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Saini SD, Lewis CL, Kerr EA, Zikmund-Fisher BJ, Hawley ST, Forman JH, Zauber AG, Lansdorp-Vogelaar I, van Hees F, Saffar D, Myers A, Gauntlett LE, Lipson R, Kim HM, Vijan S. Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1334-1342. [PMID: 37902744 PMCID: PMC10616770 DOI: 10.1001/jamainternmed.2023.5656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/01/2023] [Indexed: 10/31/2023]
Abstract
Importance Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. Objective To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Design, Setting, and Participants Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. Intervention The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. Main Outcomes and Measures The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. Results A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). Conclusions and Relevance In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. Trial Registration ClinicalTrials.gov Identifier: NCT02027545.
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Affiliation(s)
- Sameer D. Saini
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | - Eve A. Kerr
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Brian J. Zikmund-Fisher
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
| | - Sarah T. Hawley
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jane H. Forman
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Darcy Saffar
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Aimee Myers
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Lauren E. Gauntlett
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Rachel Lipson
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - H. Myra Kim
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Schuttner L, Richardson C, Parikh T, Wong ES. "Low-value" glycemic outcomes among older adults with diabetes cared for by primary care nurse practitioners or physicians: A retrospective cohort study. Int J Nurs Stud 2023; 145:104532. [PMID: 37315453 PMCID: PMC10760981 DOI: 10.1016/j.ijnurstu.2023.104532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND "Low-value" healthcare is care without benefit to patients. Overly intensive glycemic control (i.e., HgbA1C < 7 %) can cause harm to patients at high risk of hypoglycemia, particularly among older adults with co-morbidities. It is unknown whether overly intensive glycemic control differs among patients with diabetes and at high-risk of hypoglycemia cared for by primary care nurse practitioners versus physicians. OBJECTIVE This study examined patients with diabetes at high risk of hypoglycemia receiving primary care between Jan 2010 and Jan 2012, comparing patients reassigned to nurse practitioners to those reassigned to physicians after their previous physician separated from practice in an integrated United States health system. DESIGN This was a retrospective cohort study. Study outcomes were collected at two years after reassignment to a new primary care provider. Outcomes were predicted probabilities of HgbA1C < 7 % using two-stage residual inclusion instrumental variable models, controlling for baseline confounders. SETTING Primary care clinics within the United States Veterans Health Administration. PARTICIPANTS 38,543 patients with diabetes at increased risk for hypoglycemia (age ≥ 65 years with renal disease, dementia, or cognitive impairment), who had their primary care physician leave the Veterans Health Administration and who were reassigned to a new primary care provider in the following year. RESULTS Cohort patients were on average 76 years and 99 % men. Of these, 33,700 were reassigned to physicians and 4843 to nurse practitioners. After two years with their new provider, in adjusted models, patients reassigned to nurse practitioners had a -20.4 percentage-point [95 % CI -37.9 to -2.8] lower probability of two-year HgbA1C < 7 %. CONCLUSIONS Aligned with prior studies on care quality, rates of overly intensive glycemic control may be appropriately lower among older patients with diabetes at high-risk of hypoglycemia, cared for by nurse practitioners than physicians. TWEETABLE ABSTRACT Primary care nurse practitioners deliver equivalent or better rates of low-value diabetes care for older patients, compared to physicians.
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Affiliation(s)
- Linnaea Schuttner
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Claire Richardson
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Toral Parikh
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Edwin S Wong
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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3
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Estabrooks PA, Glasgow RE. Developing a dissemination and implementation research agenda for aging and public health: The what, when, how, and why? Front Public Health 2023; 11:1123349. [PMID: 36815160 PMCID: PMC9939692 DOI: 10.3389/fpubh.2023.1123349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/13/2023] [Indexed: 02/09/2023] Open
Affiliation(s)
- Paul A. Estabrooks
- Department of Health and Kinesiology, College of Health, University of Utah, Salt Lake City, UT, United States
| | - Russell E. Glasgow
- ACCORDS Dissemination & Implementation Science Program and Department of Family Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, United States
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4
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Sparks JB, Klamerus ML, Caverly TJ, Skurla SE, Hofer TP, Kerr EA, Bernstein SJ, Damschroder LJ. Planning and Reporting Effective Web-Based RAND/UCLA Appropriateness Method Panels: Literature Review and Preliminary Recommendations. J Med Internet Res 2022; 24:e33898. [PMID: 36018626 PMCID: PMC9463617 DOI: 10.2196/33898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 06/28/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services. A substantial literature describes and tests various aspects of the traditional RAM in health research; yet we know comparatively less about how researchers implement web-based expert panels. OBJECTIVE The objectives of this study are twofold: (1) to understand how the web-based RAM process is currently used and reported in health research and (2) to provide preliminary reporting guidance for researchers to improve the transparency and reproducibility of reporting practices. METHODS The PubMed database was searched to identify studies published between 2009 and 2019 that used a web-based RAM to measure the appropriateness of medical care. Methodological data from each article were abstracted. The following categories were assessed: composition and characteristics of the web-based expert panels, characteristics of panel procedures, results, and panel satisfaction and engagement. RESULTS Of the 12 studies meeting the eligibility criteria and reviewed, only 42% (5/12) implemented the full RAM process with the remaining studies opting for a partial approach. Among those studies reporting, the median number of participants at first rating was 42. While 92% (11/12) of studies involved clinicians, 50% (6/12) involved multiple stakeholder types. Our review revealed that the studies failed to report on critical aspects of the RAM process. For example, no studies reported response rates with the denominator of previous rounds, 42% (5/12) did not provide panelists with feedback between rating periods, 50% (6/12) either did not have or did not report on the panel discussion period, and 25% (3/12) did not report on quality measures to assess aspects of the panel process (eg, satisfaction with the process). CONCLUSIONS Conducting web-based RAM panels will continue to be an appealing option for researchers seeking a safe, efficient, and democratic process of expert agreement. Our literature review uncovered inconsistent reporting frameworks and insufficient detail to evaluate study outcomes. We provide preliminary recommendations for reporting that are both timely and important for producing replicable, high-quality findings. The need for reporting standards is especially critical given that more people may prefer to participate in web-based rather than in-person panels due to the ongoing COVID-19 pandemic.
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Affiliation(s)
- Jordan B Sparks
- VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Mandi L Klamerus
- VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Tanner J Caverly
- VA Center for Clinical Management Research, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Sarah E Skurla
- VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Timothy P Hofer
- VA Center for Clinical Management Research, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Eve A Kerr
- VA Center for Clinical Management Research, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Steven J Bernstein
- VA Center for Clinical Management Research, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Laura J Damschroder
- VA Center for Clinical Management Research, Ann Arbor, MI, United States.,VA Quality Enhancement Research Initiative (QUERI) Personalizing Options through Veteran Engagement (PROVE) Program, Ann Arbor, MI, United States
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5
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Radomski TR, Zhao X, Lovelace EZ, Sileanu FE, Rose L, Schwartz AL, Schleiden LJ, Oakes AH, Pickering AN, Yang D, Hale JA, Gellad WF, Fine MJ, Thorpe CT. Use and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration. JAMA Intern Med 2022; 182:832-839. [PMID: 35788786 PMCID: PMC9257674 DOI: 10.1001/jamainternmed.2022.2482] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/08/2022] [Indexed: 01/11/2023]
Abstract
Importance Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified. Objective To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased community care. Design, Setting, and Participants This cross-sectional study assessed a national population of VA-enrolled veterans. Data on enrollment, sociodemographic characteristics, comorbidities, and health care services delivered by VA facilities or paid for by the VA through VACC programs were compiled for fiscal year 2018 from the VA Corporate Data Warehouse. Data analysis was conducted from April 2020 to January 2022. Main Outcomes and Measures VA administrative data were applied using an established low-value service metric to quantify the use of 29 potentially low-value tests and procedures delivered in VA facilities and by VACC programs across 6 domains: cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other procedures. Sensitive and specific criteria were used to determine the low-value service counts per 100 veterans overall, by domain, and by individual service; count and percentage of each low-value service delivered by each setting; and estimated cost of each service. Results Among 5.2 million enrolled veterans, the mean (SD) age was 62.5 (16.0) years, 91.7% were male, 68.0% were non-Hispanic White, and 32.3% received any service through VACC. By specific criteria, 19.6 low-value services per 100 veterans were delivered in VA facilities or by VACC programs, involving 13.6% of veterans at a total cost of $205.8 million. Overall, the most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older (5.9 per 100 veterans); this was also the service with the greatest proportion delivered by VA facilities (98.9%). The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4% of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9% of spending). Conclusions and Relevance This cross-sectional study found that among veterans enrolled in the VA, more than 1 in 10 have received a low-value service from VA facilities or VACC programs, with approximately $200 million in associated costs. Such information on the use and costs of low-value services are essential to guide the VA's efforts to reduce delivery and spending on such care.
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Affiliation(s)
- Thomas R. Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Elijah Z. Lovelace
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Liam Rose
- Health Economics Resource Center, VA Palo Alto Healthcare System, California
| | - Aaron L. Schwartz
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy and Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Loren J. Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Allison H. Oakes
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Aimee N. Pickering
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Dylan Yang
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy
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6
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Mecca MC, Zenoni M, Fried TR. Primary care clinicians' use of deprescribing recommendations: A mixed-methods study. PATIENT EDUCATION AND COUNSELING 2022; 105:2715-2720. [PMID: 35523638 DOI: 10.1016/j.pec.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/07/2022] [Accepted: 04/20/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE to explore the effects of a deprescribing intervention on primary care clinicians' medication-related communication. METHODS A clinical decision support tool provided clinicians in the intervention group with an individualized report regarding potentially inappropriate medications (PIMs), deintensification of diabetes and/or hypertension treatment, and poor adherence/cognition. Participants included 113 Veterans aged ≥ 65 prescribed ≥ 7 medications and their primary care clinicians. Encounters were recorded and analyzed. RESULTS Between 36% and 38% of intervention clinicians discussed PIMs and diabetes mellitus/hypertension deintensification and 94% discussed adherence. PIMs discussions referred to the report and prompted some medication changes. The diabetes mellitus/hypertension and adherence discussions were not prompted by the report but instead arose from enhanced medication reconciliation. Changes in diabetes mellitus/hypertension medications were not made out of overtreatment concerns. There was no deprescribing for nonadherence. Enhanced medication reconciliation also led to discussions about medications not in the report. CONCLUSION An individualized report regarding medication appropriateness prompted clinicians to perform a more thorough medication reconciliation and discuss PIMs. It did not prompt chronic care deintensification or deprescribing to enhance adherence. PRACTICE IMPLICATIONS Feedback reports can promote robust medication reconciliation in primary care. Changing clinician practice to achieve deprescribing in chronic disease management will be more challenging.
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Affiliation(s)
- Marcia C Mecca
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Ave., #240, West Haven, CT 06516, USA; Department of Medicine, Yale School of Medicine, 333 Cedar St., New Haven, CT 06520, USA.
| | - Maria Zenoni
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Ave., #240, West Haven, CT 06516, USA; Program on Aging, Yale School of Medicine, 300 George St., New Haven, CT 06511, USA
| | - Terri R Fried
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Ave., #240, West Haven, CT 06516, USA; Program on Aging, Yale School of Medicine, 300 George St., New Haven, CT 06511, USA; Department of Medicine, Yale School of Medicine, 333 Cedar St., New Haven, CT 06520, USA
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Applying User-Centered Design to Develop Practical Strategies that Address Overuse in Primary Care. J Gen Intern Med 2022; 37:57-63. [PMID: 34535845 PMCID: PMC8993977 DOI: 10.1007/s11606-021-07124-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Engaging patients and frontline clinicians in re-designing clinical care is essential for improving care delivery in a complex clinical environment. This study sought to assess an innovative user-centered design approach to improving clinical care quality, focusing on the use cases of de-intensifying non-beneficial care within the following areas: (1) de-intensifying diabetes treatment in high-risk patients; (2) stopping screening for carotid artery stenosis in asymptomatic patients; and (3) stopping colorectal cancer screening in average-risk, older adults. METHODS The user-centered design approach, consisting of patient and patient-clinician charrettes (defined as intensive workshops where key stakeholders collaborate to develop creative solutions to a specific problem) and participant surveys, has been described previously. Following the charrettes, we used inductive coding to identify and categorize themes emerging from the de-intensification ideas prioritized by participants as well as facilitator notes and audio recordings from the charrettes. RESULTS Thirty-five patients participated in the patient design charrettes, generating 134 unique de-intensification ideas and prioritizing 32, which were then distilled into six patient-generated principles of de-intensification by the study team. These principles provided a starting point for a subsequent patient-clinician charrette. In this follow-up charrette, 9 patients who had participated in an earlier patient design charrette collaborated with 7 clinicians to generate 63 potential de-intensification solutions. Six of these potential solutions were developed into multi-faceted, fully operationalized de-intensification strategies. DISCUSSION The de-intensification strategies that patients and clinicians prioritized and operationalized during the co-design charrette process were detailed and multi-faceted. Each component of a strategy had a rationale based on feasibility, practical considerations, and ways of overcoming barriers. The charrette-based process may be a useful way to engage clinicians and patients in developing the complex and multi-faceted strategies needed to improve care delivery.
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8
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Aubert CE, Henderson JB, Kerr EA, Holleman R, Klamerus ML, Hofer TP. Type 2 Diabetes Management, Control and Outcomes During the COVID-19 Pandemic in Older US Veterans: an Observational Study. J Gen Intern Med 2022; 37:870-877. [PMID: 34993873 PMCID: PMC8735737 DOI: 10.1007/s11606-021-07301-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/23/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND The COVID-19 pandemic required a change in outpatient care delivery models, including shifting from in-person to virtual visits, which may have impacted care of vulnerable patients. OBJECTIVE To describe the changes in management, control, and outcomes in older people with type 2 diabetes (T2D) associated with the shift from in-person to virtual visits. DESIGN AND PARTICIPANTS In veterans aged ≥ 65 years with T2D, we assessed the rates of visits (in person, virtual), A1c measurements, antidiabetic deintensification/intensification, ER visits and hospitalizations (for hypoglycemia, hyperglycemia, other causes), and A1c level, in March 2020 and April-November 2020 (pandemic period). We used negative binomial regression to assess change over time (reference: pre-pandemic period, July 2018 to February 2020), by baseline Charlson Comorbidity Index (CCI; > 2 vs. <= 2) and A1c level. KEY RESULTS Among 740,602 veterans (mean age 74.2 [SD 6.6] years), there were 55% (95% CI 52-58%) fewer in-person visits, 821% (95% CI 793-856%) more virtual visits, 6% (95% CI 1-11%) fewer A1c measurements, and 14% (95% CI 10-17%) more treatment intensification during the pandemic, relative to baseline. Patients with CCI > 2 had a 14% (95% CI 12-16%) smaller relative increase in virtual visits than those with CCI <= 2. We observed a seasonality of A1c level and treatment modification, but no association of either with the pandemic. After a decrease at the beginning of the pandemic, there was a rebound in other-cause (but not hypo- and hyperglycemia-related) ER visits and hospitalizations from June to November 2020. CONCLUSION Despite a shift to virtual visits and a decrease in A1c measurement during the pandemic, we observed no association with A1c level or short-term T2D-related outcomes, providing some reassurance about the adequacy of virtual visits. Further studies should assess the longer-term effects of shifting to virtual visits in different populations to help individualize care, improve efficiency, and maintain appropriate care while reducing overuse.
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Affiliation(s)
- Carole E Aubert
- Department of General Internal Medicine, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland. .,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland. .,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - James B Henderson
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Consulting for Statistics, Computing & Analytics Research (CSCAR), University of Michigan, Ann Arbor, MI, USA
| | - Eve A Kerr
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rob Holleman
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Mandi L Klamerus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Timothy P Hofer
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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9
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Affiliation(s)
- Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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10
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Radomski TR, Decker A, Khodyakov D, Thorpe CT, Hanlon JT, Roberts MS, Fine MJ, Gellad WF. Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults. JAMA Netw Open 2022; 5:e2148599. [PMID: 35166780 PMCID: PMC8848205 DOI: 10.1001/jamanetworkopen.2021.48599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Metrics that detect low-value care in common forms of health care data, such as administrative claims or electronic health records, primarily focus on tests and procedures but not on medications, representing a major gap in the ability to systematically measure low-value prescribing. OBJECTIVE To develop a scalable and broadly applicable metric that contains a set of quality indicators (EVOLV-Rx) for use in health care data to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders' perspectives. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used an online modified-Delphi method to convene an expert panel of 15 physicians and pharmacists. This panel, comprising clinicians, health system leaders, and researchers, was tasked with rating and discussing candidate low-value prescribing practices that were derived from medication safety criteria; peer-reviewed literature; and qualitative studies of patient, caregiver, and physician perspectives. The RAND ExpertLens online platform was used to conduct the activities of the panel. The panelists were engaged for 3 rounds between January 1 and March 31, 2021. MAIN OUTCOMES AND MEASURES Panelists used a 9-point Likert scale to rate and then discuss the scientific validity and clinical usefulness of the criteria to detect low-value prescribing practices. Candidate low-value prescribing practices were rated as follows: 1 to 3, indicating low validity or usefulness; 3.5 to 6, uncertain validity or usefulness; and 6.5 to 9, high validity or usefulness. Agreement among panelists and the degree of scientific validity and clinical usefulness were assessed using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method. RESULTS Of the 527 low-value prescribing recommendations identified, 27 discrete candidate low-value prescribing practices were considered for inclusion in EVOLV-Rx. After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥6.5). After round 2 panel deliberations, the criteria to detect 19 candidate practices were revised. After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for both scientific validity and clinical usefulness. Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥6.5) but uncertain clinical usefulness (scores <6.5) ratings, whereas 6 received uncertain scientific validity rating (scores <6.5). CONCLUSIONS AND RELEVANCE This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults. Applying EVOLV-Rx may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care across the full spectrum of health services.
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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 Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Alison Decker
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Dmitry Khodyakov
- RAND Corporation, Pardee RAND Graduate School, Santa Monica, California
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill
| | - Joseph T. Hanlon
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Mark S. Roberts
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - 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 (CHERP), Veterans Affairs (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 Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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11
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Schuttner L, Haraldsson B, Maynard C, Helfrich CD, Reddy A, Parikh T, Nelson KM, Wong E. Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Netw Open 2021; 4:e2130581. [PMID: 34677595 PMCID: PMC8536952 DOI: 10.1001/jamanetworkopen.2021.30581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. OBJECTIVE To understand rates and factors associated with outpatient low-value cancer screenings. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. EXPOSURES Receipt of cancer screening test. MAIN OUTCOMES AND MEASURES Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. RESULTS Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. CONCLUSIONS AND RELEVANCE This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | | | - Charles Maynard
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Christian D. Helfrich
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Ashok Reddy
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Toral Parikh
- Department of Medicine, University of Washington, Seattle
- Geriatrics and Extended Care, VA Puget Sound Healthcare System
| | - Karin M. Nelson
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Edwin Wong
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
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12
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Ospina NS, Salloum RG, Maraka S, Brito JP. De-implementing low-value care in endocrinology. Endocrine 2021; 73:292-300. [PMID: 33977312 PMCID: PMC8476071 DOI: 10.1007/s12020-021-02732-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/15/2021] [Indexed: 01/18/2023]
Abstract
Low-value care exposes patients to ineffective, costly, and potentially harmful care. In endocrinology, low-value care practices are common in the care of patients with highly prevalent conditions. There is an urgent need to move past the identification of these practices to an active process of de-implementation. However, clinicians, researchers, and other stakeholders might lack familiarity with the frameworks and processes that can help guide successful de-implementation. To address this gap and support the de-implementation of low-value care, we provide a summary of low-value care practices in endocrinology and a primer on the fundamentals of de-implementation science. Our goal is to increase awareness of low-value care within endocrinology and suggest a path forward for addressing low-value care using principles of de-implementation science.
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Affiliation(s)
- Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, 1600 SW Archer Road, Room H2, Gainesville, FL, 32606, USA.
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road, Room 2243, Gainesville, FL, 32610, USA
| | - Spyridoula Maraka
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, #587, Little Rock, AR, 72205, USA
- Central Arkansas Veterans Healthcare System, 4300W 7th St, #4E-132, Little Rock, AR, 72205, USA
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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13
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Sierocinski E, Angelow A, Mainz A, Walker J, Chenot JF. [Patient safety in the treatment of rheumatic diseases : Laboratory monitoring in methotrexate treatment]. Z Rheumatol 2021; 80:418-424. [PMID: 33709166 PMCID: PMC8189943 DOI: 10.1007/s00393-021-00976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Methotrexate (MTX) is the most commonly prescribed disease-modifying drug in the treatment of rheumatic diseases. Regular laboratory testing is recommended to recognize side effects, such as hepatotoxicity and myelotoxicity as well as decreases in renal function that may cause toxic MTX accumulation. Additionally, folic acid is recommended as prophylaxis against specific side effects. In this study we investigated whether laboratory monitoring and prescription of folic acid took place according to published recommendations. MATERIAL AND METHODS Claims data from the statutory health insurance from 1 January 2009 to 31 December 2013 were retrospectively analyzed. A total of 40,087 adults with a rheumatic diagnosis (ICD10 codes M05-M18), no malignant disease and no previous MTX prescription within 12 months were extracted from the InGef (Institute for Applied Health Research in Berlin, formerly Health Risk Institute) research database. The frequency of recommended laboratory testing, appointments with rheumatologists and the prescription of folic acid prophylaxis were investigated. RESULTS Of the patients 12,451 began treatment with MTX in the observation period. Between 42% and 46% of recommended blood counts, liver values and kidney function tests and 14% of urinalyses were performed according to recommendations. Of the patients 84% were seen regularly by a rheumatologist and 74% received a prescription for prophylactic folic acid. Serious conditions potentially resulting from MTX treatment were observed in 0.7-3.5 cases/1000 person years. DISCUSSION Laboratory monitoring in the context of MTX treatment is carried out less frequently than recommended in the literature. Potential MTX-associated serious complications are rare from a practice perspective. On the one hand solutions are needed for a better coordination of laboratory monitoring. On the other hand more empirical evidence is needed regarding the benefits of laboratory monitoring and the appropriate intervals thereof.
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Affiliation(s)
- Elizabeth Sierocinski
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald, Fleischmannstr. 6, 17485, Greifswald, Deutschland.
| | - Aniela Angelow
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald, Fleischmannstr. 6, 17485, Greifswald, Deutschland
| | - Armin Mainz
- Hausarztpraxis Korbach, Korbach, Deutschland
| | - Jochen Walker
- InGef - Institut für angewandte Gesundheitsforschung Berlin (früher Health Risk Institute), Berlin, Deutschland
| | - Jean-François Chenot
- Abteilung Allgemeinmedizin, Institut für Community Medicine, Universitätsmedizin Greifswald, Fleischmannstr. 6, 17485, Greifswald, Deutschland
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14
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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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15
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Elwenspoek MMC, Mann E, Alsop K, Clark H, Patel R, Watson JC, Whiting P. GP's perspectives on laboratory test use for monitoring long-term conditions: an audit of current testing practice. BMC FAMILY PRACTICE 2020; 21:257. [PMID: 33278890 PMCID: PMC7719260 DOI: 10.1186/s12875-020-01331-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/25/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND We have shown previously that current recommendations in UK guidelines for monitoring long-term conditions are largely based on expert opinion. Due to a lack of robust evidence on optimal monitoring strategies and testing intervals, the guidelines are unclear and incomplete. This uncertainty may underly variation in testing that has been observed across the UK between GP practices and regions. METHODS Our objective was to audit current testing practices of GPs in the UK; in particular, perspectives on laboratory tests for monitoring long-term conditions, the workload, and how confident GPs are in ordering and interpreting these tests. We designed an online survey consisting of multiple-choice and open-ended questions that was promoted on social media and in newsletters targeting GPs practicing in UK. The survey was live between October-November 2019. The results were analysed using a mixed-methods approach. RESULTS The survey was completed by 550 GPs, of whom 69% had more than 10 years of experience. The majority spent more than 30 min per day on testing (78%), but only half of the respondents felt confident in dealing with abnormal results (53%). There was a high level of disagreement for whether liver function tests and full blood counts should be done 'routinely', 'sometimes', or 'never' in patients with a certain long-term condition. The free text comments revealed three common themes: (1) pressures that promote over-testing, i.e. guidelines or protocols, workload from secondary care, fear of missing something, patient expectations; (2) negative consequences of over-testing, i.e. increased workload and patient harm; and (3) uncertainties due to lack of evidence and unclear guidelines. CONCLUSION These results confirm the variation that has been observed in test ordering data. The results also show that most GPs spent a significant part of their day ordering and interpreting monitoring tests. The lack of confidence in knowing how to act on abnormal test results underlines the urgent need for robust evidence on optimal testing and the development of clear and unambiguous testing recommendations. Uncertainties surrounding optimal testing has resulted in an over-use of tests, which leads to a waste of resources, increased GP workload and potential patient harm.
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Affiliation(s)
- Martha M C Elwenspoek
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
| | - Ed Mann
- Tyntesfield Medical Group, Bristol, BS48 2XX, UK
| | - Katharine Alsop
- Nightingale Valley Practice, Bristol, BS4 4HU, UK.,Brisdoc Healthcare Services, Bristol, BS14 0BB, UK
| | - Hannah Clark
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Rita Patel
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Penny Whiting
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
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16
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Mehta R, Lehman R. A Solution for Guideline Overkill-More Guidelines or Shared Understanding? JAMA Intern Med 2020; 180:1508-1509. [PMID: 32926070 DOI: 10.1001/jamainternmed.2020.3969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Raj Mehta
- Family Medicine Residency, AdventHealth Winter Park, Winter Park, Florida
| | - Richard Lehman
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
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