
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
| | - Nadia Ismail
- From the Departments of Pathology & Immunology (Dr Roth), Family Medicine (Dr Huang), Internal Medicine (Drs Caruso, Purkiss, and Ismail), Emergency Medicine (Dr Sekhon), Neurology (Dr Kung), OB-GYN, (Dr Greely), and the Office of the Curriculum (Drs Purkiss and Ismail), Baylor College of Medicine, Houston, Texas
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Anderson TS, Lin GA. Testing Cascades-A Call to Move From Descriptive Research to Deimplementation Science. JAMA Intern Med 2020; 180:984-985. [PMID: 32511685 DOI: 10.1001/jamainternmed.2020.1588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Grace A Lin
- Division of General Internal Medicine, University of California, San Francisco.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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Chimonas SC, Diaz-MacInnis KL, Lipitz-Snyderman AN, Barrow BE, Korenstein DR. Why Not? Persuading Clinicians to Reduce Overuse. Mayo Clin Proc Innov Qual Outcomes 2020; 4:266-275. [PMID: 32542218 PMCID: PMC7283946 DOI: 10.1016/j.mayocpiqo.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023] Open
Abstract
OBJECTIVE To explore how best to deimplement nonrecommended medical services, which can result in excess costs and patient harm. METHODS We conducted telephone interviews with 15 providers at 3 health systems from June 19 to November 21, 2017. Using the case of nonrecommended imaging in patients with cancer, participants assessed the potential for 7 rationales or "arguments," each characterizing overuse in terms of a single problem type (cost or quality) and affected stakeholder group (clinicians, institutions, society, or patients), to convince colleagues to change their practices. We tested rationales for all problem-stakeholder combinations appearing in prior deimplementation studies. RESULTS Participants' views varied widely. Relatively few found cost arguments powerful, except for patients' out-of-pocket costs. Participants were divided on institution-quality and clinician-quality rationales. Patient-quality rationales resonated strongly with nearly all participants. However, a "yes, but" phenomenon emerged: after initially expressing strong support for a rationale, participants often undercut it with denials or rationalizations. CONCLUSION Deimplementation efforts should combine multiple rationales appealing to clinicians' diverse perspectives and priorities. In addition, efforts must consider the complex cognitive dynamics that can undercut data and reasoned argumentation.
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Affiliation(s)
- Susan C. Chimonas
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Allison N. Lipitz-Snyderman
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brooke E. Barrow
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Deborah R. Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY
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Sypes EE, de Grood C, Whalen-Browne L, Clement FM, Parsons Leigh J, Niven DJ, Stelfox HT. Engaging patients in de-implementation interventions to reduce low-value clinical care: a systematic review and meta-analysis. BMC Med 2020; 18:116. [PMID: 32381001 PMCID: PMC7206676 DOI: 10.1186/s12916-020-01567-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/18/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Many decisions regarding health resource utilization flow through the patient-clinician interaction. Thus, it represents a place where de-implementation interventions may have considerable effect on reducing the use of clinical interventions that lack efficacy, have risks that outweigh benefits, or are not cost-effective (i.e., low-value care). The objective of this systematic review with meta-analysis was to determine the effect of de-implementation interventions that engage patients within the patient-clinician interaction on use of low-value care. METHODS MEDLINE, EMBASE, and CINAHL were searched from inception to November 2019. Gray literature was searched using the CADTH tool. Studies were screened independently by two reviewers and were included if they (1) described an intervention that engaged patients in an initiative to reduce low-value care, (2) reported the use of low-value care with and without the intervention, and (3) were randomized clinical trials (RCTs) or quasi-experimental designs. Studies describing interventions solely focused on clinicians or published in a language other than English were excluded. Data was extracted independently in duplicate and pertained to the low-value clinical intervention of interest, components of the strategy for patient engagement, and study outcomes. Quality of included studies was assessed using the Cochrane Risk of Bias tool for RCTs and a modified Downs and Black checklist for quasi-experimental studies. Random effects meta-analysis (reported as risk ratio, RR) was used to examine the effect of de-implementation interventions on the use of low-value care. RESULTS From 6736 unique citations, 9 RCTs and 13 quasi-experimental studies were included in the systematic review. Studies mostly originated from the USA (n = 13, 59%), targeted treatments (n = 17, 77%), and took place in primary care (n = 10, 45%). The most common intervention was patient-oriented educational material (n = 18, 82%), followed by tools for shared decision-making (n = 5, 23%). Random effects meta-analysis demonstrated that de-implementation interventions that engage patients within the patient-clinician interaction led to a significant reduction in low-value care in both RCTs (RR 0.74; 95% CI 0.66-0.84) and quasi-experimental studies (RR 0.61; 95% CI 0.43-0.87). There was significant inter-study heterogeneity; however, intervention effects were consistent across subgroups defined by low-value practice and patient-engagement strategy. CONCLUSIONS De-implementation interventions that engage patients within the patient-clinician interaction through patient-targeted educational materials or shared decision-making tools are effective in decreasing the use of low-value care. Clinicians and policymakers should consider engaging patients within initiatives that seek to reduce low-value care. REGISTRATION Open Science Framework (https://osf.io/6fsxm).
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Affiliation(s)
- Emma E Sypes
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Chloe de Grood
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada.
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| | - Henry T Stelfox
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
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74
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael A Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco, San Francisco
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Young B, Fogarty AW, Skelly R, Shaw D, Sturrock N, Norwood M, Thurley P, Lewis S, Langley T, Cranwell J. Hospital doctors' attitudes to brief educational messages that aim to modify diagnostic test requests: a qualitative study. BMC Med Inform Decis Mak 2020; 20:80. [PMID: 32349739 PMCID: PMC7191798 DOI: 10.1186/s12911-020-1087-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/31/2020] [Indexed: 11/25/2022] Open
Abstract
Background Avoidable use of diagnostic tests can both harm patients and increase the cost of healthcare. Nudge-type educational interventions have potential to modify clinician behaviour while respecting clinical autonomy and responsibility, but there is little evidence how this approach may be best used in a healthcare setting. This study aims to explore attitudes of hospital doctors to two nudge-type messages: one concerning potential future cancer risk after receiving a CT scan, another about the financial costs of blood tests. Methods We added two brief educational messages to diagnostic test results in a UK hospital for one year. One message on the associated long-term potential cancer risk from ionising radiation imaging to CT scan reports, and a second on the financial costs incurred to common blood test results. We conducted a qualitative study involving telephone interviews with doctors working at the hospital to identify themes explaining their response to the intervention. Results Twenty eight doctors were interviewed. Themes showed doctors found the intervention to be highly acceptable, as the group had a high awareness of the need to prevent harm and optimise use of finite resources, and most found the nudge-type approach to be inoffensive and harmless. However, the messages were not seen as personally relevant because doctors felt they were already relatively conservative in their use of tests. Cancer risk was important in decision-making but was not considered to represent new knowledge to doctors. Conversely, financial costs were considered to be novel information that was unimportant in decision-making. Defensive medicine was commonly cited as a barrier to individual behaviour change. The educational cancer risk message on CT scan reports increased doctors’ confidence to challenge decisions and explain risks to patients and there were some modifications in clinical practice prompted by the financial cost message. Conclusion The nudge-type approach to target avoidable use of tests was acceptable to hospital doctors but there were barriers to behaviour change. There was evidence doctors perceived this cheap and light-touch method can contribute to culture change and form a foundation for more comprehensive educational efforts to modify behaviour in a healthcare environment.
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Affiliation(s)
- Ben Young
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - Andrew W Fogarty
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Rob Skelly
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Dominick Shaw
- NIHR Nottingham Biomedical Research Centre, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Nigel Sturrock
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Mark Norwood
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Peter Thurley
- Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Tessa Langley
- Division of Epidemiology and Public Health, Clinical Sciences Building, University of Nottingham, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Jo Cranwell
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK
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76
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Understanding the public's role in reducing low-value care: a scoping review. Implement Sci 2020; 15:20. [PMID: 32264926 PMCID: PMC7137456 DOI: 10.1186/s13012-020-00986-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/23/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Low-value care initiatives are rapidly growing; however, it is not clear how members of the public should be involved. The objective of this scoping review was to systematically examine the literature describing public involvement in initatives to reduce low-value care. METHODS Evidence sources included MEDLINE, EMBASE, and CINAHL databases from inception to November 26, 2019, grey literature (CADTH Tool), reference lists of included articles, and expert consultation. Citations were screened in duplicate and included if they referred to the public's perception and/or involvement in reducing low-value care. Public included patients or citizens without any advanced healthcare knowledge. Low-value care included medical tests or treatments that lack efficacy, have risks that exceed benefit, or are not cost-effective. Extracted data pertained to study characteristics, low-value practice, clinical setting, and level of public involvement (i.e., patient-clinician interaction, research, or policy-making). RESULTS The 218 included citations were predominantly original research (n = 138, 63%), published since 2010 (n = 192, 88%), originating from North America (n = 146, 67%). Most citations focused on patient engagement within the patient-clinician interaction (n = 156, 72%), using tools that included shared decision-making (n = 66, 42%) and patient-targeted educational materials (n = 72, 46%), and reported both reductions in low-value care and improved patient perceptions regarding low-value care. Fewer citations examined public involvement in low-value care policy-making (n = 33, 15%). Among citations that examined perspectives regarding public involvement in initiatives to reduce low-value care (n = 10, 5%), there was consistent support for the utility of tools applied within the patient-clinician interaction and less consistent support for involvement in policy-making. CONCLUSIONS Efforts examining public involvement in low-value care concentrate within the patient-clinician interaction, wherein patient-oriented educational materials and shared decision-making tools have been commonly studied and are associated with reductions in low-value care. This contrasts with inclusion of the public in low-value care policy decisions wherein tools to promote engagement are less well-developed and involvement not consistently viewed as valuable. TRIAL REGISTRATION Open Science Framework (https://osf.io/6fsxm).
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Del Giorno R, Ottini A, Greco A, Stefanelli K, Kola F, Clivio L, Ceschi A, Gabutti L. Peer-pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals. Int J Clin Pract 2020; 74:e13448. [PMID: 31750587 PMCID: PMC7065013 DOI: 10.1111/ijcp.13448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/05/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter-hospital monitoring/benchmarking, via peer-pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter-hospital variation. METHODS Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter-hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra-hospital prescription rate. The variance was used to assess inter-hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed. RESULTS A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter-hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by -0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction. CONCLUSIONS Thanks to a multimodal approach based on monitoring-benchmarking, a significant reduction in inter-hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation-based suspicion of overuse, into an occasion to actively review prescription habits.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Andrea Ottini
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Angela Greco
- Quality and Patient Safety ServiceLa Carità HospitalLocarnoSwitzerland
| | - Kevyn Stefanelli
- Department of Social Sciences and EconomicsSapienza University of RomeRomeItaly
| | - Florenc Kola
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Luca Clivio
- Department of InformaticsEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and ToxicologyInstitute of Pharmacological Sciences of Southern SwitzerlandEnte Ospedaliero CantonaleLuganoSwitzerland
- Department of Clinical Pharmacology and ToxicologyUniversity Hospital ZurichZurichSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
| | - Luca Gabutti
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
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78
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Is early initiation of infertility treatment justified in women over the age of 35 years? Reprod Biomed Online 2020; 40:393-398. [DOI: 10.1016/j.rbmo.2019.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 11/12/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
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Vrijsen B, Naaktgeboren C, Vos L, van Solinge W, Kaasjager H, ten Berg M. Inappropriate laboratory testing in internal medicine inpatients: Prevalence, causes and interventions. Ann Med Surg (Lond) 2020; 51:48-53. [PMID: 32082564 PMCID: PMC7021522 DOI: 10.1016/j.amsu.2020.02.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/22/2020] [Accepted: 02/03/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND To reduce overutilization of laboratory testing many interventions have been tried, but selecting the most effective intervention for a given setting is challenging. To be sustainable, interventions need to align with healthcare providers' needs and daily practices. This study aimed to assess the extent of overutilization and the perspectives of healthcare providers, which may be used to guide the choice of intervention. METHODS The extent of inappropriate laboratory testing in internal medicine inpatients was evaluated using a database. Surveys and focus groups were used to investigate healthcare providers' perceptions on its causes and solutions. RESULTS On average, patients had 5.7 laboratory orders done during the first week of admission, whereas guidelines advise performing laboratory testing no more than twice per week. Repeat testing of normal test results occurred in up to 85% of patients. The frequency of laboratory testing was underestimated by survey responders, even though the majority of responders (78%) thought that laboratory tests are ordered too frequently. Residents were considered to be most responsible for laboratory test ordering.The primary causes of overutilization discussed were personal factors, such as a lack of awareness and knowledge, as well as feelings of insecurity. Regarding possible solutions, residents generally recommended educational interventions, whereas specialists tended to favour technical solutions such as lockouts. CONCLUSION Inappropriate laboratory testing is common in internal medicine. The most important causes are a lack of awareness and knowledge, especially in residents. The intervention most favoured by residents is education, suggesting educational interventions may be most applicable.
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Affiliation(s)
- B.E.L. Vrijsen
- University Medical Center Utrecht, Department of Internal Medicine, Utrecht, the Netherlands
- Corresponding author.
| | - C.A. Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L.M. Vos
- University Medical Center Utrecht, Department of Internal Medicine, Utrecht, the Netherlands
| | - W.W. van Solinge
- University Medical Center Utrecht, Laboratory of Clinical Chemistry and Haematology, Utrecht, the Netherlands
| | - H.A.H. Kaasjager
- University Medical Center Utrecht, Department of Internal Medicine, Utrecht, the Netherlands
| | - M.J. ten Berg
- University Medical Center Utrecht, Laboratory of Clinical Chemistry and Haematology, Utrecht, the Netherlands
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Pournamdari AB, Tkachenko E, Barbieri J, Adamson AS, Mostaghimi A. A State-of-the-Art Review Highlighting Medical Overuse in Dermatology, 2017-2018. JAMA Dermatol 2019; 155:1410-1415. [DOI: 10.1001/jamadermatol.2019.3064] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ashley B. Pournamdari
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- School of Medicine, University of California, San Francisco
| | - Elizabeth Tkachenko
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Barbieri
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Adewole S. Adamson
- Division of Dermatology, Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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81
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Affiliation(s)
- Flora Lum
- Quality and Data Science, American Academy of Ophthalmology, San Francisco, California
| | - Paul Lee
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
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Abstract
Purpose of review Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is associated with decreased mortality by enabling early tumor detection. However, the benefits of any cancer screening program must be considered in light of potential physical, financial, and psychological harms, as well as the risk of overdiagnosis. Herein, we summarize the potential harms of HCC surveillance. Recent findings To date, two retrospective studies have addressed physical harms of HCC surveillance. Based on these data, 15% to 28% of patients undergoing HCC surveillance experience physical harm including additional cross-sectional imaging or liver biopsy. Although psychological and financial harms have been reported for other cancers, there are currently limited data specific to HCC. An ongoing multi-center prospective study assessing all four types of harms should provide data in near future. Summary HCC screening may prevent death by diagnosing tumors at an early stage, but limited sensitivity and specificity of screening tests can result in unintended harms. There is a need for further quality data evaluating both the benefits and harms of HCC surveillance.
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83
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Ganguli I, Simpkin AL, Lupo C, Weissman A, Mainor AJ, Orav EJ, Rosenthal MB, Colla CH, Sequist TD. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open 2019; 2:e1913325. [PMID: 31617925 PMCID: PMC6806665 DOI: 10.1001/jamanetworkopen.2019.13325] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Arabella L. Simpkin
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Gupta A, Meddings J, Houchens N. Quality and safety in the literature: November 2019. BMJ Qual Saf 2019; 28:949-953. [PMID: 31537630 DOI: 10.1136/bmjqs-2019-010327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Ashwin Gupta
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA .,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer Meddings
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Departments of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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85
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Ganguli I, Lupo C, Mainor AJ, Raymond S, Wang Q, Orav EJ, Chang CH, Morden NE, Rosenthal MB, Colla CH, Sequist TD. Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Intern Med 2019; 179:1211-1219. [PMID: 31158270 PMCID: PMC6547245 DOI: 10.1001/jamainternmed.2019.1739] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care. OBJECTIVE To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019. EXPOSURES Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG. MAIN OUTCOMES AND MEASURES Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade. RESULTS Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade. CONCLUSIONS AND RELEVANCE Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
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Affiliation(s)
- Ishani Ganguli
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Partners HealthCare, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alexander J Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephanie Raymond
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Chiang-Hua Chang
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Meredith B Rosenthal
- Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Thomas D Sequist
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Partners HealthCare, Boston, Massachusetts
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86
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Ioannidis JPA. Guidelines Do Not Entangle Practitioners With Unavoidable Conflicts as Authors, and When There Is No Evidence, Just Say So. Circ Cardiovasc Qual Outcomes 2019; 11:e005205. [PMID: 30354581 DOI: 10.1161/circoutcomes.118.005205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John P A Ioannidis
- Stanford Prevention Research Center, Meta-Research Innovation Center at Stanford, Department of Medicine, Department of Health Research and Policy, Department of Biomedical Data Science, and Department of Statistics, Stanford University, CA
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87
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Stelfox HT, Bourgault AM, Niven DJ. De-implementing low value care in critically ill patients: a call for action-less is more. Intensive Care Med 2019; 45:1443-1446. [PMID: 31396643 DOI: 10.1007/s00134-019-05694-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 5A1, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Alberta Health Services, Alberta, Canada.
| | - Annette M Bourgault
- College of Nursing, Academic Health Sciences Center, University of Central Florida, Orlando, FL, USA
- Orlando Health, Orlando, FL, USA
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 5A1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Health Services, Alberta, Canada
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88
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Radomski TR, Huang Y, Park SY, Sileanu FE, Thorpe CT, Thorpe JM, Fine MJ, Gellad WF. Low-Value Prostate Cancer Screening Among Older Men Within the Veterans Health Administration. J Am Geriatr Soc 2019; 67:1922-1927. [PMID: 31276198 DOI: 10.1111/jgs.16057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/23/2019] [Accepted: 05/25/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Prostate-specific antigen (PSA) screening can be of low value in older adults. Our objective was to quantify the prevalence and variation of low-value PSA screening across the Veterans Health Administration (VA), which has instituted programs to reduce low-value care. DESIGN Retrospective cohort. SETTING VA administrative data, 2014 to 2015. PARTICIPANTS National random sample (N = 214 480) of male veterans, aged 75 years or older. MEASUREMENTS We defined PSA screening in men aged 75 years or older without a history of prostate cancer as low value, per established definitions in Medicare. We calculated screening rates overall and by VA Medical Center (VAMC), adjusting for patient and VAMC-level factors. We characterized variation across VAMCs using the adjusted median odds ratio (OR) and compared the adjusted OR of screening between VAMCs in different deciles of low-value screening rates. In separate sensitivity analyses, we assessed screening in veterans at greatest risk of 1-year mortality and among veterans after excluding those who underwent prostatectomy, had a prior PSA elevation, or had a clinical indication for testing. RESULTS Overall, 37 867 (17.7%) of veterans underwent low-value PSA screening (VAMC range = 3.3%-38.2%). The adjusted median OR was 1.88, meaning the median odds of screening would increase by 88% were a veteran to transfer his care to a VAMC with higher screening rates. Veterans at VAMCs in the top decile had an adjusted OR of 12.9 (95% confidence interval = 11.0-15.2) compared to those veterans in the lowest decile. Among veterans with the greatest mortality risk (n = 23 377), 3496 (15.0%) underwent screening (VAMC range = 1.7%-46.3%). After excluding veterans with a prior prostatectomy, PSA elevation, or a potential clinical indication, 31 556 (14.7%) underwent screening (VAMC range = 2.0%-49.9%). CONCLUSIONS In a national cohort of older veterans, more than one in six received low-value PSA screening, with greater than 10-fold variation across VAMCs and high rates of screening among those with the greatest mortality risk. J Am Geriatr Soc 67:1922-1927, 2019.
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Affiliation(s)
- Thomas R Radomski
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Yan Huang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,UPMC Center for High-Value Health Care, UPMC Insurance Services Division, Pittsburgh, Pennsylvania
| | - Seo Young Park
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Florentina E Sileanu
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Michael J Fine
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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89
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Tieder JS, Beck JB. Overuse Stewardship: An Ongoing Problem That Must Be Tackled. Pediatrics 2019; 144:peds.2019-1334. [PMID: 31171585 DOI: 10.1542/peds.2019-1334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Joel S Tieder
- Division of General Pediatrics and Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Jimmy B Beck
- Division of General Pediatrics and Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington
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90
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Herrera-Perez D, Haslam A, Crain T, Gill J, Livingston C, Kaestner V, Hayes M, Morgan D, Cifu AS, Prasad V. A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals. eLife 2019; 8:45183. [PMID: 31182188 PMCID: PMC6559784 DOI: 10.7554/elife.45183] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/12/2019] [Indexed: 12/24/2022] Open
Abstract
The ability to identify medical reversals and other low-value medical practices is an essential prerequisite for efforts to reduce spending on such practices. Through an analysis of more than 3000 randomized controlled trials (RCTs) published in three leading medical journals (the Journal of the American Medical Association, the Lancet, and the New England Journal of Medicine), we have identified 396 medical reversals. Most of the studies (92%) were conducted on populations in high-income countries, cardiovascular disease was the most common medical category (20%), and medication was the most common type of intervention (33%).
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Affiliation(s)
- Diana Herrera-Perez
- Knight Cancer Institute, Oregon Health & Science University, Portland, United States
| | - Alyson Haslam
- Knight Cancer Institute, Oregon Health & Science University, Portland, United States
| | - Tyler Crain
- Knight Cancer Institute, Oregon Health & Science University, Portland, United States
| | - Jennifer Gill
- Knight Cancer Institute, Oregon Health & Science University, Portland, United States
| | | | - Victoria Kaestner
- Knight Cancer Institute, Oregon Health & Science University, Portland, United States
| | - Michael Hayes
- Division of Internal Medicine, Oregon Health & Science University, Portland, United States
| | - Dan Morgan
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, United States
| | - Adam S Cifu
- Department of Medicine, University of Chicago, Chigcago, United States
| | - Vinay Prasad
- Knight Cancer Institute, Oregon Health & Science University, Portland, United States.,Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, United States.,Center for Health Care Ethics, Oregon Health & Science University, Portland, United States.,Department of Medicine, Oregon Health & Science University, Portland, United States
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91
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Lopez AM, Hudson L, Vanderford NL, Vanderpool R, Griggs J, Schonberg M. Epidemiology and Implementation of Cancer Prevention in Disparate Populations and Settings. Am Soc Clin Oncol Educ Book 2019; 39:50-60. [PMID: 31099623 DOI: 10.1200/edbk_238965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Successful cancer prevention strategies must be tailored to support usability. In this article, we will focus on cancer prevention strategies in populations that differ by race and ethnicity, place and location, sexual orientation and gender identity, and age by providing examples of effective approaches. An individual may belong to none of these categories, to all of these categories, or to some. This intersectionality of belonging characterizes individuals and shapes their experiences. Even within a category, broad diversity exists. Effective cancer prevention strategies comprehensively engage the community at multiple levels of influence and may effectively include lay health workers and faith-based cancer education interventions. Health system efforts that integrate cancer health with other health promotion activities show promise. At the individual physician level, culturally literate approaches have demonstrated success. For example, when discussing cancer screening tests with older adults, clinicians should indicate whether any data suggest that the screening test improves quality or quantity of life and the lag time to benefit from the screening test. This will allow older adults to make an informed cancer screening decision based on a realistic understanding of the potential benefits and risks and their values and preferences. Addressing individual and health system bias remains a challenge. Quality improvement strategies can address gaps in quality of care with respect to timeliness of care, coordination of care, and patient experience. The time is ripe for research on effective and interdisciplinary prevention strategies that harness expertise from preventive medicine, behavioral medicine, implementation science, e-health, telemedicine, and other diverse fields of health promotion.
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Affiliation(s)
- Ana Maria Lopez
- 1 Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Lauren Hudson
- 2 University of Kentucky Markey Cancer Center, Lexington, KY
| | | | | | | | - Mara Schonberg
- 4 Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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92
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Badgery-Parker T, Pearson SA, Dunn S, Elshaug AG. Measuring Hospital-Acquired Complications Associated With Low-Value Care. JAMA Intern Med 2019; 179:499-505. [PMID: 30801628 PMCID: PMC6450303 DOI: 10.1001/jamainternmed.2018.7464] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Studies of low-value care have focused on the prevalence of low-value care interventions but have rarely quantified downstream consequences of these interventions for patients or the health care system. OBJECTIVE To measure immediate in-hospital harm associated with 7 low-value procedures. DESIGN, SETTING, AND PARTICIPANTS A cohort study with a descriptive analysis using hospital admission data from 225 public hospitals in New South Wales, Australia, was conducted from July 1, 2014, to June 30, 2017. All 9330 episodes involving 1 of 7 low-value procedures were evaluated, including endoscopy for dyspepsia in people younger than 55 years (3689 episodes); knee arthroscopy for osteoarthritis or meniscal tears (3963 episodes); colonoscopy for constipation in people younger than 50 years (665 episodes); endovascular repair of abdominal aortic aneurysm in asymptomatic, high-risk patients (508 episodes); carotid endarterectomy in asymptomatic, high-risk patients (273 episodes); renal artery angioplasty (176 episodes); and spinal fusion for uncomplicated low back pain (56 episodes). Sixteen hospital-acquired complications (HACs) were used as a measure of harm associated with low-value care. MAIN OUTCOMES AND MEASURES For each low-value procedure, the percentage associated with any HAC and the difference in mean length of stay for patients receiving low-value care with and without HACs were calculated. RESULTS Across the 225 hospitals and 9330 episodes of low-value care, rates of HACs were low for low-value endoscopy (4 [0.1%] episodes; 95% CI, 0.02%-0.2%), knee arthroscopy (18 [0.5%] episodes; 95% CI, 0.2%-0.7%), and colonoscopy (2 [0.3%] episodes; 95% CI, 0.0%-0.9%) but higher for low-value spinal fusion (4 [7.1%] episodes; 95% CI, 2.2%-11.5%), endovascular repair of abdominal aortic aneurysm (76 [15.0%] episodes; 95% CI, 11.1%-19.7%), carotid endarterectomy (21 [7.7%] episodes; 95% CI, 5.2%-10.1%), and renal artery angioplasty (15 [8.5%] episodes; 95% CI, 5.8%-11.5%). For most procedures, the most common HAC was health care-associated infection, which accounted for 83 (26.3%) (95% CI, 21.8%-31.5%) of all HACs observed. The highest rate of health care-associated infection was 8.4% (95% CI, 5.2%-11.4%) for renal artery angioplasty. For all 7 low-value procedures, median length of stay for patients with an HAC was 2 times or more the median length of stay for patients without a complication. For example, median length of stay was 1 (interquartile range [IQR], 1-1) day for knee arthroscopy with no HACs but increased to 10.5 (IQR, 1.0-21.3) days for patients with an HAC. CONCLUSIONS AND RELEVANCE These findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate. Although only some immediate consequences of just 7 low-value services were examined, harm related to all low-value procedures was noted, including high rates of harm for certain higher-risk procedures. The full burden of low-value care for patients and the health system is yet to be quantified.
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Affiliation(s)
- Tim Badgery-Parker
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia.,Capital Markets Cooperative Research Centre, Health Market Quality Program, Sydney, Australia
| | - Sallie-Anne Pearson
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia.,Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Susan Dunn
- Activity Based Management, New South Wales Ministry of Health, Sydney, Australia
| | - Adam G Elshaug
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia
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93
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Cho HJ, Krouss M. Priorities In Patient Safety. Health Aff (Millwood) 2019; 38:330. [DOI: 10.1377/hlthaff.2018.05349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Mona Krouss
- Icahn School of Medicine at Mount Sinai New York, New York
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94
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Abstract
IMPORTANCE Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse. OBSERVATIONS A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits). CONCLUSIONS AND RELEVANCE Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore.,Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore
| | - Sanket S Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut.,Department of Veterans Affairs West Haven, West Haven, Connecticut
| | - Eric R Coon
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Scott M Wright
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah Korenstein
- Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
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95
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Cook CE, Décary S. Higher order thinking about differential diagnosis. Braz J Phys Ther 2019; 24:1-7. [PMID: 30723033 DOI: 10.1016/j.bjpt.2019.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/17/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Differential diagnosis is a systematic process used to identify the proper diagnosis from a set of possible competing diagnoses. METHODS The goal of this masterclass is to discuss the higher order thinking components of differential diagnosis. CONCLUSIONS For healthcare providers, diagnosis is one of many necessary components during the clinical decision making process and it is hallmarked by differentiation of competing structures for a definitive understanding of the underlying condition. The diagnostic process involves identifying or determining the etiology of a disease or condition through evaluation of patient history, physical examination, and review of laboratory data or diagnostic imaging; and the subsequent descriptive title of that finding. Whereas differential diagnosis is a varied skill set among all healthcare providers, the concept of a diagnosis is equally germane, regardless of one's background. In theory, a diagnosis improves the use of classification tools, improves clarity and communication, provides a trajectory of treatment, improves understanding of a person's prognosis, and in some cases, may be useful for preventative treatments. To achieve these improvements, one must have an understanding of relation of the clinical utility of tests and measures with diagnosis, and how to best implement these findings in clinical practice. This requires a deeper understanding (higher order thinking) of the role of diagnosis in the management of patients.
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Affiliation(s)
- Chad E Cook
- Division of Physical Therapy, Duke Clinical Research Institute, Duke University, Durham, NC, United States.
| | - Simon Décary
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Faculty of Medicine, Québec, Canada
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