Overtreatment in the United States

Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands

BACKGROUND

Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries.

METHODS

We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis.

RESULTS

The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy.

CONCLUSION

Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing

BACKGROUND

Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization.

METHODS

We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins.

RESULTS

Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty.

CONCLUSIONS

Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.

Analyzing Unnecessary Imaging for Low Back Pain in Nebraska from a Statewide Health Information Exchange

Excessive amounts of resources in healthcare are wasted due to duplicated or unnecessary health screenings, especially in the diagnosis of low back pain (LBP). Research shows that two-thirds of people will present with LBP at some point throughout their lifetime, but 20-50% of high-tech imaging procedures fail to provide information that improves the patient's condition, representing unnecessary services. The purpose of this study was to evaluate the existence of unnecessary imaging for low back pain throughout healthcare systems in Nebraska based on what was documented in the electronic health record. This study was a retrospective electronic health record analysis of a limited data set focused on procedures related to imaging for LBP extracted from Nebraska Health Information Exchange (HIE) managed by CyncHealth. The sample included 937 patient records with a diagnosis of LBP who received imaging in the state of Nebraska and whose health record was recorded in the Nebraska HIE. To determine necessity, records were categorized in three areas including necessary imaging, likely wasteful imaging, or wasteful imaging based on the criteria from the "First, Do No Harm" study conducted by the Washington Health Alliance. Results revealed a total of 51% of low back pain imaging considered wasteful, 35% likely wasteful, and 14% necessary. Based on these results, further research is warranted to determine specific demographics related to necessary, likely wasteful, and wasteful imaging and the purpose for performing these expensive imaging procedures.

Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018

OBJECTIVES

Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system.

METHODS

A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index.

RESULTS

There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was €56,338,247 (an average of €17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024).

CONCLUSIONS

Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.

Practice Variation in the Surgical Management of Children With Acute Hematogenous Osteomyelitis

INTRODUCTION

The surgical indications to manage children with acute hematogenous osteomyelitis (AHO) remain poorly defined. The purpose of this study was to identify if practice pattern variation exists in the surgical management of pediatric AHO among tertiary pediatric medical centers across the United States. A secondary purpose was to evaluate variables that may impact the rate of surgical intervention among these institutions.

METHODS

Children with AHO were retrospectively analyzed between January 1, 2010, and December 31, 2016, from 18 pediatric medical centers throughout the United States. The rates of surgery were identified. Admission vitals, labs, weight-bearing status, length of stay, and readmission rates were compared between those who did and did not undergo surgery. Multivariate regression and classification and regression tree analyses were performed to identify the variables that were associated with surgical intervention.

RESULTS

Of the 1003 children identified with AHO in this retrospective, multicenter database, 619/1003 (62%) were treated surgically. Multivariate analysis revealed institution, inability to ambulate, presence of multifocal infection, elevated admission C-reactive protein, increased admission platelet count, and location of the osteomyelitis were significant predictors of surgery (P<0.01). Patients who underwent surgery were more than twice as likely to have a recurrence or readmission and stayed a median of 2 days longer than those who did not have surgery. In the classification and regression tree analysis, 2 distinct patterns of surgical intervention were identified based on institution, with 12 institutions operating in most cases (72%), regardless of clinical factors. A second cohort of 6 institutions operated less routinely, with 47% receiving surgery overall. At these 6 institutions, patients without multifocal infection only received surgery 26% of the time, which increased to 74% with multifocal infection and admission erythrocyte sedimentation rate >37.5 mm/h.

CONCLUSIONS

This study is the first to objectively identify significant differences in the rates of surgical management of pediatric AHO across the United States. Variation in the surgical management of AHO appears to be driven primarily based on institutional practice. Twelve institutions operated on 72% of patients, regardless of the severity of disease, indicating that the institution custom or dogma may drive the surgical indications. Six institutions relied more on clinical judgment with significant variability in rates of surgical intervention (26% vs. 74%), depending on the severity of the disease. Surgical intervention is associated with increased recurrence, readmission, and hospital length of stay. As a result of these findings, it is essential to prospectively study the appropriate surgical indications and measure the outcomes in children with pediatric AHO.

LEVEL OF EVIDENCE

Level III.

Health Literacy, Equity, and Communication in the COVID-19 Era of Misinformation: Emergence of Health Information Professionals in Infodemic Management

The health information management (HIM) field’s contribution to health care delivery is invaluable in a pandemic context where the need for accurate diagnoses will hasten responsive, evidence-based decision-making. The COVID-19 pandemic offers a unique opportunity to transform the practice of HIM and bring more awareness to the role that frontline workers play behind the scenes in safeguarding reliable, comprehensive, accurate, and timely health information. This transformation will support future research, utilization management, public health surveillance, and forecasting and enable key stakeholders to plan and ensure equitable health care resource allocation, especially for the most vulnerable populations. In this paper, we juxtapose critical health literacy, public policy, and HIM perspectives to understand the COVID-19 infodemic and new opportunities for HIM in infodemic management.

Emergency Medicine Physicians' Views on Providing Unnecessary Management in the Emergency Department

Purpose

To assess the views of emergency medicine physicians (EMPs) on the practice of providing unnecessary medical management in the emergency department.

Methods

All EMPs in Saudi Arabia were approached to participate in this cross-sectional study. A self-administered online survey that collected the participants' demographic information and opinions regarding the unnecessary management provided by EMPs in Saudi Arabia was conducted between December 2020 and February 2021. SPSS 22.0 was used to analyze the data.

Results

A total of 181 EMPs returned the questionnaire. More than 80% of the participants believed that EMPs order unnecessary tests or procedures at least a few times per week. The major reasons for ordering unnecessary medical tests or procedures were "concern about malpractice issues" (60.8%), "not having enough time with a patient for meaningful discussion" (47%), and "just to be safe" (46.4%). More than 55% of the respondents also believed that EMPs are in the best position to address the problem of unnecessary testing.

Conclusion

Most of the EMPs who participated in this study recognized that ordering unnecessary tests is a serious problem that happens on a daily basis. Many factors and reasons were described by the participants, and multiple possible solutions were suggested to help overcome the issue. Evaluating physicians' perspectives on the issue is a key step in addressing the problem and implementing appropriate interventions.

Functional Cognitive Disorder Presents High Frequency and Distinct Clinical Profile in Patients With Low Education

Introduction

Functional Cognitive Disorder (FCD) is a non-degenerative, common cause of memory complaint in patients with high educational levels. FCD has been insufficiently described in individuals with low education. Here, we investigated the frequency of FCD among individuals with low education.

Methods

We analyzed retrospectively all new referrals from primary care to a tertiary memory clinic from 2014 to 2021. Final diagnosis, diagnostic work-up, clinical and cognitive testing data were compared between FCD and other diagnoses, grouped as Neurodegenerative Disorders (NDD). A regression model was used to assess the effect of education on the diagnosis. Data is shown in Mean [SD].

Results

A total of 516 individuals (70.76 [10.3] years) with low educational attainment (4.5 [3.94] years) were divided into FCD (146, 28.3%) and NDD. Compared with NDD, FCD patients showed lower age at presentation (66.2 [9.4] vs. 72.6 [10.2], p < 0.001), higher Mini-Mental State Examination (MMSE) scores (22.4 [6.2] vs. 14.7 [7.8], p < 0.001) and Geriatric Depression Scale (GDS) scores (7.4 [5.4] vs. 5.3 [3.7], p = 0.0001).

Discussion

Surprisingly, FCD was the most frequent diagnosis in a low educational setting. However, education was not associated with FCD. Individuals presenting FCD showed a distinct clinical profile, including younger age and higher depressive scores. Strategies to identify FCD in primary care settings may benefit both patients and healthcare systems.

Learning Analytics Applied to Clinical Diagnostic Reasoning Using a Natural Language Processing-Based Virtual Patient Simulator: Case Study

BACKGROUND

Virtual patient simulators (VPSs) log all users' actions, thereby enabling the creation of a multidimensional representation of students' medical knowledge. This representation can be used to create metrics providing teachers with valuable learning information.

OBJECTIVE

The aim of this study is to describe the metrics we developed to analyze the clinical diagnostic reasoning of medical students, provide examples of their application, and preliminarily validate these metrics on a class of undergraduate medical students. The metrics are computed from the data obtained through a novel VPS embedding natural language processing techniques.

METHODS

A total of 2 clinical case simulations (tests) were created to test our metrics. During each simulation, the students' step-by-step actions were logged into the program database for offline analysis. The students' performance was divided into seven dimensions: the identification of relevant information in the given clinical scenario, history taking, physical examination, medical test ordering, diagnostic hypothesis setting, binary analysis fulfillment, and final diagnosis setting. Sensitivity (percentage of relevant information found) and precision (percentage of correct actions performed) metrics were computed for each issue and combined into a harmonic mean (F₁), thereby obtaining a single score evaluating the students' performance. The 7 metrics were further grouped to reflect the students' capability to collect and to analyze information to obtain an overall performance score. A methodological score was computed based on the discordance between the diagnostic pathway followed by students and the reference one previously defined by the teacher. In total, 25 students attending the fifth year of the School of Medicine at Humanitas University underwent test 1, which simulated a patient with dyspnea. Test 2 dealt with abdominal pain and was attended by 36 students on a different day. For validation, we assessed the Spearman rank correlation between the performance on these scores and the score obtained by each student in the hematology curricular examination.

RESULTS

The mean overall scores were consistent between test 1 (mean 0.59, SD 0.05) and test 2 (mean 0.54, SD 0.12). For each student, the overall performance was achieved through a different contribution in collecting and analyzing information. Methodological scores highlighted discordances between the reference diagnostic pattern previously set by the teacher and the one pursued by the student. No significant correlation was found between the VPS scores and hematology examination scores.

CONCLUSIONS

Different components of the students' diagnostic process may be disentangled and quantified by appropriate metrics applied to students' actions recorded while addressing a virtual case. Such an approach may help teachers provide students with individualized feedback aimed at filling competence drawbacks and methodological inconsistencies. There was no correlation between the hematology curricular examination score and any of the proposed scores as these scores address different aspects of students' medical knowledge.

Predictors of thoracic and lumbar spine injuries in patients with TBI: A nationwide analysis

OBJECTIVE

Cervical spine injury screening is common practice for traumatic brain injury (TBI) patients. However, risk factors for concomitant thoracolumbar trauma remain unknown. We characterized epidemiology and clinical risk for concomitant thoracolumbar trauma in TBI.

METHODS

We conducted a multi-center, retrospective cohort analysis of TBI patients in the National Trauma Data Bank from 2011-2014 using multivariable logistic regression.

RESULTS

Out of 768,718 TBIs, 46,654 (6.1%) and 42,810 (5.6%) patients were diagnosed with thoracic and lumbar spine fractures, respectively. Only 11% of thoracic and 7% of lumbar spine fracture patients had an accompanying spinal cord injury at any level. The most common mechanism of injury was motor vehicle accident (67% of thoracic and 71% and lumbar fractures). Predictors for both thoracic and lumbar fractures included moderate (thoracic: OR 1.26, 95%CI 1.21-1.31; lumbar: OR 1.13, 95%CI 1.08-1.18) and severe Glasgow Coma Scale (GCS) score (OR 1.71, 95%CI 1.67-1.75; OR 1.17, 95%CI 1.13-1.20) compared to mild; epidural hematoma (OR 1.36, 95%CI 1.28-1.44; OR 1.1, 95%CI 1.04-1.19); lower extremity injury (OR 1.38, 95%CI 1.35-1.41; OR 2.50, 95%CI 2.45-2.55); upper extremity injury (OR 2.19, 95%CI 2.14-2.23; OR 1.15, 95%CI 1.13-1.18); smoking (OR 1.09, 95%CI 1.06-1.12; OR 1.12, 95%CI 1.09-1.15); and obesity (OR 1.39, 95%CI 1.34-1.45; OR 1.29, 95%CI 1.24-1.35). Thoracic injuries (OR 4.45; 95% CI 4.35-4.55) predicted lumbar fractures, while abdominal injuries (OR 2.02; 95% CI 1.97-2.07) predicted thoracic fractures.

CONCLUSIONS

We identified GCS, smoking, upper and lower extremity injuries, and obesity as common risk factors for thoracic and lumbar spinal fractures in TBI.

Nonindicated Brain Computed Tomography Scans for Children: Adaptation of an American Measurement Tool and Contrast of Current Practice in an Australian Hospital

OBJECTIVES

Clinical guidelines state brain computed tomography (CT) for atraumatic headache or first generalized afebrile, atraumatic seizure as nonindicated in neurologically normal children. We aimed to adapt 2 rigorously validated United States-based measures that examine overuse of CT in children with these conditions, and to determine whether these measures can be used in an Australian setting to determine rates of CT scanning in current practice.

METHODS

Within an Australian tertiary pediatric hospital, we successfully adapted the measures from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system of the United States measures to the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) coding system used in Australia. We conducted a retrospective audit of electronic medical record data from April 1, 2017, to March 31, 2018. Eligible patients were children aged 4 to 17 years who attended one of the hospital outpatient clinics and/or emergency department and/or were admitted to an inpatient ward. The conditions of interest were (1) atraumatic headache and (2) first generalized afebrile, atraumatic seizure.

RESULTS

The measure for afebrile seizure was found to have low accuracy and low feasibility in this setting and was not tested further. The adapted measure for atraumatic headache was highly accurate in determining the encounters of interest; however, manual chart review was required to identify nonindicated brain CTs. Using this measure, 601 encounters for atraumatic headache were identified, of which 98 (16.3%) received at least 1 brain CT. We found that 14.1% of these scans were nonindicated, meaning 2% all atraumatic headache encounters received a nonindicated scan; lower than rates reported in international literature.

CONCLUSIONS

Using the tool developed in this study, rigorous measurement of the overuse of CT scans in other settings may determine the reasons for the lower rates observed in this study; inform future interventions to minimize overuse; and provide safer, higher quality care to children.

International practice variation in perioperative laboratory testing in glioblastoma patients-a retrospective cohort study

PURPOSE

Although standard-of-care has been defined for the treatment of glioblastoma patients, substantial practice variation exists in the day-to-day clinical management. This study aims to compare the use of laboratory tests in the perioperative care of glioblastoma patients between two tertiary academic centers-Brigham and Women's Hospital (BWH), Boston, USA, and University Medical Center Utrecht (UMCU), Utrecht, the Netherlands.

METHODS

All glioblastoma patients treated according to standard-of-care between 2005 and 2013 were included. We compared the number of blood drawings and laboratory tests performed during the 70-day perioperative period using a Poisson regression model, as well as the estimated laboratory costs per patient. Additionally, we compared the likelihood of an abnormal test result using a generalized linear mixed effects model.

RESULTS

After correction for age, sex, IDH1 status, postoperative KPS score, length of stay, and survival status, the number of blood drawings and laboratory tests during the perioperative period were 3.7-fold (p < 0.001) and 4.7-fold (p < 0.001) higher, respectively, in BWH compared to UMCU patients. The estimated median laboratory costs per patient were 82 euros in UMCU and 256 euros in BWH. Furthermore, the likelihood of an abnormal test result was lower in BWH (odds ratio [OR] 0.75, p < 0.001), except when the prior test result was abnormal as well (OR 2.09, p < 0.001).

CONCLUSIONS

Our results suggest a substantially lower clinical threshold for ordering laboratory tests in BWH compared to UMCU. Further investigating the clinical consequences of laboratory testing could identify over and underuse, decrease healthcare costs, and reduce unnecessary discomfort that patients are exposed to.

Metastatic uveal melanoma: The final frontier

Treatment of primary intraocular uveal melanoma has developed considerably, its driver genes are largely unraveled, and the ways to assess its risk for metastases are very precise, being based on an international staging system and genetic data. Unfortunately, the risk of distant metastases, which emerge in approximately one half of all patients, is unaltered. Metastases are the leading single cause of death after uveal melanoma is diagnosed, yet no consensus exists regarding surveillance, staging, and treatment of disseminated disease, and survival has not improved until recently. The final frontier in conquering uveal melanoma lies in solving these issues to cure metastatic disease. Most studies on metastatic uveal melanoma are small, uncontrolled, retrospective, and do not report staging. Meta-analyses confirm a median overall survival of 10-13 months, and a cure rate that approaches nil, although survival exceeding 5 years is possible, estimated 2% either with first-line treatment or with best supportive care. Hepatic ultrasonography and magnetic resonance imaging as surveillance methods have a sensitivity of 95-100% and 83-100%, respectively, to detect metastases without radiation hazard according to prevailing evidence, but computed tomography is necessary for staging. No blood-based tests additional to liver function tests are generally accepted. Three validated staging systems predict, each in defined situations, overall survival after metastasis. Their essential components include measures of tumor burden, liver function, and performance status or metastasis free interval. Age and gender may additionally influence survival. Exceptional mutational events in metastases may make them susceptible to checkpoint inhibitors. In a large meta-analysis, surgical treatment was associated with 6 months longer median overall survival as compared to conventional chemotherapy and, recently, tebentafusp as first-line treatment at the first interim analysis of a randomized phase III trial likewise provided a 6 months longer median overall survival compared to investigator's choice, mostly pembrolizumab; these treatments currently apply to selected patients. Promoting dormancy of micrometastases, harmonizing surveillance protocols, promoting staging, identifying predictive factors, initiating controlled clinical trials, and standardizing reporting will be critical steppingstones in reaching the final frontier of curing metastatic uveal melanoma.

Overtreatment in elderly care: ethical considerations

letter to editor.

Swiss GPs' preferences for antidepressant treatment in mild depression: vignette-based quantitative analysis

Background

GPs frequently prescribe antidepressants in mild depression. The aim of this study was to examine, how often Swiss GPs recommend antidepressants in various clinical presentations of mild depression and which factors contribute to antidepressant treatment recommendations.

Methods

We conducted an online survey among Swiss GPs with within-subject effect analysis. Alternating case vignettes described a typical female case of mild depression according to International Classification of Diseases, 10^th edition criteria, with and without anxiety symptoms and sleep problems. GPs indicated for each vignette their preferred treatments (several recommendations were possible). Additionally, we assessed GP characteristics, attitudes towards depression treatments, and elements of clinical decision-making.

Results

Altogether 178 GPs completed the survey. In the initial description of a case with mild depression, 11% (95%-CI: 7%-17%) of GPs recommended antidepressants. If anxiety symptoms were added to the same case, 29% (23%-36%) recommended antidepressants. If sleep problems were mentioned, 47% (40%-55%) recommended antidepressants, and if both sleep problems and anxiety symptoms were mentioned, 63% (56%-70%) recommended antidepressants. Several factors were independently associated with increased odds of recommending antidepressants, specifically more years of practical experience, an advanced training in psychosomatic and psychosocial medicine, self-dispensation, and a higher perceived effectiveness of antidepressants. By contrast, a higher perceived influence of patient characteristics and the use of clinical practice guidelines were associated with reduced odds of recommending antidepressants.

Conclusions

Consistent with depression practice guidelines, Swiss GPs rarely recommended antidepressants in mild depression if no co-indications (i.e., sleep problems and anxiety symptoms) were depicted. However, presence of sleep problems and anxiety symptoms, many years of practical experience, overestimation of antidepressants’ effectiveness, self-dispensation, an advanced training in psychosomatic and psychosocial medicine, and non-use of clinical practice guidelines may independently lead to antidepressant over-prescribing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01621-7.

High Compliance With Choosing Wisely Breast Surgical Guidelines at a Safety-Net Hospital

BACKGROUND

Professional organizations recently set guidelines for avoiding surgeries of low utility and overutilization for the Choosing Wisely campaign. These include re-excision for invasive cancer close to margins, double mastectomy in patients with unilateral breast cancer, axillary lymph node dissection in patients with limited nodal disease, and sentinel lymph node biopsy (SLNB) in patients ≥70 years with early-stage breast cancer. Variable adherence to these recommendations led us to evaluate implementation rates of low-value surgical guidelines at a safety-net hospital.

METHODS

We retrospectively analyzed breast cancer patients who underwent surgery from 2015 to 2020. Each patient was assessed for eligibility for omission of the listed surgeries. Trends were evaluated by cohorts before and after a fellowship-trained breast surgeon joined the faculty in 2018. Outcomes were compared using Fisher's exact test.

RESULTS

Among 195 patients, none underwent re-excision for close margins of invasive cancer. Only 6.7% of patients (3/45) received contralateral mastectomy and 1.8% of eligible patients (3/169) received axillary lymph node dissection. Overall, 60% of patients ≥ 70 years with stage 1 hormone-positive breast cancer (9/15) received SLNB. There was a downward trend from 71% of eligible patients receiving SLNB in 2015-2018 to 50% in 2019-2020.

CONCLUSIONS

De-implementation of traditional surgical practices, deemed as low-value care, toward newer guidelines is achievable even at community hospitals serving a low socioeconomic community. By avoiding overtreatment, hospitals can achieve effective resource allocation which allow for social distributive justice among patients with breast cancer and ensure strategic use of scarce health economic resources while preserving patient outcomes.

Latent Strongyloides stercoralis in an Asymptomatic Male With Chronic Peripheral Eosinophilia

Peripheral eosinophilia is a potentially concerning finding that can occur due to a multitude of causes. One such cause is latent helminth infections such as Strongyloides stercoralis. These parasites have broad distributions throughout the developing world, particularly South and Southeast Asia and it is estimated that roughly 200 million people have latent infections. We present the case of a 74-year-old patient from India who had asymptomatic eosinophilia since before 2006. He previously underwent an extensive workup which included testing for neoplasms, gene mutations, and lymphoproliferative disorders. After carefully examining the patient's travel history and demographic information, a parasite panel was administered which was positive for Strongyloides, thereby establishing a cause for his condition after years of expensive testing. Latent Strongyloides infections can lead to fatal dissemination if the host becomes immunocompromised. It is therefore essential to keep a detailed history of patient travel, occupation, and functional status when assessing peripheral eosinophilia so that obvious causes are not overlooked.

Evaluation of a Physician Peer-Benchmarking Intervention for Practice Variability and Costs for Endovenous Thermal Ablation

IMPORTANCE

The frequency of use of endovenous thermal ablation (EVTA) to treat chronic venous insufficiency has increased rapidly in the US. Wide variability in EVTA use among physicians has been documented, and standard EVTA rates were defined in the 2017 Medicare database.

OBJECTIVE

To assess whether providing individualized physician performance reports is associated with reduced variability in EVTA use and cost savings.

DESIGN, SETTING, AND PARTICIPANTS

This prospective quality improvement study used data from all US Medicare patients aged 18 years or older who underwent at least 1 EVTA between January 1, 2017, and December 31, 2017, and between January 1, 2019, and December 31, 2019. All US physicians who performed at least 11 EVTAs yearly for Medicare patients in 2017 and 2019 were included in the assessment.

INTERVENTION

A performance report comprising individual physician EVTA use per patient with peer-benchmarking data was distributed to all physicians in November 2018.

MAIN OUTCOMES AND MEASURES

The mean number of EVTAs performed per patient was calculated for each physician. Physicians who performed 3.4 or more EVTA procedures per patient per year were considered outliers. The change in the number of procedures from 2017 to 2019 was analyzed overall and by inlier and outlier status. An economic analysis was also performed to estimate the cost savings associated with the intervention.

RESULTS

A total of 188 976 patients (102 222 in 2017 and 86 754 in 2019) who had an EVTA performed by 1558 physicians were included in the analysis. The median patient age was 72.2 years (IQR, 67.9-77.8 years); 67.3% of patients were female, and 84.9% were White. Among all physicians, the mean (SD) number of EVTAs per patient decreased from 2017 to 2019 (1.97 [0.85] vs 1.89 [0.77]; P < .001). There was a modest decrease in the mean number of EVTAs per patient among inlier physicians (1.83 [0.57] vs 1.78 [0.55]; P < .001) and a more substantial decrease among outlier physicians (4.40 [1.01] vs 3.67 [1.41] ; P < .001). Outliers in 2017 consisted of 90 physicians, of whom 71 (78.9%) reduced their EVTA use after the intervention. The number of EVTAs per patient decreased by a mean (SD) of 0.09 (0.46) procedures overall (median, 0.10 procedures [IQR, -0.10 to 0.30 procedures]; P < .001). The estimated cost savings associated with the decrease was $6.3 million in 2019.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, substantial variability in the number of EVTAs performed per patient was observed across the US. When physicians were provided with a 1-time peer-benchmarked performance report card, the timing of the intervention was associated with a significant decrease in the number of EVTAs performed per patient, particularly among outlier physicians. This quality improvement initiative was associated with reduced variability in EVTA use in the US and a substantial savings for Medicare.

Development and validation of psychological status questionnaire for parents of infantile hemangiomas

BACKGROUND

Infantile hemangioma (IH) is the most frequent benign tumor of infancy which impacts the psychological status of parents of affected children. Parental psychological status has a significant effect on the therapeutic effect and long-term prognosis of IH children. However, no standard questionnaires had been established previously to assess the psychological status of Chinese parents of children with IH.

METHODS

This study prospectively developed and validated a psychological status instrument for the assessment of parents of patients with IH and to identify clinical features with effects on the psychological status. A total of 350 parents completed the 35-item Psychologic Status Questionnaire for parents of Infantile Hemangiomas (IH-PSQ) and provided demographic information. The IH-PSQ was refined via item analysis, validity analysis (including exploratory factor analysis and criterion-related validity) and reliability analysis (including internal consistency reliability, split half reliability, and test-retest reliability).

RESULTS

The dimensionality of the items was evaluated using factor analysis, with results suggesting 5 factors: anxiety, depression, psychological imbalance, disease shame, and disease fear. The final instrument consists of 4 scales with a total of 23 items. Construct validity was demonstrated and IH-PSQ showed good internal coherence (Cronbach's α: 0.957), good split half reliability (0.971), and good test-retest reliability (correlation coefficient: 0.967). The correlation coefficient between the Self-Rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) of children with IH was 0.874 and 0.754, respectively. Multiple linear regression analysis found that some characteristics will affect the score of IH-PSQ.

CONCLUSIONS

The IH-PSQ contains 5 dimensions and 23 entries, and with good reliability and validity, can objectively and effectively evaluate the psychological status of IH parents. Certain clinical characteristics of IH families, including parents' own factors (including their monthly income and cultural level) and disease-related factors of affected children (including the duration of illness, tumor size, with or without complications, single or multiple, whether being treated or not), were associated with a greater impact on IH-PSQ.

A scoping review of de-implementation frameworks and models

BACKGROUND

Reduction or elimination of inappropriate, ineffective, or potentially harmful healthcare services and public health programs can help to ensure limited resources are used effectively. Frameworks and models (FM) are valuable tools in conceptualizing and guiding the study of de-implementation. This scoping review sought to identify and characterize FM that can be used to study de-implementation as a phenomenon and identify gaps in the literature to inform future model development and application for research.

METHODS

We searched nine databases and eleven journals from a broad array of disciplines (e.g., healthcare, public health, public policy) for de-implementation studies published between 1990 and June 2020. Two raters independently screened titles and abstracts, and then a pair of raters screened all full text records. We extracted information related to setting, discipline, study design, methodology, and FM characteristics from included studies.

RESULTS

The final search yielded 1860 records, from which we screened 126 full text records. We extracted data from 27 articles containing 27 unique FM. Most FM (n = 21) were applicable to two or more levels of the Socio-Ecological Framework, and most commonly assessed constructs were at the organization level (n = 18). Most FM (n = 18) depicted a linear relationship between constructs, few depicted a more complex structure, such as a nested or cyclical relationship. Thirteen studies applied FM in empirical investigations of de-implementation, while 14 articles were commentary or review papers that included FM.

CONCLUSION

De-implementation is a process studied in a broad array of disciplines, yet implementation science has thus far been limited in the integration of learnings from other fields. This review offers an overview of visual representations of FM that implementation researchers and practitioners can use to inform their work. Additional work is needed to test and refine existing FM and to determine the extent to which FM developed in one setting or for a particular topic can be applied to other contexts. Given the extensive availability of FM in implementation science, we suggest researchers build from existing FM rather than recreating novel FM.

REGISTRATION

Not registered.

The reduction of race and gender bias in clinical treatment recommendations using clinician peer networks in an experimental setting

Bias in clinical practice, in particular in relation to race and gender, is a persistent cause of healthcare disparities. We investigated the potential of a peer-network approach to reduce bias in medical treatment decisions within an experimental setting. We created "egalitarian" information exchange networks among practicing clinicians who provided recommendations for the clinical management of patient scenarios, presented via standardized patient videos of actors portraying patients with cardiac chest pain. The videos, which were standardized for relevant clinical factors, presented either a white male actor or Black female actor of similar age, wearing the same attire and in the same clinical setting, portraying a patient with clinically significant chest pain symptoms. We found significant disparities in the treatment recommendations given to the white male patient-actor and Black female patient-actor, which when translated into real clinical scenarios would result in the Black female patient being significantly more likely to receive unsafe undertreatment, rather than the guideline-recommended treatment. In the experimental control group, clinicians who were asked to independently reflect on the standardized patient videos did not show any significant reduction in bias. However, clinicians who exchanged real-time information in structured peer networks significantly improved their clinical accuracy and showed no bias in their final recommendations. The findings indicate that clinician network interventions might be used in healthcare settings to reduce significant disparities in patient treatment.

Abuse detection in healthcare insurance with disease-treatment network embedding

Abuse in healthcare insurance refers to a medical service or practice inconsistent with the generally accepted sound fiscal practices, such as overtreatment or overcharging. These types of abuses may lead to prescriptions that do not meet the criteria for medical stability. On the other hand, abuse may incur unnecessary costs by deliberately executing gratuitous treatments. In efforts to detect and prevent abuse, insurance companies hire medical professionals to manually examine the legitimacy of claim filings. It is, however, very costly in terms of labor and time to review all of the claims given the exploding amount of filings. In this light, there are growing interests for employing data mining techniques to automatically detect abusive claims or providers showing an abnormal billing pattern. Unfortunately, most of these models do not consider the disease-treatment information explicitly. In order for detection models to properly address the issues rising from individual drugs with similar efficacy, it is absolutely essential to account for the relationship between diseases and treatments during the learning process. In this paper, we propose a network-based approach which assesses the relationship between the diseases and treatments when detecting abuse from claim filings. Our proposed model consists of three stages. During the first stage, a disease-treatment network is constructed based on information extracted from the claim filings. Since the association between diseases and treatments is not explicitly expressed on these filings, we infer the disease-treatment relationship by computing the relative risk (RR). Second stage involves selecting the best graph embedding method from several candidates. We select the best method by comparing performances on link prediction. At the final stage, we solve a link prediction problem as a vehicle to detecting overtreatments. If our link prediction model predicts links to be nonexistent for all of the diseases and treatments listed in a given claim, then the claim is classified as an overtreatment case. We test the proposed model using the real-world claim data and showed that the proposed method classifies the treatment well which does not explicitly exist in the training network.

Financial Profit in Medicine: A Position Paper From the American College of Physicians

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

Impacts of the COVID-19 Pandemic on Public Hospitals of Different Levels: Six-Month Evidence from Shanghai, China

PURPOSE

Hospitals suffered from a precipitous loss of medical service globally due to COVID-19. The tragedy paradoxically produced an opportunity to investigate the patterns of change in medical services and revenue in hospitals at different levels when faced with a natural shock. This study aims to examine the effects of the COVID-19 pandemic in the first half of 2020 on hospital operation in Shanghai.

METHODS

We obtained monthly characteristic and operational data of public hospitals (N=156) from January 1, 2018, to July 31, 2020, in Shanghai from the China Statistical Survey of Health Resources and Services Program. We constructed a set of difference-in-differences models to investigate the pandemic (from February 1 to March 31, 2020) and post-pandemic (from April 1 to July 31, 2020) effects on operational outcomes in hospitals of different levels, including outpatient and inpatient visits, outpatient and inpatient revenue, as well as the differential effects on local and nonlocal patients.

RESULTS

There were 46 tertiary hospitals and 110 non-tertiary hospitals involved in this study. Compared to a non-tertiary hospital during the COVID-19 pandemic, a tertiary hospital averagely experienced substantially more significant losses in outpatient visits (57.91 thousand, p < 0.01), inpatient visits (1.93 thousand, p < 0.01), outpatient revenue (18.88 million RMB, p < 0.01), and inpatient revenue (30.65 million RMB, p < 0.01) monthly. Compared to a non-tertiary hospital in the post-pandemic period, a tertiary hospital averagely lost more outpatient visits (18.02 thousand, p < 0.01) from all patients and inpatient visits (0.15 thousand, p < 0.01) from nonlocal patients, but was associated with higher inpatient revenue (2.24 million RMB, p < 0.01) from all patients and outpatient revenue (0.87 million RMB, p < 0.01) from nonlocal patients monthly.

CONCLUSION

Medical service and revenue for public hospitals in Shanghai dropped precipitously during the COVID-19 pandemic, but mainly recovered after the pandemic. Compared to non-tertiary hospitals, medical services and revenue in tertiary hospitals experienced more substantial reduction during the pandemic but had a faster recovery that maintained longer during the post-pandemic period.

Evidence for the 4Ms: Interactions and Outcomes across the Care Continuum

Objectives: An expert panel reviewed and summarized the literature related to the evidence for the 4Ms-what matters, medication, mentation, and mobility-in supporting care for older adults. Methods: In 2017, geriatric experts and health system executives collaborated with the Institute for Healthcare Improvement (IHI) to develop the 4Ms framework. Through a strategic search of the IHI database and recent literature, evidence was compiled in support of the framework's positive clinical outcomes. Results: Asking what matters from the outset of care planning improved both psychological and physiological health statuses. Using screening protocols such as the Beers' criteria inhibited overprescribing. Mentation strategies aided in prevention and treatment. Fall risk and physical function assessment with early goals and safe environments allowed for safe mobility. Discussion: Through a framework that reduces cognitive load of providers and improves the reliability of evidence-based care for older adults, all clinicians and healthcare workers can engage in age-friendly care.

Renal function in children with a congenital solitary functioning kidney: A systematic review

INTRODUCTION

Abnormal renal development that results in lack of function or development of one of two kidneys is known as congenital solitary functioning kidney (CSFK). Two well characterized sub-categories of CFSK are unilateral renal agenesis (URA) and multicystic dysplastic kidney (MCDK). This systematic review sought to evaluate the change in renal function in children ≤18 years old with a CSFK as a result of URA or MCDK.

METHODS

A literature search in MEDLINE and Embase was conducted (1946 to July 13, 2020). All relevant articles were retrieved and evaluated based on pre-selected criteria by two independent researchers. Data was then extracted from variables of interest and conflicts were resolved by a third researcher. The primary outcome was renal function, and the secondary outcomes were proteinuria and hypertension.

RESULTS

Forty-five studies were included, of which 49% (n = 22) were retrospective and/or 58% (n = 26) were cohort studies. A combined total of 2148 and 885 patients were diagnosed with MCDK or URA, respectively. The proportion of children with worsened renal function at follow-up was found to be 8.4% (95% CI: 5.2%-13.4%). Among the studies reporting renal function as a group mean or median at follow-up, 84% (21/25) had a GFR/CrCl above 90 (mL/min/1.73  m²/ml/min). In terms of secondary outcomes, the proportion of children with proteinuria and hypertension was found to be 10.1% (95% CI: 6.9%-14.6%) and 7.4% (95% CI: 5.0%-10.9%), respectively.

CONCLUSION

The risk of developing proteinuria (10.1%), hypertension (7.4%), and/or worsened renal function (8.4%) for children with CFSK as a result of MCDK or URA is low. However, the level of evidence in the literature is weak. Further research is needed to identify the predisposing factors that may differentiate the small subset of children with CSFK at a higher risk of developing adverse renal outcomes.

Impact of differential copayment on patient healthcare choice: evidence from South Korean National Cohort Study

OBJECTIVE

We evaluate the effectiveness of mild disease differential copayment policy aimed at reducing unnecessary patient visits to secondary/tertiary healthcare institutions in South Korea.

DESIGN

Retrospective study using difference-in-difference design.

SETTING

Sample Research database provided by the Korean National Health Insurance Service, between 2010 and 2013.

PARTICIPANTS

206 947 patients who visited healthcare institutions to treat mild diseases during the sample period.

METHODS

A linear probability model with difference-in-difference approach was adopted to estimate the changes in patients' healthcare choices associated with the differential copayment policy. The dependent variable was a binary variable denoting whether a patient visited primary healthcare or secondary/tertiary healthcare to treat her/his mild disease. Patients' individual characteristics were controlled with a fixed effect.

RESULTS

We observed significant decrease in the proportion of patients choosing secondary/tertiary healthcare over primary healthcare by 2.99 per cent point. The decrease associated with the policy was smaller by 14% in the low-income group compared with richer population, greater by 19% among the residents of Seoul metropolitan area than among people living elsewhere, and greater among frequent healthcare visitors by 33% than among people who less frequently visit healthcare.

CONCLUSION

The mild disease differential copayment policy of South Korea was successful in discouraging unnecessary visits to secondary/tertiary healthcare institutions to treat mild diseases that can be treated well in primary healthcare.

Spending On Targeted Therapies Reduced Mortality In Patients With Advanced-Stage Breast Cancer

Costly targeted therapies are playing an increasingly important role in treating cancer. To characterize trends in spending on targeted therapies for breast cancer and to estimate the association of these therapies with cancer mortality, we analyzed cancer diagnoses in the Surveillance, Epidemiology, and End Results Program-Medicare linked database. We categorized total cancer spending into spending on targeted therapies, spending on nontargeted therapies, and spending on other cancer care. Diagnosis-year spending on targeted therapies increased from $1,024 per patient in 2000 to $18,809 per patient in 2015 for patients with advanced-stage cancer and from $82 to $3,289 for patients with early-stage cancer. For patients with advanced-stage cancer, a $1,000 increase in spending on targeted therapies in the diagnosis year was associated with a 0.55-percentage-point decrease in adjusted three-year cancer mortality, whereas for patients with early-stage cancer, there was no association. The other two types of spending (on nontargeted therapies and other cancer care) were not associated with mortality among patients with either advanced- or early-stage cancer. Our results indicate that among various types of cancer treatments, only targeted therapies generated meaningful survival gains for patients with advanced-stage breast cancer.

Impact of Molecular Testing on the Management of Indeterminate Thyroid Nodules Among Western and Asian Countries: a Systematic Review and Meta-analysis

Molecular testing has a potential to improve the management of patients with indeterminate thyroid nodules considered for surgery. This study examined the influence of molecular tests on the treatment of indeterminate nodules, particularly the differences between Western and Asian countries. Electronic databases including PubMed and Web of Science were searched for relevant articles from 2010 to March 2019. We computed meta-analysis of proportion and their 95% confidence intervals (CIs) utilizing the random-effect model. We used independent samples t test to compare the resection rate (RR), rate of malignancy (ROM), rate of preoperative molecular testing (RMT), and rate of positive test (RP) between subgroups. We included a total of 34 studies with 7976 indeterminate nodules. The multigene panel testing methods were exclusively used in the USA. Compared with the non-molecular era, molecular testing was associated with a significantly increased ROM (47.9% versus 32.1%; p = 0.001). The ROM of indeterminate nodules in Asian institutes was significantly higher than that in Western countries (75.3% versus 36.6%; p < 0.001, respectively). Institutes employing single-gene tests achieved a higher ROM (59.8% versus 37.9%; p = 0.013). Molecular testing is a promising method to tailor the clinical management for indeterminate thyroid FNA. Certain differences in routine thyroid cytopathology practice among the West and the East are still present. The combination of molecular testing and active surveillance enhances the accuracy of case selection for surgery in Asian countries.

Clinical decision-making framework against over-testing based on modeling implicit evaluation criteria

Different statistical methods include various subjective criteria that can prevent over-testing. However, no unified framework that defines generalized objective criteria for various diseases is available to determine the appropriateness of diagnostic tests recommended by doctors. We present the clinical decision-making framework against over-testing based on modeling the implicit evaluation criteria (CDFO-MIEC). The CDFO-MIEC quantifies the subjective evaluation process using statistics-based methods to identify over-testing. Furthermore, it determines the test's appropriateness with extracted entities obtained via named entity recognition and entity alignment. More specifically, implicit evaluation criteria are defined-namely, the correlation among the diagnostic tests, symptoms, and diseases, confirmation function, and exclusion function. Additionally, four evaluation strategies are implemented by applying statistical methods, including the multi-label k-nearest neighbor and the conditional probability algorithms, to model the implicit evaluation criteria. Finally, they are combined into a classification and regression tree to make the final decision. The CDFO-MIEC also provides interpretability by decision conditions for supporting each clinical decision of over-testing. We tested the CDFO-MIEC on 2,860 clinical texts obtained from a single respiratory medicine department in China with the appropriate confirmation by physicians. The dataset was supplemented with random inappropriate tests. The proposed framework excelled against the best competing text classification methods with a Mean_F₁ of 0.9167. This determined whether the appropriate and inappropriate tests were properly classified. The four evaluation strategies captured the features effectively, and they were imperative. Therefore, the proposed CDFO-MIEC is feasible because it exhibits high performance and can prevent over-testing.

Docs with their eyes on the clock? The effect of time pressures on primary care productivity

This paper examines how time pressure, an important constraint faced by medical care providers, affects productivity in primary care. We generate empirical predictions by incorporating time pressure into a model of physician behavior by Tai-Seale and McGuire (2012). We use data from the electronic health records of a large integrated delivery system and leverage unexpected schedule changes as variation in time pressure. We find that greater time pressure reduces the number of diagnoses recorded during a visit and increases both scheduled and unscheduled follow-up care. We also find some evidence of increased low-value care, decreased preventive care, and decreased opioid prescribing.

How to Draw the Line Between Health and Disease? Start with Suffering

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization.

Are chest X-rays valuable for patients presenting to emergency departments with acute abdominal pain?

BACKGROUND

Emergency department patients presenting with acute abdominal pain are often prescribed a chest X-ray; however, the value of chest X-rays in acute abdominal pain is poorly understood. The aim of this study was to assess the value of chest X-rays in acute abdominal pain.

METHODS

A retrospective analysis of 944 chest X-rays performed for acute abdominal pain was conducted. Patient clinical information, radiology reports, and findings of other diagnostic investigations were also collected. MedCal® software was used to calculate diagnostic performance of chest X-rays. A Chi-Square test was used to assess the association between positive chest X-ray findings and both age and gender.

RESULTS

Of the 944 chest X-rays identified as satisfying inclusion factors, only 10 cases (approximately 1%) demonstrated pathology that was likely to be the cause of the abdominal pain. Further analysis demonstrated the following performance metrics at 95%CI: sensitivity (12.8; 8.78-17.72); specificity (100; 98.4-100); positive predictive value (100%); negative predictive value (52.76; 51.54-53.98); accuracy (55.82; 51.17-60.40).

CONCLUSION

Chest X-ray has limited sensitivity and diagnostic value in patients presenting to the emergency department with abdominal pain and does not appear to be a useful diagnostic investigation for abdominal pain.

Ten tips for improving your clinical practice during the COVID-19 pandemic

PURPOSE OF REVIEW

This review provides ten tips for improving clinical practice during COVID-19 as pandemic fatigue begins to complicate personal and professional lives of clinicians.

RECENT FINDINGS

COVID-19 has created unique and unexpected challenges to healthcare delivery, but has also provided opportunities for re-evaluation of practice patterns to optimize high-value practices. With ongoing uncertainty, key factors to appreciate for patient and population health include the continued touchstones of empathy and compassion, the use of effective risk communication with shared clinical decision-making when appropriate, attention to resource stewardship and vulnerable populations, importance of health literacy and need for critical assessment of media and medical literature to mitigate misinformation, and the hidden costs of the pandemic on children. Although there has been some international concern for allergic reactions to the recently approved Pfizer-BioNTech COVID-19 vaccine, neither the United States Pfizer-BioNTech or Moderna COVID-19 vaccine emergency use authorizations exclude patients without a specific allergy to a vaccine component from receiving vaccination.

SUMMARY

Practical adjustments to practice during COVID-19 are feasible and acceptable. Experience during COVID-19 reinforces the critical need for human connection while providing care and service in every encounter.

A systematic review on endovascular repair of isolated common iliac artery aneurysms and suggestions regarding diameter thresholds for intervention

OBJECTIVE

Our aim was to systematically review results of endovascular aneurysm repair for isolated common iliac artery aneurysms (CIAA) regarding outcomes and to determine if changes should be made to current diameter threshold recommendations for intervention.

METHODS

A comprehensive systematic review was performed according to the PRISMA guidelines. PubMed, Scopus, and the Cochrane Central databases were searched.

RESULTS

Twenty-one studies were deemed eligible and provided data for 879 patients and 981 isolated CIAA treated with endovascular repair. The majority of the patients (90.8%) were males. The weighted mean age of the patients was 71.7 years (range, 37-91 years). The weighted mean diameter for the CIAA was 41. mm 1 (range, 15-110 mm) and for ruptured aneurysms 58.4 mm. The overall technical success rate was 97.6%. The perioperative mortality rate was 0.7%. Secondary patency rates were reported in only four studies and varied between 96.7% and 100%. The overall morbidity rate was 14%, ranging from 0% to 25%. Most of the studies did not report long-term or adequate follow-up data. Rupture of an isolated CIAA at <4 cm diameter was extremely low.

CONCLUSIONS

Endovascular treatment of isolated CIAA is feasible and safe with a low mortality and excellent technical success rates. Consideration of increasing the diameter threshold for intervention of CIAA to 4 cm should be considered. Studies with longer follow-up and reliable long-term results are needed.

Ethical care requires pragmatic care research to guide medical practice under uncertainty

BACKGROUND

The current research-care separation was introduced to protect patients from explanatory studies designed to gain knowledge for future patients. Care trials are all-inclusive pragmatic trials integrated into medical practice, with no extra tests, risks, or cost, and have been designed to guide practice under uncertainty in the best medical interest of the patient.

PROPOSED REVISION

Patients need a distinction between validated care, previously verified to provide better outcomes, and promising but unvalidated care, which may include unnecessary or even harmful interventions. While validated care can be practiced normally, unvalidated care should only be offered within declared pragmatic care research, designed to protect patients from harm. The validated/unvalidated care distinction is normative, necessary to the ethics of medical practice. Care trials, which mark the distinction and allow the tentative use of promising interventions necessarily involve patients, and thus the design and conduct of pragmatic care research must respect the overarching rule of care ethics "to always act in the best medical interest of the patient." Yet, unvalidated interventions offered in contexts of medical uncertainty cannot be prescribed or practiced as if they were validated care. The medical interests of current patients are best protected when unvalidated practices are restricted to a care trial protocol, with 1:1 random allocation (or "hemi-prescription") versus previously validated care, to optimize potential benefits and minimize risks for each patient.

CONCLUSION

Pragmatic trials can regulate medical practice by providing (i) a transparent demarcation between unvalidated and validated care; (ii) norms of medical conduct when using tests and interventions of yet unknown benefits in practice; and eventually (iii) a verdict regarding optimal care.

What the COVID-19 Pandemic Can Teach Us About Resource Stewardship and Quality in Health Care

The coronavirus disease 2019 pandemic has forever changed how we view health care service delivery. Although there are undoubtedly some unintended consequences that will result from current health care service reallocation, it provides a unique opportunity to consider how to deliver quality care currently, and after the pandemic. In the context of lessons learned, moving forward some of what was previously routine could remain reserved for more exceptional circumstances. To determine what is "routine," what is "essential," and what is "exceptional," it is necessary to view medical decisions within the paradigm of high-quality care. The Institute for Healthcare Improvement definition of the dimensions of quality is based on whether the care is safe, effective, patient-centered, timely, efficient, and equitable. This type of stewardship has been applied to many interventions already deemed unnecessary by organizations such as the Choosing Wisely initiative, but the coronavirus disease 2019 pandemic provides a lens from which to consider other aspects of care. The following will provide examples from Allergy/Immunology that outline how we can reconsider what quality means in the post-coronavirus disease health care system.

Site-Level Variation in the Characteristics and Care of Infants With Neonatal Opioid Withdrawal

BACKGROUND AND OBJECTIVES

Variation in pediatric medical care is common and contributes to differences in patient outcomes. Site-to-site variation in the characteristics and care of infants with neonatal opioid withdrawal syndrome (NOWS) has yet to be quantified. Our objective was to describe site-to-site variation in maternal-infant characteristics, infant management, and outcomes for infants with NOWS.

METHODS

Cross-sectional study of 1377 infants born between July 1, 2016, and June 30, 2017, who were ≥36 weeks' gestation, with NOWS (evidence of opioid exposure and NOWS scoring within the first 120 hours of life) born at or transferred to 1 of 30 participating hospitals nationwide. Site-to-site variation for each parameter within the 3 domains was measured as the range of individual site-level means, medians, or proportions.

RESULTS

Sites varied widely in the proportion of infants whose mothers received adequate prenatal care (31.3%-100%), medication-assisted treatment (5.9%-100%), and prenatal counseling (1.9%-75.5%). Sites varied in the proportion of infants with toxicology screening (50%-100%) and proportion of infants receiving pharmacologic therapy (6.7%-100%), secondary medications (1.1%-69.2%), and nonpharmacologic interventions including fortified feeds (2.9%-90%) and maternal breast milk (22.2%-83.3%). The mean length of stay varied across sites (2-28.8 days), as did the proportion of infants discharged with their parents (33.3%-91.1%).

CONCLUSIONS

Considerable site-to-site variation exists in all 3 domains. The magnitude of the observed variation makes it unlikely that all infants are receiving efficient and effective care for NOWS. This variation should be considered in future clinical trial development, practice implementation, and policy development.

Medicine and Phlebolymphology: Time to Change?

Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients' management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients' lack of education, industry-influenced science, and physician's improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.

Deciding without data: clinical decision-making in pediatric orthopedic surgery

OBJECTIVE

Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision-making, national guidelines and clinical pathways for many conditions in pediatric orthopedic surgery are limited. This study investigated decision-making rationale and quantified the evidence supporting decisions made by pediatric orthopedic surgeons in an outpatient clinic.

DESIGN/SETTING/PARTICIPANTS/INTERVENTION(S)/MAIN OUTCOME MEASURE(S)

We recorded decisions made by eight pediatric orthopedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. 'Experience/anecdote,' 'First principles,' 'Trained to do it,' 'Arbitrary/instinct,' 'General study,' 'Specific study').

RESULTS

Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were 'First principles' (n = 310, 27.0%) and 'Experience/anecdote' (n = 253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. As high as 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions.

CONCLUSIONS

With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence and help create clinical care pathways in pediatric orthopedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools and aids could also be implemented to guide these decisions.

Promoting Value Through Patient-Centered Communication: A Multisite Validity Study of Third-Year Medical Students

PURPOSE

To examine validity evidence for a standardized patient scenario assessing medical students' ability to promote value using patient-centered communication (in response to a patient requesting an unnecessary test) and to explore the potential effect of various implementation and curricular factors on student scores.

METHOD

Third-year medical students (N = 516) from 5 U.S. MD-granting medical schools completed the communication scenario between 2014 and 2017 as part of a larger objective structured clinical examination (OSCE). Centralized raters assessed performance using an 11-item checklist. The authors collected multiple sources of validity evidence.

RESULTS

The mean checklist score was 0.85 (standard deviation 0.09). Interrater reliability for checklist scores was excellent (0.87, 95% confidence interval = 0.78-0.93). Generalizability and Phi-coefficients were, respectively, 0.65 and 0.57. Scores decreased as the number of OSCE stations increased (r = -0.15, P = .001) and increased when they were used for summative purposes (r = 0.26, P < .001). Scores were not associated with curricular time devoted to high-value care (r = 0.02, P = .67) and decreased when more clerkships were completed before the assessment (r = -0.12, P = .006).

CONCLUSIONS

This multisite study provides validity evidence supporting the use of scenario scores to assess the ability of medical students to promote value in clinical encounters using patient-centered communication. Findings illuminate the potential effect of OSCE structure and purpose on student performance and suggest clerkship learning experiences may not reinforce what students are taught in the formal curriculum regarding high-value care. Devoting more time to the topic appears insufficient to counteract this erosion.

[Diagnostics and therapy in children and adolescents with chronic pain : Trends in interventions potentially dangerous to health]

Hintergrund und Ziel der Arbeit

Bei der Behandlung chronischer funktioneller Schmerzen im Kindes- und Jugendalter nimmt international sowohl die Anzahl an diagnostischen und therapeutischen Maßnahmen als auch ihre Invasivität zu. Studienziel ist die Erforschung der vor Beginn einer spezialisierten stationären Schmerztherapie durchgeführten, die pädiatrischen Patienten potenziell gefährdenden Maßnahmen in Deutschland.

Material und Methoden

In einem retrospektiven Studiendesign wurden Patientenakten eines tertiären Kinderschmerzzentrums der Jahre 2004, 2008, 2012 und 2016 ausgewertet (N = 585). Neben diagnostischen und therapeutischen Maßnahmen wurden primäre Schmerzparameter und Patientencharakteristika erfasst. In einer interdisziplinären Expertenumfrage (N = 13) wurden die Invasivität, das Risiko und die psychische Belastung von Maßnahmen bewertet.

Ergebnisse

Diagnostische und medikamentöse Maßnahmen nehmen bis 2012 zu. Ab 2012 lässt sich ein abnehmender Trend erkennen (χ²(3) = 11,708; p = 0,008). Die Invasivität (χ²(3) = 13,342; p = 0,004), das Risiko (χ²(3) = 13,135; p = 0,004) und die psychische Belastung (χ²(3) = 14,403; p = 0,002) durchgeführter Maßnahmen zeigen ein gleiches Veränderungsmuster. In der Gesamtstichprobe sind Patienten mit Bauch- oder Gliederschmerzen besonders gefährdet für hoch invasive und sehr risikoreiche Diagnostik.

Diskussion

Eine Zunahme diagnostischer und therapeutischer Maßnahmen bei funktionellen Schmerzstörungen lässt sich nur bis 2012 beobachten. Bei bestimmten Patientengruppen kommen invasive, risikoreiche und die Psyche stärker belastende Maßnahmen häufiger zur Anwendung.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00482-020-00506-5) enthält vier weitere Tabellen. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.