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Zenger B, Torre M, Zhang Y, Boo L, Jamshidian F, Young J, Bunch TJ, Steinberg BA. Comprehensive analysis of same day discharge after atrial fibrillation ablation: Clinical, cost, and patient reported outcomes. J Cardiovasc Electrophysiol 2024. [PMID: 38837730 DOI: 10.1111/jce.16331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/03/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Same day discharge (SDD) following atrial fibrillation (AF) ablation procedure has emerged as routine practice, and primarily driven by operator discretion. However, the impacts of SDD on clinical outcomes, healthcare system costs, and patient reported outcomes (PROs) have not been systematically studied. METHODS We retrospectively analyzed patients undergoing routine AF ablation procedures with SDD versus overnight observation (NSDD). After propensity adjustment we compared postprocedure adverse events (AEs), healthcare system costs, and changes in PROs. RESULTS We identified 310 cases, with 159 undergoing SDD and 151 staying at least one midnight in the hospital (NSDD). Compared with NSDD, SDD patients were similar age (mean 64 vs. 66, p = 0.3), sex (26% female vs. 27%, p = 0.8), and with lower mean CHADS2-VA2Sc scores (2.0 vs. 2.7; p < 0.011). The primary outcome of AEs was noninferior in SDD versus NSDD patients (odds ratio 0.45, 95% confidence interval 0.21-0.99; noninferiority margin of 10%). There were also no differences in overall cost to the healthcare system between SDD and NSDD (p = 0.11). PROs numerically favored SDD (p = NS for all scores). CONCLUSIONS Physician selection for SDD appears at least as safe as NSDD with respect to clinical outcomes and SDD is not significantly less costly to the health system. There is a trend towards more favorable, general PROs among SDD patients. Routine SDD should be strongly considered for patients undergoing routine AF ablation procedures.
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Affiliation(s)
- Brian Zenger
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Michael Torre
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Yue Zhang
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leeming Boo
- Biosense Webster Inc., Irvine, California, USA
| | | | - Jeff Young
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Thomas J Bunch
- University of Utah School of Medicine, Salt Lake City, Utah, USA
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Tian EJ, Nguyen C, Chung L, Morris C, Kumar S. The Effectiveness of Public Awareness Initiatives Aimed at Encouraging the Use of Evidence-Based Recommendations by Health Professionals: A Systematic Review. J Patient Saf 2024; 20:147-163. [PMID: 38372511 DOI: 10.1097/pts.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Public awareness initiatives have attracted growing attention globally, as a strategy to reduce low-value care and disinformation. However, knowledge gap remains in determining their effects. The aim of this systematic review was to summarize existing evidence to date on global effectiveness of public awareness initiatives. METHODS Primary quantitative studies focusing on passive delivery of public awareness initiatives that targeted health professionals were included. Eligible studies were identified through search of MEDLINE, Embase, Emcare, the Cochrane Library, PsycINFO, Business Source Complete, Emerald Insight, and Google (initially on December 19, 2018, followed by updated search between July 8-10, 2019, and then between March 8-9, 2022) and the reference list of relevant studies. Methodological quality of included studies was assessed using modified McMaster critical appraisal tool. A narrative synthesis of the study outcomes was conducted. RESULTS Twenty studies from United States, United Kingdom, Canada, Australia, and multicountry were included. Nineteen studies focused on Choosing Wisely initiative and one focused on National Institute of Clinical Excellence reminders. Most studies investigated one recommendation of a specialty. The findings showed conflicting evidence on the effectiveness of public awareness initiatives, suggesting passive delivery has limited success in reducing low-value care among health professionals. CONCLUSIONS This review highlights the complexity of change in an established practice pattern in health care. As passive delivery of public awareness initiatives has limited potential to initiate and sustain change, wide-ranging intervention components need to be integrated for a successful implementation.
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Affiliation(s)
| | - Cathy Nguyen
- UniSA Business, University of South Australia, University of South Australia, Adelaide, Australia
| | - Lilian Chung
- From the UniSA Allied Health and Human Performance
| | - Chloe Morris
- From the UniSA Allied Health and Human Performance
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Shimoni Z, Gazi M, Froom P. Do Laboratory Blood Tests Change Medical Care in Patients Hospitalized with Community-Acquired Pneumonia? Diagnostics (Basel) 2024; 14:302. [PMID: 38337819 PMCID: PMC10855841 DOI: 10.3390/diagnostics14030302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Background and Objectives: The prevalence of inappropriate laboratory testing is believed to be high, but only a limited number of studies have reviewed medical charts to determine whether tests impact medical care. Materials and Methods: From the electronic database, we selected 500 consecutive patients with community-acquired pneumonia who were hospitalized between January 2020 and October 2021. We excluded eight patients who had COVID-19, but were not identified in the database, and were only identified after chart review. To assess the impact of tests on medical care, we conducted a thorough review of the patients' charts. Results: The age of the patients was 78 ± 16 years, with 42.3% female (n = 208) hospitalized for a median of 4 days (25-75%, 3-6 days). There were 27957 laboratory test results during 2690 hospital days (10.4 tests per day of hospitalization). Of the 2997 tests carried out on admission 5.7% (n = 170) resulted in changes of medical care in 34.5% (170/492) of the patients, nearly all from the results of electrolytes, renal function tests, and serum glucose measurements. Tests that did not lead to any decision on medical care included 75.8% (7181/9478) on admission and 86.0% (15,898/18,479) on repetitive testing, i.e., repetitive testing accounted for 68.9% (15,898/23,079) of tests that did not change medical care. By excluding tests that did not change medical care, the overall testing rate would decrease by 82.6% (23,079/27,947), and from 10.4 tests per day to 2.1 tests per day. Conclusions: We conclude that the estimate of the overuse of laboratory testing, which includes all testing that does not change patient care, is much higher than reported using other methodologies. Most of the overuse was from repetitive testing that included unnecessary testing in patients without admission test results that changed medical care. Further investigation is needed to determine if these findings can be applied to patients with diverse health conditions and in different healthcare settings.
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Affiliation(s)
- Zvi Shimoni
- The Adelson School of Medicine, Ariel University, Ariel 4077625, Israel;
- Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel;
| | - Muhamad Gazi
- Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel;
| | - Paul Froom
- Clinical Utility Department, Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
- School of Public Health, University of Tel Aviv, Tel Aviv 6997801, Israel
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Zeschick N, Gollnick J, Muth J, Hörbrand F, Killian P, Donner-Banzhoff N, Kühlein T, Sebastião M. Physicians' assessment of the Bavarian drug-expenditure control system: a qualitative study. BMC Health Serv Res 2023; 23:961. [PMID: 37679698 PMCID: PMC10483772 DOI: 10.1186/s12913-023-09844-3] [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: 10/20/2022] [Accepted: 07/24/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND In 2014 a new system for drug expenditures, the Wirkstoffvereinbarung (WSV, English: Active substance agreement) was implemented in Bavaria. In pre-defined indication groups, economic prescription of medications shall be enabled based on the selection, quantity, and proportion of an individual drug. Ambulatory care physicians receive quarterly trend reports on their prescribing behavior. This study examines physicians' perceptions of the WSV. METHODS Qualitative interviews (n = 20) and seven focus groups (n = 36) were conducted with ambulatory care physicians (e.g. general practitioners, cardiologists, pulmonologists). The methodology followed Qualitative Content Analysis. RESULTS Physicians generally accepted the necessity of prescribing economically. The majority of them rated the WSV positively and better than the previous system. As an improvement, they especially named timely feedback in form of easily understandable trend reports, encouraging self-reflection as well as allowing early control options. Problems perceived were drug discount contracts that were strongly criticized as leading to patients mixing up medications. Some perceived constraints of therapeutic freedom. CONCLUSIONS The implementation of the WSV is mostly viewed positively by physicians. The restrictions of therapeutic freedom partially perceived might be met by improved information on the reasons why some drugs are rated as less economical than others. TRIAL REGISTRATION NUMBER Main ID: DRKS00019820 (German Register of Clinical Studies and World Health Organization).
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Affiliation(s)
- Nikoletta Zeschick
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Allgemeinmedizinisches Institut, Universitätsstr. 29, 91054, Erlangen, Germany
| | - Julia Gollnick
- Abteilung Für Allgemeinmedizin, Philipps Universität Marburg, Präventive und Rehabilitative Medizin, Karl-Von-Frisch-Straße 4, 35032, Marburg, Germany
| | - Julia Muth
- Abteilung Für Allgemeinmedizin, Philipps Universität Marburg, Präventive und Rehabilitative Medizin, Karl-Von-Frisch-Straße 4, 35032, Marburg, Germany
| | - Franziska Hörbrand
- Kassenärztliche Vereinigung Bayerns, Elsenheimerstraße 39, 80687, Munich, Germany
| | - Peter Killian
- Kassenärztliche Vereinigung Bayerns, Elsenheimerstraße 39, 80687, Munich, Germany
| | - Norbert Donner-Banzhoff
- Abteilung Für Allgemeinmedizin, Philipps Universität Marburg, Präventive und Rehabilitative Medizin, Karl-Von-Frisch-Straße 4, 35032, Marburg, Germany
| | - Thomas Kühlein
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Allgemeinmedizinisches Institut, Universitätsstr. 29, 91054, Erlangen, Germany
| | - Maria Sebastião
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Allgemeinmedizinisches Institut, Universitätsstr. 29, 91054, Erlangen, Germany.
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LaCroix GA, Danford DA, Marshall AM. Impact of Phlebotomy Volume Knowledge on Provider Laboratory Ordering and Transfusion Practices in the Pediatric Cardiac ICU. Pediatr Crit Care Med 2023; 24:e342-e351. [PMID: 37097037 DOI: 10.1097/pcc.0000000000003240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
OBJECTIVES Phlebotomy can account for significant blood loss in post-surgical pediatric cardiac patients. We investigated the effectiveness of a phlebotomy volume display in the electronic medical record (EMR) to decrease laboratory sampling and blood transfusions. Cost analysis was performed. DESIGN This is a prospective interrupted time series quality improvement study. Cross-sectional surveys were administered to medical personnel pre- and post-intervention. SETTING The study was conducted in a 19-bed cardiac ICU (CICU) at a Children's hospital. PATIENTS One hundred nine post-surgical pediatric cardiac patients weighing 10 kg or less with an ICU stay of 30 days or less were included. INTERVENTIONS We implemented a phlebotomy volume display in the intake and output section of the EMR along with a calculated maximal phlebotomy volume display based on 3% of patient total blood volume as a reference. MEASUREMENTS AND MAIN RESULTS Providers poorly estimated phlebotomy volume regardless of role, practice setting, or years in practice. Only 12% of providers reported the availability of laboratory sampling volume. After implementation of the phlebotomy display, there was a reduction in mean laboratories drawn per patient per day from 9.5 to 2.5 ( p = 0.005) and single electrolytes draw per patient over the CICU stay from 6.1 to 1.6 ( p = 0.016). After implementation of the reference display, mean phlebotomy volume per patient over the CICU stay decreased from 30.9 to 14.4 mL ( p = 0.038). Blood transfusion volume did not decrease. CICU length of stay, intubation time, number of reintubations, and infections rates did not increase. Nearly all CICU personnel supported the use of the display. The financial cost of laboratory studies per patient has a downward trend and decreased for hemoglobin studies and electrolytes per patient after the intervention. CONCLUSIONS Providers may not readily have access to phlebotomy volume requirements for laboratories, and most estimate phlebotomy volumes inaccurately. A well-designed phlebotomy display in the EMR can reduce laboratory sampling and associated costs in the pediatric CICU without an increase in adverse patient outcomes.
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Affiliation(s)
- Gary A LaCroix
- Department of Cardiology, University of Nebraska Medical Center, Omaha, NE
| | - David A Danford
- Department of Cardiology, University of Nebraska Medical Center, Omaha, NE
- Department of Cardiology, Children's Hospital & Medical Center, Omaha, NE
| | - Amanda M Marshall
- Department of Cardiology, University of Nebraska Medical Center, Omaha, NE
- Department of Cardiology, Children's Hospital & Medical Center, Omaha, NE
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Weinerman AS, Guo Y, Saha S, Yip PM, Lapointe-Shaw L, Fralick M, Kwan JL, MacMillan TE, Liu J, Rawal S, Sheehan KA, Simons J, Tang T, Bhatia S, Razak F, Verma AA. Data-driven approach to identifying potential laboratory overuse in general internal medicine (GIM) inpatients. BMJ Open Qual 2023; 12:e002261. [PMID: 37495257 PMCID: PMC10373691 DOI: 10.1136/bmjoq-2023-002261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge. OBJECTIVE To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests. DESIGN, SETTING AND PARTICIPANTS A multicentre, retrospective study at three academic hospitals in Toronto, Canada. All general internal medicine (GIM) hospitalisations between 1 April 2010 and 31 October 2017. RESULTS There were 106 813 GIM hospitalisations during the study period, with median hospital length-of-stay of 4.6 days (IQR: 2.33-9.19). There were 21 tests which had a cumulative cost >US$15 400 at all three sites. The costliest test was plasma electrolytes (US$4 907 775), the test with the lowest proportion of abnormal results was red cell folate (0.2%) and the test with the greatest physician-level variation in use was antiphospholipid antibodies (coefficient of variation 3.08). The five tests with the highest cumulative rank based on greatest cost, lowest proportion of abnormal results and highest physician-level variation were: (1) lactate, (2) antiphospholipid antibodies, (3) magnesium, (4) troponin and (5) partial thromboplastin time. In addition, this method identified unique tests that may be a potential source of laboratory overuse at each hospital. CONCLUSIONS A simple multidimensional, data-driven approach combining cost, proportion of abnormal results and physician-level variation can inform interventions to reduce laboratory test overuse. Reducing low value laboratory testing is important to promote high value, patient-centred care.
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Affiliation(s)
- Adina S Weinerman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yishan Guo
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sudipta Saha
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Paul M Yip
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
| | - Michael Fralick
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Janice L Kwan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Thomas E MacMillan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jessica Liu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Shail Rawal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kathleen A Sheehan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Janet Simons
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, Ontario, Canada
| | - Terence Tang
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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7
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Zenger B, Li H, Bunch TJ, Crawford C, Fang JC, Groh CA, Hess R, Navaravong L, Ranjan R, Young J, Zhang Y, Steinberg BA. Major drivers of healthcare system costs and cost variability for routine atrial fibrillation ablation. Heart Rhythm O2 2023; 4:251-257. [PMID: 37124552 PMCID: PMC10134392 DOI: 10.1016/j.hroo.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Catheter ablation is an effective treatment for atrial fibrillation (AF) but incurs significant financial costs to payers. Reducing variability may improve cost effectiveness. Objectives We aimed to measure (1) the components of direct and indirect costs for routine AF ablation procedures, (2) the variability of those costs, and (3) the main factors driving ablation cost variability. Methods Using data from the University of Utah Health Value Driven Outcomes system, we were able to measure direct, inflation-adjusted costs of uncomplicated, routine AF ablation to the healthcare system. Direct costs were considered costs incurred by pharmacy, disposable supplies, patient labs, implants, and other services categories (primarily anesthesia support) and indirect costs were considered within imaging, facility, and electrophysiology lab management categories. Results A total of 910 patients with 1060 outpatient ablation encounters were included from January 1, 2013, to December 31, 2020. Disposable supplies accounted for the largest component of cost with 44.8 ± 9.7%, followed by other services (primarily anesthesia support) with 30.4 ± 7.7% and facility costs with 16.1 ± 5.6%; pharmacy, imaging, and implant costs each contributed <5%. Direct costs were larger than indirect costs (82.4 ± 5.6% vs 17.6 ± 5.6%). Multivariable regression showed that procedure operator was the primary factor associated with AF ablation overall cost (up to 12% differences depending on operator). Conclusions Direct costs and other services (primarily anesthesia) drive the majority costs associated with AF ablations. There is significant variability in costs for these routine, uncomplicated AF ablation procedures. The procedure operator, and not patient characteristic, is the main driver for cost variability.
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Affiliation(s)
- Brian Zenger
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Haojia Li
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - T. Jared Bunch
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Candice Crawford
- Decision Support, University of Utah Health, Salt Lake City, Utah
| | - James C. Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Christopher A. Groh
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Rachel Hess
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jeff Young
- Decision Support, University of Utah Health, Salt Lake City, Utah
| | - Yue Zhang
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Fischer KA, Anand S, Walling A, Larson SM, Glaspy J. Cost-Health Literacy as an Educational Objective in Fellowship Training. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1479-1485. [PMID: 33761118 DOI: 10.1007/s13187-021-01987-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 06/12/2023]
Abstract
Physicians are encouraged to communicate with their patients about financial concerns, but are infrequently taught skills necessary to do so. This study describes a curriculum for oncology fellows aimed to improve skills of cost-health literacy, and provides assessment of the curriculum impact on self-perceived cost communication practices. Oncology fellows at a large academic program in 2019 participated in a cost-health literacy curriculum over 3 months. The curriculum consisted of a didactic on financial toxicity (45 min), a problem-based learning case highlighting financial toxicity risk factors and areas for intervention (30 min), and a group discussion (30 min) to review and consolidate strategies to navigate financial toxicity in direct patient care. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Of 19 participants, 16 completed both the pre-survey and post-survey and were included in the analysis. After the intervention, participants were more likely to report comfort discussing out-of-pocket costs (50% vs. 19%, p = 0.002) and to feel they could help a patient experiencing financial toxicity (62% vs. 6%, p = 0.005). There was no improvement in the subjective assessment of patient financial distress (57% v 50%, p = 0.759). Oncology fellows can improve self-reported cost-health literacy skills through participation in a targeted, brief curriculum. Further studies are warranted to determine how this approach can be applied in other settings and if it objectively impacts cost communication practices.
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Affiliation(s)
- Katrina A Fischer
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA.
- 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA.
| | - Sidharth Anand
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - Anne Walling
- Department of Medicine (Division of General Internal Medicine & Health Services Research), UCLA School of Medicine, Los Angeles, CA, USA
| | - Sarah M Larson
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - John Glaspy
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
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Hamada O, Tsutsumi T, Imanaka Y. Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis. Intern Med 2022; 62:1131-1138. [PMID: 36070954 PMCID: PMC10183293 DOI: 10.2169/internalmedicine.8944-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.
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Affiliation(s)
- Osamu Hamada
- Department of General Internal Medicine, Takatsuki General Hospital, Japan
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Japan
| | - Takahiko Tsutsumi
- Department of General Internal Medicine, Takatsuki General Hospital, Japan
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Japan
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10
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Kherad O, Bottequin E, Steiner D, Alibert A, Eurin R, Bothorel H. Implementing a Multifaceted Intervention among Internal Medicine Residents with Audit and Educative Data Feedback Significantly Reduces Low-Value Care in Hospitalized Patients. J Clin Med 2022; 11:jcm11092435. [PMID: 35566562 PMCID: PMC9104072 DOI: 10.3390/jcm11092435] [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] [Received: 03/11/2022] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: The dissemination of recommendations on low-value care alone may not lead to physicians’ behavioral changes. The aim of this study was to evaluate whether a multifaceted behavioral intervention among internal medicine residents could reduce low-value care in hospitalized patients. Methods: A pre–post quality improvement intervention was conducted at the Internal Medicine Division of La Tour hospital (Geneva, Switzerland) from May 2020 to October 2021. The intervention period (3 months) consisted of a multifaceted informational intervention with audits and educative feedback about low-value care. The pre- and post-intervention periods including the same six calendar months were compared in terms of number of blood samples per patient day, prescription rates of benzodiazepines (BZDs) and proton pump inhibitors (PPIs), as well as safety indicators including potentially avoidable readmissions, premature deaths and complications. results: A total of 3400 patients were included in this study; 1095 (32.2%) and 1155 (34.0%) were, respectively, hospitalized during the pre- and post-intervention periods. Patient characteristics were comparable between the two periods. Only the number of blood tests per patient day and the BZD prescription rate at discharge were significantly reduced in the post-intervention phase (pre: 0.54 ± 0.43 vs. post: 0.49 ± 0.60, p ≤ 0.001; pre: 4.2% vs. post: 1.7%, p = 0.003, respectively). PPI prescription rates remained comparable. Safety indicators analyses revealed no significant differences between the two periods of interest. Conclusions: Our results demonstrate a modest but statistically significant effect of a multifaceted educative intervention in reducing the number of blood tests and the BZD prescription rate at discharge in hospitalized patients. Limiting low-value services is very challenging and additional long-term interventions are necessary for wider implementation.
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Affiliation(s)
- Omar Kherad
- Internal Medicine Division, Hôpital de la Tour and University of Geneva, 1217 Geneva, Switzerland
- Business Intelligence Unit, Hôpital de la Tour, 1217 Geneva, Switzerland;
- Correspondence: ; Tel.: +41-227196099
| | - Ezra Bottequin
- Business Intelligence Unit, Hôpital de la Tour, 1217 Geneva, Switzerland;
| | - Dorsaf Steiner
- Quality Department, Hôpital de la Tour, 1217 Geneva, Switzerland; (D.S.); (A.A.)
| | - Axelle Alibert
- Quality Department, Hôpital de la Tour, 1217 Geneva, Switzerland; (D.S.); (A.A.)
- General Management Department, Hôpital de la Tour, 1217 Geneva, Switzerland;
| | - Rodolphe Eurin
- General Management Department, Hôpital de la Tour, 1217 Geneva, Switzerland;
| | - Hugo Bothorel
- Research Department, Hôpital de la Tour, 1217 Geneva, Switzerland;
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11
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Debbink MP, Metz TD, Nelson RE, Janes SE, Kroes A, Begaye LJ, Heuser CC, Smid MC, Silver RM, Varner MW, Einerson BD. Directly Measured Costs of Severe Maternal Morbidity Events during Delivery Admission Compared with Uncomplicated Deliveries. Am J Perinatol 2022; 39:567-576. [PMID: 34856617 PMCID: PMC9420545 DOI: 10.1055/s-0041-1740237] [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] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To estimate the actual excess costs of care for delivery admissions complicated by severe maternal morbidity (SMM) compared with uncomplicated deliveries. STUDY DESIGN This is a retrospective cohort study of all deliveries between October 2015 and September 2018 at a single tertiary academic center. Pregnant individuals ≥ 20 weeks' gestation who delivered during a hospital admission (i.e., a "delivery admission") were included. The primary exposure was SMM, as defined by Centers for Disease Control and Prevention (CDC) criteria, CDC criteria excluding blood transfusion, or by validated hospital-defined criteria (intensive care unit admission or ≥ 4 units of blood products). Potential SMM events identified via administrative and blood bank data were reviewed to confirm SMM events had occurred. Primary outcome was total actual costs of delivery admission derived from time-based accounting and acquisition costs in the institutional Value Driven Outcomes database. Cost of delivery admissions with SMM events was compared with the cost of uncomplicated delivery using adjusted generalized linear models, with separate models for each of the SMM definitions. Relative cost differences are reported due to data restrictions. RESULTS Of 12,367 eligible individuals, 12,361 had complete cost data. Two hundred and eighty individuals (2.3%) had confirmed SMM events meeting CDC criteria. CDC criteria excluding transfusion alone occurred in 1.0% (n = 121) and hospital-defined SMM in 0.6% (n = 76). In adjusted models, SMM events by CDC criteria were associated with a relative cost increase of 2.45 times (95% confidence interval [CI]: 2.29-2.61) the cost of an uncomplicated delivery. SMM by CDC criteria excluding transfusion alone was associated with a relative increase of 3.26 (95% CI: 2.95-3.60) and hospital-defined SMM with a 4.19-fold (95% CI: 3.64-4.83) increase. Each additional CDC subcategory of SMM diagnoses conferred a relative cost increase of 1.60 (95% CI: 1.43-1.79). CONCLUSION SMM is associated with between 2.5- and 4-fold higher cost than uncomplicated deliveries. KEY POINTS · Severe maternal morbidity as defined by CDC criteria confers a 2.5-fold increase in delivery hospitalization costs.. · Intensive care unit admission or ≥ 4 units of blood products confer a fourfold increase in cost.. · Costs of maternal morbidity may motivate SMM review..
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Affiliation(s)
- Michelle P. Debbink
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Torri D. Metz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Richard E. Nelson
- Department of Internal Medicine, Division of Epidemiology, University of Utah Health, Salt Lake City, Utah,Department of Pediatrics, Division of Pediatric Administration, University of Utah Health, Salt Lake City, Utah
| | - Sophie E. Janes
- University of Utah School of Medicine, University of Utah Health, Salt Lake City, Utah
| | - Alexandra Kroes
- University of Utah School of Medicine, University of Utah Health, Salt Lake City, Utah
| | - Lori J. Begaye
- Department of international Studies, University of Utah, Salt Lake City, Utah
| | - Cara C. Heuser
- Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Marcela C. Smid
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah
| | - Michael W. Varner
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Brett D. Einerson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, Utah,Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
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12
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Kukhareva PV, Weir C, Fiol GD, Aarons GA, Taft TY, Schlechter CR, Reese TJ, Curran RL, Nanjo C, Borbolla D, Staes CJ, Morgan KL, Kramer HS, Stipelman CH, Shakib JH, Flynn MC, Kawamoto K. Evaluation in Life Cycle of Information Technology (ELICIT) framework: Supporting the innovation life cycle from business case assessment to summative evaluation. J Biomed Inform 2022; 127:104014. [PMID: 35167977 PMCID: PMC8959015 DOI: 10.1016/j.jbi.2022.104014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/16/2021] [Accepted: 02/02/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Our objective was to develop an evaluation framework for electronic health record (EHR)-integrated innovations to support evaluation activities at each of four information technology (IT) life cycle phases: planning, development, implementation, and operation. METHODS The evaluation framework was developed based on a review of existing evaluation frameworks from health informatics and other domains (human factors engineering, software engineering, and social sciences); expert consensus; and real-world testing in multiple EHR-integrated innovation studies. RESULTS The resulting Evaluation in Life Cycle of IT (ELICIT) framework covers four IT life cycle phases and three measure levels (society, user, and IT). The ELICIT framework recommends 12 evaluation steps: (1) business case assessment; (2) stakeholder requirements gathering; (3) technical requirements gathering; (4) technical acceptability assessment; (5) user acceptability assessment; (6) social acceptability assessment; (7) social implementation assessment; (8) initial user satisfaction assessment; (9) technical implementation assessment; (10) technical portability assessment; (11) long-term user satisfaction assessment; and (12) social outcomes assessment. DISCUSSION Effective evaluation requires a shared understanding and collaboration across disciplines throughout the entire IT life cycle. In contrast with previous evaluation frameworks, the ELICIT framework focuses on all phases of the IT life cycle across the society, user, and IT levels. Institutions seeking to establish evaluation programs for EHR-integrated innovations could use our framework to create such shared understanding and justify the need to invest in evaluation. CONCLUSION As health care undergoes a digital transformation, it will be critical for EHR-integrated innovations to be systematically evaluated. The ELICIT framework can facilitate these evaluations.
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Affiliation(s)
- Polina V. Kukhareva
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA.
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Gregory A. Aarons
- Department of Psychiatry, UC San Diego ACTRI Dissemination and Implementation Science Center, UC San Diego, La Jolla, CA, USA
| | - Teresa Y. Taft
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Chelsey R. Schlechter
- Department of Population Health Sciences, Center for Health Outcomes and Population Equity, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Thomas J. Reese
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA
| | - Rebecca L. Curran
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Claude Nanjo
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA.
| | - Damian Borbolla
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA.
| | | | - Keaton L. Morgan
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Heidi S. Kramer
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | | | - Julie H. Shakib
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Michael C. Flynn
- Department of Family & Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA.
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13
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Ito H, Okamoto K, Yamamoto S, Yamashita M, Kanno Y, Jubishi D, Ikeda M, Harada S, Okugawa S, Moriya K. Incidence and Risk Factors for Inappropriate Use of Non-Culture-Based Fungal Assays: Implication for Diagnostic Stewardship. Open Forum Infect Dis 2022; 9:ofab601. [PMID: 35024373 PMCID: PMC8743121 DOI: 10.1093/ofid/ofab601] [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] [Received: 10/10/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background Non-culture-based fungal assays (NCBFAs) have been used increasingly to help diagnose invasive fungal diseases. However, little is known about inappropriate use of NCBFAs. We aimed to investigate inappropriate use of NCBFAs in a tertiary academic hospital. Methods This retrospective cohort study included patients who underwent testing with beta-D glucan (BDG) between January and March 2018 or with galactomannan antigen (GMA) or cryptococcal antigen (CRAG) between January and June 2018. Testing was deemed appropriate if the clinical presentation was compatible with a fungal infection and there was a predisposing host factor at the time of ordering. We compared patients with appropriate and inappropriate use of NCBFAs using multivariate logistic regression analysis. Results Four hundred seventy patients (BDG, 394; GMA, 138; CRAG, 164) met inclusion criteria and were evaluated. About 80% of NCBFAs were deemed inappropriate. Ordering by transplant medicine physicians, repetitions of the test, the absence of predisposing factors for fungal infections, and the absence of recommendations from infectious diseases consultants were associated with an increased risk of inappropriate NCBFA use. Conclusions We found that a large proportion of NCBFAs were deemed inappropriate. There is an opportunity for diagnostic stewardship to reduce avoidable fungal testing among patients at low risk for fungal infection.
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Affiliation(s)
- Hiroshi Ito
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan.,Division of Hospital Medicine, University of Tsukuba Hospital, Ibaraki, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Shinya Yamamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Marie Yamashita
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshiaki Kanno
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Daisuke Jubishi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Mahoko Ikeda
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Sohei Harada
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan.,Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
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14
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Transfusion Preparedness in the Labor and Delivery Unit: An Initiative to Improve Safety and Cost. Obstet Gynecol 2021; 138:788-794. [PMID: 34619726 DOI: 10.1097/aog.0000000000004571] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery. METHODS Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation. Patients were risk-stratified in alignment with California Maternal Quality Care Collaborative recommendations. Under the new policy, the blood bank holds a blood sample for processing (hold clot) on patients at low- and medium-risk of hemorrhage. Type and screen and crossmatch are obtained on high-risk patients or with a prior positive antibody screen. We collected patient outcomes, safety and cost data, and compliance and resource utilization metrics. Cost included direct costs of transfusion-related testing in the labor and delivery unit during the study period, from a health system perspective. RESULTS In 1 year postimplementation, there were no differences in emergency-release transfusion events (4 vs 3, P>.99). There were fewer emergency-release red blood cell (RBC) units transfused (9 vs 24, P=.002) and O-negative RBC units transfused (8 vs 18, P=.016) postimplementation compared with preimplementation. Hysterectomies (0.05% vs 0.1%, P=.44) and intensive care unit admissions (0.45% vs 0.51%, P=.43) were not different postimplementation compared with preimplementation. Postimplementation, mean monthly type and screen-related costs (ABO typing, antibody screen, and antibody workup costs) were lower, $9,753 compared with $20,676 in the preimplementation year, P<.001. CONCLUSION Implementation of selective type and screen policy in the labor and delivery unit was associated with projected annual savings of $181,000 in an institution with 4,000 deliveries per year, without evidence of increased maternal morbidity.
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15
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Read AJ, Waljee AK, Sussman JB, Singh H, Chen GY, Vijan S, Saini SD. Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians. JAMA Netw Open 2021; 4:e2127827. [PMID: 34596670 PMCID: PMC8486982 DOI: 10.1001/jamanetworkopen.2021.27827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer. OBJECTIVE To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy. DESIGN, SETTING, AND PARTICIPANTS This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA. MAIN OUTCOMES AND MEASURES Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation. RESULTS Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years. CONCLUSIONS AND RELEVANCE In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.
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Affiliation(s)
- Andrew J. Read
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Jeremy B. Sussman
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Grace Y. Chen
- Department of Internal Medicine, 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
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer D. Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
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16
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Cliff BQ, Avanceña ALV, Hirth RA, Lee SYD. The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systematic Review. Milbank Q 2021; 99:1024-1058. [PMID: 34402553 DOI: 10.1111/1468-0009.12531] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Policy Points Dissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low-value health services. Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low-value services. Multicomponent interventions targeting clinicians are currently the most effective types of interventions. CONTEXT Choosing Wisely aims to reduce the use of unnecessary, low-value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low-value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective. METHODS We searched peer-reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi-squared tests or Wald tests to compare across interventions. FINDINGS We reviewed 131 articles. Eighty-eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician-based interventions were more effective than consumer-based, though there is a dearth of studies on consumer-based interventions. Only 17% of studies included a control arm. CONCLUSIONS Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low-value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high-quality studies that include active controls.
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Affiliation(s)
- Betsy Q Cliff
- School of Public Health, University of Illinois Chicago
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17
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Tackling the unknowns in understanding and management of hospital acquired anemia. Blood Rev 2021; 49:100830. [PMID: 33810899 DOI: 10.1016/j.blre.2021.100830] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/21/2021] [Accepted: 03/21/2021] [Indexed: 01/29/2023]
Abstract
Hospital acquired anemia (HAA) has been a recognized entity for nearly 50 years. Despite multiple hypotheses, a mechanistic understanding is lacking, and targeted interventions have not yet yielded significantly impactful results. Known risk factors include advanced age, multiple co-morbidities, low bone marrow reserve, admission to the intensive care unit, and frequent phlebotomy. However, confounding variables in many studies continues to complicate the identification of additional risk factors. Improved understanding of iron metabolism, erythropoiesis, and the erythroid iron restriction response in the last few decades, as well as the recent demonstration of poor outcomes correlating with increased transfusion have refocused attention on HAA. While retrospective database studies provide ample correlative data between 1) HAA and poor outcomes; 2) reduction of phlebotomy volume and decrease in transfusion requirement; and 3) over-transfusion and increased mortality, no causal link between reduced phlebotomy volume, decreased rates of HAA, and improved mortality or other relevant outcomes have been definitely established. Here, we review the current state of knowledge and provide a summary of potential directions to understand and mitigate HAA. There are at present no clear guidelines on whether and when to evaluate hospitalized patients for underlying causes of anemia. We thus provide a guide for clinicians in general practice toward identifying patients at the highest risk for HAA, decreasing blood loss through phlebotomy to the greatest degree feasible, and evaluating and treating reversible causes of anemia in a targeted population.
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18
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Cost of Elective Labor Induction Compared With Expectant Management in Nulliparous Women. Obstet Gynecol 2020; 136:19-25. [PMID: 32541288 DOI: 10.1097/aog.0000000000003930] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the actual health-system cost of elective labor induction at 39 weeks of gestation with expectant management. METHODS This was an economic analysis of patients enrolled in the five Utah hospitals participating in a multicenter randomized trial of elective labor induction at 39 weeks of gestation compared with expectant management in low-risk nulliparous women. The entire trial enrolled more than 6,000 patients. For this subset, 1,201 had cost data available. The primary outcome was relative direct health care costs of maternal and neonatal care from a health system perspective. Secondary outcomes included the costs of each phase of maternal and neonatal care. Direct health system costs of maternal and neonatal care were measured using advanced costing analytics from the time of randomization at 38 weeks of gestation until exit from the study up to 8 weeks postpartum. Costs in each randomization arm were compared using generalized linear models and reported as the relative cost of induction compared with expectant management. With a fixed sample size, we had adequate power to detect a 7.3% or greater difference in overall costs. RESULTS The total cost of elective induction was no different than expectant management (mean difference +4.7%; 95% CI -2.1% to +12.0%; P=.18). Maternal outpatient antenatal care costs were 47.0% lower in the induction arm (95% CI -58.3% to -32.6%; P<.001). Maternal inpatient intrapartum and delivery care costs, conversely, were 16.9% higher among women undergoing labor induction (95% CI +5.5% to +29.5%; P=.003). Maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge did not differ between arms. CONCLUSION Total costs of elective labor induction and expectant management did not differ significantly. These results challenge the assumption that elective induction of labor leads to significant cost escalation.
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Porter ED, Kelly JL, Fay KA, Hasson RM, Millington TM, Finley DJ, Phillips JD. Reducing Unnecessary Chest X-Ray Films After Thoracic Surgery: A Quality Improvement Initiative. Ann Thorac Surg 2020; 111:1012-1018. [PMID: 32739255 DOI: 10.1016/j.athoracsur.2020.05.161] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/11/2020] [Accepted: 05/27/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized. METHODS A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees. RESULTS During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P < .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year. CONCLUSIONS Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing.
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Affiliation(s)
- Eleah D Porter
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Kayla A Fay
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rian M Hasson
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| | - Timothy M Millington
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| | - David J Finley
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| | - Joseph D Phillips
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire.
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Chakravarthy R, Goggins K, Leverenz D, Trumbo SP, Kripalani S, Limper HM. Lessons Learned from Efforts to Reduce Overuse of Cardiac Telemetry Monitoring. Jt Comm J Qual Patient Saf 2020; 46:464-470. [PMID: 32505628 DOI: 10.1016/j.jcjq.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Inappropriate use of telemetry monitoring is common, increasing costs, false alarms, and length of stay. The Society of Hospital Medicine and Choosing Wisely encourage the use of discontinuation protocols. METHODS This quality improvement initiative measured the impact of an educational intervention and distribution of performance reports for physicians and residents on the general medicine service. The intervention group received a 15-minute didactic session on appropriate indications for telemetry followed by weekly performance reports for 78 weeks. A segmented linear regression model and Student's t-test were used to determine intervention effects on percentage of patients on telemetry and telemetry orders lasting more than 48 hours. RESULTS Prior to the intervention, 4.8% of patients received telemetry monitoring; 13.4% of telemetry orders exceeded 48 hours. The control service had a baseline telemetry utilization of 2.4%; 1.2% of telemetry orders exceeded 48 hours. After the intervention, 3.9% of patients received telemetry monitoring; 10.6% of telemetry orders exceeded 48 hours. The control service had a postintervention telemetry utilization of 2.1%; 1.1% of telemetry orders exceeded 48 hours. The Student's t-test showed a statistically significant (p = 0.002) decrease in telemetry ordering rate on the intervention service and no significant change in the control group. However, when using segmented linear regression analysis, these changes could not be attributed to the intervention nor were there any significant changes in balancing metrics. CONCLUSION Education and weekly performance feedback did not significantly impact telemetry according to segmented linear regression results. Segmented linear regression analysis of an interrupted time series yielded significantly different results from a pre-post comparison using Student's t-test. Rigorous evaluation is vital to decreasing unnecessary care and successful reduction in unnecessary care may require interventions that capitalize on systems-level change.
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Ambasta A, Ma IWY, Woo S, Lonergan K, Mackay E, Williamson T. Impact of an education and multilevel social comparison–based intervention bundle on use of routine blood tests in hospitalised patients at an academic tertiary care hospital: a controlled pre-intervention post-intervention study. BMJ Qual Saf 2020; 29:1-2. [DOI: 10.1136/bmjqs-2019-010118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/16/2020] [Accepted: 01/26/2020] [Indexed: 11/03/2022]
Abstract
BackgroundRepetitive inpatient laboratory testing contributes to waste in healthcare. We evaluated an intervention bundle combining education and multilevel social comparison feedback to safely reduce repetitive use of inpatient routine laboratory tests.MethodsThis non-randomised controlled pre-intervention post-intervention study was conducted in four adult hospitals from October 2016 to March 2018. In the medical teaching unit (MTU) of the intervention site, learners received education and aggregate social comparison feedback and attending internists received individual comparison feedback on routine laboratory test utilisation. MTUs of the remaining three sites served as control units. Number and cost of routine laboratory tests ordered per patient-day before and after the intervention was compared with the control units, adjusting for patient factors. Safety endpoints included number of critically abnormal laboratory test results, number of stat laboratory test orders, patient length of stay, transfer rate to the ICU, and 30-day readmission and mortality.ResultsA total of 14 000 patients were included. Pre-intervention and post-intervention groups were similar in age, sex, Charlson Comorbidity Index and length of stay. From the pre-intervention period to the post-intervention period, significantly fewer routine laboratory tests were ordered at the intervention MTU (incidence rate ratio=0.89; 95% CI 0.79 to 1.00; p=0.048) with associated costs savings of $C68 877 (p=0.020) as compared with the control sites. The variability in the ordering pattern of internists at the intervention site also decreased post-intervention. No worsening was noted in the safety endpoints between the pre-intervention and post-intervention period at the intervention unit compared with the controls.ConclusionsCombination of education and multilevel social comparison feedback significantly and safely led to cost savings through reduced use of routine laboratory tests in hospitalised patients.
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Jalbert R, Gob A, Chin-Yee I. Decreasing daily blood work in hospitals: What works and what doesn't. Int J Lab Hematol 2019; 41 Suppl 1:151-161. [PMID: 31069984 DOI: 10.1111/ijlh.13015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022]
Abstract
Recurrent, inappropriate laboratory testing is a costly and wasteful use of healthcare resources. Recognizing this problem, the American Board of Internal Medicine, Canadian Society of Internal Medicine, and the Canadian Association of Pathologist all supported the Choosing Wisely campaign to reduce laboratory investigations in patients who demonstrate clinical and laboratory stability. In this narrative, we review studies looking at a variety of approaches to reduce excessive testing including education, audit and feedback, computerized physician order entry system changes, and forcing functions. Each type of intervention has its own unique advantages and disadvantages, varying in complexity, disruptiveness, effectiveness, and sustainability. Before implementing any quality improvement project, it is important to analyze the local context to identify the root causes for the practice behavior and aim to use the minimal amount of intervention to achieve the desired result. Change is often incremental and will seldom occur with a single intervention or Plan-Do-Study-Act cycle. Garnering the support of opinion leaders and a quality improvement team will help make the process and intervention a success.
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Affiliation(s)
- Rochelle Jalbert
- Division of Hematology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Alan Gob
- Division of Hematology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Ian Chin-Yee
- Division of Hematology, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
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Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training. AJR Am J Roentgenol 2019; 212:859-866. [PMID: 30779671 DOI: 10.2214/ajr.18.19931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources. MATERIALS AND METHODS Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1-9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non-house staff. Generalized linear models further estimated the modifying effect of the house staff variable. RESULTS Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17-0.64) and non-house staff (baseline increase, 0.58; 95% CI, 0.34-0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period. CONCLUSION Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non-house staff.
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Graham LA, Wagner TH, Richman JS, Morris MS, Copeland LA, Harris AH, Itani KM, Hawn MT. Exploring Trajectories of Health Care Utilization Before and After Surgery. J Am Coll Surg 2018; 228:116-128. [PMID: 30359825 DOI: 10.1016/j.jamcollsurg.2018.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term trajectories of health care utilization in the context of surgery have not been well characterized. The objective of this study was to examine health care utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated after surgical admissions. STUDY DESIGN Hospital medical and surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (October 1, 2007 to September 30, 2014) were identified. Group-based trajectory analysis identified 5 distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression. RESULTS Of 280,681 surgery inpatients, most underwent orthopaedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of health care utilization were identified, with 5.2% of patients among consistently high inpatient users accounting for 34.0% of inpatient days. Male (95.4% vs 93.5%, p < 0.01), African-American (21.6% vs 17.3%, p < 0.01), or unmarried patients (61.6% vs 52.5%, p < 0.01) were more likely to be high health care users as compared with other trajectories. High users also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs 16.3%; bipolar disorder: 5.3% vs 2.1%, p < 0.01), social/behavioral risk factors (smoker: 41.1% vs 33.6%, p < 0.01; alcohol use disorder: 28.9% vs 12.9%, p < 0.01), and chronic pain (6.4% vs 2.8%, p < 0.01). CONCLUSIONS Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative health care utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.
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Affiliation(s)
- Laura A Graham
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL
| | - Todd H Wagner
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA
| | - Joshua S Richman
- Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Melanie S Morris
- Birmingham Health Services Research & Development Unit, Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA; University of Massachusetts Medical School, Worcester, MA
| | - Alex Hs Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA
| | - Kamal Mf Itani
- VA Boston Health Care System, Boston University and Harvard Medical School, Boston, MA
| | - Mary T Hawn
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Stanford, CA.
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Bindraban RS, Ten Berg MJ, Naaktgeboren CA, Kramer MHH, Van Solinge WW, Nanayakkara PWB. Reducing Test Utilization in Hospital Settings: A Narrative Review. Ann Lab Med 2018; 38:402-412. [PMID: 29797809 PMCID: PMC5973913 DOI: 10.3343/alm.2018.38.5.402] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/23/2018] [Accepted: 05/06/2018] [Indexed: 11/19/2022] Open
Abstract
Background Studies addressing the appropriateness of laboratory testing have revealed approximately 20% overutilization. We conducted a narrative review to (1) describe current interventions aimed at reducing unnecessary laboratory testing, specifically in hospital settings, and (2) provide estimates of their efficacy in reducing test order volume and improving patient-related clinical outcomes. Methods The PubMed, Embase, Scopus, Web of Science, and Canadian Agency for Drugs and Technologies in Health-Health Technology Assessment databases were searched for studies describing the effects of interventions aimed at reducing unnecessary laboratory tests. Data on test order volume and clinical outcomes were extracted by one reviewer, while uncertainties were discussed with two other reviewers. Because of the heterogeneity of interventions and outcomes, no meta-analysis was performed. Results Eighty-four studies were included. Interventions were categorized into educational, (computerized) provider order entry [(C)POE], audit and feedback, or other interventions. Nearly all studies reported a reduction in test order volume. Only 15 assessed sustainability up to two years. Patient-related clinical outcomes were reported in 45 studies, two of which found negative effects. Conclusions Interventions from all categories have the potential to reduce unnecessary laboratory testing, although long-term sustainability is questionable. Owing to the heterogeneity of the interventions studied, it is difficult to conclude which approach was most successful, and for which tests. Most studies had methodological limitations, such as the absence of a control arm. Therefore, well-designed, controlled trials using clearly described interventions and relevant clinical outcomes are needed.
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Affiliation(s)
- Renuka S Bindraban
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maarten J Ten Berg
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark H H Kramer
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Wouter W Van Solinge
- Departments of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Prabath W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Hueth KD, Jackson BR, Schmidt RL. An Audit of Repeat Testing at an Academic Medical Center: Consistency of Order Patterns With Recommendations and Potential Cost Savings. Am J Clin Pathol 2018; 150:27-33. [PMID: 29718090 DOI: 10.1093/ajcp/aqy020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To evaluate the prevalence of potentially unnecessary repeat testing (PURT) and the associated economic burden for an inpatient population at a large academic medical facility. METHODS We evaluated all inpatient test orders during 2016 for PURT by comparing the intertest times to published recommendations. Potential cost savings were estimated using the Centers for Medicare & Medicaid Services maximum allowable reimbursement rate. We evaluated result positivity as a determinant of PURT through logistic regression. RESULTS Of the evaluated 4,242 repeated target tests, 1,849 (44%) were identified as PURT, representing an estimated cost-savings opportunity of $37,376. Collectively, the association of result positivity and PURT was statistically significant (relative risk, 1.2; 95% confidence interval, 1.1-1.3; P < .001). CONCLUSIONS PURT contributes to unnecessary health care costs. We found that a small percentage of providers account for the majority of PURT, and PURT is positively associated with result positivity.
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Affiliation(s)
- Kyle D Hueth
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
| | - Brian R Jackson
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
- ARUP Laboratories, Salt Lake City, UT
| | - Robert L Schmidt
- Department of Pathology, Health Sciences Center, University of Utah, Salt Lake City
- ARUP Laboratories, Salt Lake City, UT
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Tchou MJ, Tang Girdwood S, Wormser B, Poole M, Davis-Rodriguez S, Caldwell JT, Shannon L, Hagedorn PA, Biondi E, Simmons J, Anderson J, Brady PW. Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods. Pediatrics 2018; 141:peds.2017-3187. [PMID: 29618583 PMCID: PMC7008632 DOI: 10.1542/peds.2017-3187] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.
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Affiliation(s)
- Michael J. Tchou
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | | | | | - Meifawn Poole
- Pediatric Residency Training Program, Cincinnati, Ohio
| | | | | | - Lauren Shannon
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Philip A. Hagedorn
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Eric Biondi
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Jeffrey Simmons
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | - Jeffrey Anderson
- James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio;,Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W. Brady
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
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Schmidt RL, Colbert-Getz JM, Milne CK, Vargo DJ, Hussong JW, Hoidal JR, Markewitz BA, Walker BS, Kawamoto K. Impact of Laboratory Charge Display Within the Electronic Health Record Across an Entire Academic Medical Center: Results of a Randomized Controlled Trial. Am J Clin Pathol 2017; 148:513-522. [PMID: 29165570 DOI: 10.1093/ajcp/aqx110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the impact of systemwide charge display on laboratory utilization. METHODS This was a randomized controlled trial with a baseline period and an intervention period. Tests were randomized to a control arm or an active arm. The maximum allowable Medicare reimbursement rate was displayed for tests in the active arm during the intervention period. Total volume of tests in the active arm was compared with those in the control arm. Residents were surveyed before and after the intervention to assess charge awareness. RESULTS Charge display had no effect on order behavior. This result held for patient type (inpatient vs outpatient) and for insurance category (commercial, government, self-pay). Residents overestimated the charges of tests both before and after the intervention. Many residents failed to notice the charge display in the computerized order entry system. CONCLUSIONS The impact of charge display depends on context. Charge display is not always effective.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City
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Kurtzman G, Dine J, Epstein A, Gitelman Y, Leri D, Patel MS, Ryskina K. Internal Medicine Resident Engagement with a Laboratory Utilization Dashboard: Mixed Methods Study. J Hosp Med 2017; 12:743-746. [PMID: 28914280 PMCID: PMC5803096 DOI: 10.12788/jhm.2811] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The objective of this study was to measure internal medicine resident engagement with an electronic medical record-based dashboard providing feedback on their use of routine laboratory tests relative to service averages. From January 2016 to June 2016, residents were e-mailed a snapshot of their personalized dashboard, a link to the online dashboard, and text summarizing the resident and service utilization averages. We measured resident engagement using e-mail read-receipts and web-based tracking. We also conducted 3 hour-long focus groups with residents. Using grounded theory approach, the transcripts were analyzed for common themes focusing on barriers and facilitators of dashboard use. Among 80 residents, 74% opened the e-mail containing a link to the dashboard and 21% accessed the dashboard itself. We did not observe a statistically significant difference in routine laboratory ordering by dashboard use, although residents who opened the link to the dashboard ordered 0.26 fewer labs per doctor-patient-day than those who did not (95% confidence interval, -0.77 to 0.25; 𝑃 = 0 .31). While they raised several concerns, focus group participants had positive attitudes toward receiving individualized feedback delivered in real time.
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Affiliation(s)
- Gregory Kurtzman
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Jessica Dine
- Division of Pulmonary and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew Epstein
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Yevgenly Gitelman
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Damien Leri
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Miltesh S Patel
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Kyra Ryskina
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ellenbogen MI, O'Leary KJ. Reducing Routine Labs-Teaching Residents Restraint. J Hosp Med 2017; 12:781-782. [PMID: 28914290 DOI: 10.12788/jhm.2817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Michael I Ellenbogen
- Hospitalist Program, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Kevin J O'Leary
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Barnard JG, Dempsey AF, Brewer SE, Pyrzanowski J, Mazzoni SE, O'Leary ST. Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings. Am J Obstet Gynecol 2017; 216:69.e1-69.e7. [PMID: 27687213 DOI: 10.1016/j.ajog.2016.09.096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/02/2016] [Accepted: 09/17/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many young and middle-aged women receive their primary health care from their obstetrician-gynecologists. A recent change to vaccination recommendations during pregnancy has forced the integration of new clinical processes at obstetrician-gynecology practices. Evidence-based best practices for vaccination delivery include the establishment of vaccination standing orders. OBJECTIVES As part of an intervention to increase adoption of evidence-based vaccination strategies for women in safety-net and private obstetrician-gynecology settings, we conducted a qualitative study to identify the facilitators and barriers experienced by obstetrician-gynecology sites when establishing vaccination standing orders. STUDY DESIGN At 6 safety-net and private obstetrician-gynecology practices, 51 semistructured interviews were completed by trained qualitative researchers over 2 years with clinical staff and vaccination program personnel. Standardized qualitative research methods were used during data collection and team-based data analysis to identify major themes and subthemes within the interview data. RESULTS All study practices achieved partial to full implementation of vaccine standing orders for human papillomavirus, tetanus diphtheria pertussis, and influenza vaccines. Facilitating factors for vaccine standing order adoption included process standardization, acceptance of a continual modification process, and staff training. Barriers to vaccine standing order adoption included practice- and staff-level competing demands, pregnant women's preference for medical providers to discuss vaccine information with them, and staff hesitation in determining HPV vaccine eligibility. CONCLUSIONS With guidance and commitment to integration of new processes, obstetrician-gynecology practices are able to establish vaccine standing orders for pregnant and nonpregnant women. Attention to certain process barriers can aid the adoption of processes to support the delivery of vaccinations in obstetrician-gynecology practice setting, and provide access to preventive health care for many women.
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Affiliation(s)
- Juliana G Barnard
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO; General Academic Pediatrics, University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO.
| | - Amanda F Dempsey
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO; General Academic Pediatrics, University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO
| | - Sarah E Brewer
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
| | - Jennifer Pyrzanowski
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO
| | - Sara E Mazzoni
- Department of Obstetrics and Gynecology, Denver Health and Hospitals Authority, Denver, CO
| | - Sean T O'Leary
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO; General Academic Pediatrics, University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO
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Kahn SE. Improving Laboratory Utilization Is a Top Priority for Laboratory Directors. ACTA ACUST UNITED AC 2016; 1:325-328. [DOI: 10.1373/jalm.2016.021105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/15/2016] [Indexed: 11/06/2022]
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