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Dave YA, Temple LKF, Juviler PG, Nabozny MJ, Cvetanovska M, Wakeman D, Cannon LM. Think Twice: De-implementation of Laboratory Testing After Colorectal Surgery. Dis Colon Rectum 2024; 67:587-595. [PMID: 38108409 DOI: 10.1097/dcr.0000000000003156] [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: 12/19/2023]
Abstract
BACKGROUND Clinically unindicated laboratory testing contributes to low-value care. Most postoperative day 1 laboratory tests after colorectal surgery are normal. However, no published interventions have shown that reducing overall postoperative laboratory testing is safe. OBJECTIVE This study aimed to investigate the impact of reducing postoperative laboratory testing after colorectal surgery. DESIGN This is a quality improvement study. SETTINGS The study was conducted at an academic center with an enhanced recovery after surgery program that included 5 daily laboratory tests until discharge. PATIENTS All adults undergoing colorectal or small-bowel surgery formed intervention and nonintervention cohorts based on surgeons who chose to opt into the study. Preimplementation (November 2019-October 2021), there were 545 intervention and 577 nonintervention patients. Postimplementation (November 2021-March 2023), there were 448 intervention and 437 nonintervention patients. INTERVENTIONS The intervention included 3 postoperative day 1 laboratory tests and subsequent clinically indicated laboratory tests. MAIN OUTCOME MEASURES Outcome measures included laboratory tests and days free of laboratory work. RESULTS Postintervention, the intervention group had a 33% reduction in laboratory tests per hospital stay, a 26% reduction in laboratory tests per day, and a 49% increase in laboratory test-free days. There was no difference in length of stay (4 vs 4; p = 0.79) or readmissions (14.9% vs 12.9%; p = 0.39). The nonintervention group had no significant changes in laboratory work or laboratory test-free days, with no differences in length of stay (4 vs 4; p = 0.49) or readmissions (11.1% vs 11.0%; p = 0.96). LIMITATIONS Demographics and complication rates were not reported. CONCLUSIONS An intervention targeting reflexive laboratory testing after colorectal surgery resulted in safe, significant, sustained reductions in postoperative laboratory work, with substantial cost savings. These findings prompted a change in the laboratory order set to an opt-out system, and laboratory work reduction approaches have been implemented within other surgical divisions. Continuation and spread of these efforts are instrumental for prioritization of high-value surgical care. See Video Abstract . PINSELO DOS VECES ELIMINACIN DE LAS PRUEBAS DE LABORATORIO DESPUS DE LA CIRUGA COLORRECTAL ANTECEDENTES:Las pruebas de laboratorio clínicamente no indicadas contribuyen a una atención de bajo valor. La mayoría de los análisis de laboratorio del primer día post operatorios de una cirugía colorrectal son normales. Sin embargo, ninguna intervención publicada ha demostrado que reducir las pruebas de laboratorio post operatorias generales sea seguro.OBJETIVO:El objetivo de este estudio fue investigar el impacto de reducir las pruebas de laboratorio pos toperatorias después de la cirugía colorrectal.DISEÑO:Este es un estudio de mejora de la calidad.AJUSTES:El estudio se llevó a cabo en un centro académico con un programa mejorado de recuperación después de la cirugía que incluye 5 laboratorios diarios hasta el alta.PACIENTES:Todos los adultos sometidos a cirugía colorrectal o de intestino delgado formaron cohortes de intervención y no intervención basadas en los cirujanos que optaron por participar en el estudio. Antes de la implementación (noviembre de 2019 - octubre de 2021) había 545 pacientes con intervención y 577 sin intervención. Después de la implementación (noviembre de 2021 - marzo de 2023) hubo 448 pacientes con intervención y 437 sin intervención.INTERVENCIONES:La intervención incluyó 3 laboratorios post operatorios del primer día y laboratorios posteriores clínicamente indicados.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron pruebas de laboratorio y días sin laboratorio.RESULTADOS:Después de la intervención, el grupo de intervención tuvo una reducción del 33 % en laboratorios por estancia hospitalaria, una reducción del 26 % en laboratorios por día y un aumento del 49 % en los días sin laboratorio. No hubo diferencias en la duración de la estancia hospitalaria (4 frente a 4; p = 0,79) ni en los reingresos (14,9% frente a 12,9%; p = 0,39). El grupo de no intervención no tuvo cambios significativos en el trabajo de laboratorio o en los días sin laboratorio, sin diferencias en la duración de la estadía (4 versus 4; p = 0,49) o reingresos (11,1% versus 11,0%; p = 0,96).LIMITACIONES:No se informaron datos demográficos ni tasa de complicaciones.CONCLUSIONES:Una intervención dirigida a pruebas de laboratorio reflexivas después de la cirugía colorrectal resultó en reducciones seguras, significativas y sostenidas en el trabajo de laboratorio post operatorio, con ahorros sustanciales de costos. Estos hallazgos provocaron un cambio en el orden del laboratorio establecido hacia un sistema de exclusión voluntaria, y se han implementado enfoques de reducción del trabajo de laboratorio en otras divisiones quirúrgicas. La continuación y difusión de estos esfuerzos son fundamentales para priorizar la atención quirúrgica de alto valor. (Traducción-Dr. Mauricio Santamaria ).
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Affiliation(s)
- Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
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Lehut T, Lambert C, Mortier R, Futier E, Chabanne R, Bauer U, Verdier P, Ravan R, Ocquidant P, Mourgues C, Lautrette A. Cost awareness among intensivists in their daily clinical practice: a prospective multicentre study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024:10.1007/s10198-024-01686-y. [PMID: 38472725 DOI: 10.1007/s10198-024-01686-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Better cost-awareness is a prerogative in achieving the best benefit/risk/cost ratio in the care. We aimed to assess the cost-awareness of intensivists in their daily clinical practice and to identify factors associated with accurate estimate of cost (50-150% of the real cost). METHODS We performed a prospective observational study in seven French ICUs. We compared the estimate of intensivists of the daily costs of caring with the real costs on a given day. The estimates covered five categories (drugs, laboratory tests, imaging modalities, medical devices, and waste) whose sum represented the overall cost. RESULTS Of the 234 estimates made by 65 intensivists, 70 (29.9%) were accurate. The median overall cost estimate (€330 [170; 620]) was significantly higher than the real cost (€178 [124; 239], p < 0.001). This overestimation was found in four categories, in particular for waste (€40 [15; 100] vs. €1.1 [0.6; 2.3], p < 0.001). Only the laboratory tests were underestimated (€65 [30; 120] vs. €106 [79; 138], p < 0.001). Being aware of the financial impact of prescriptions was factor associated with accurate estimate (OR: 5.05, 95%CI:1.47-17.4, p = 0.01). However, feeling able to accurately perform estimation was factor negatively associated with accurate estimate (OR: 0.11, 95%CI: 0.02-0.71, p = 0.02). CONCLUSION French intensivists have a poor awareness of costs in their daily clinical practice. Raising awareness of the financial impact of prescriptions, and of the cost of laboratory tests and waste are the main areas for improvement that could help achieve the objective of the best care at the best cost.
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Affiliation(s)
- Timothée Lehut
- Department of Anaesthesiology and Critical Care Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Romain Mortier
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Anaesthesiology and Critical Care Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Russell Chabanne
- Department of Anaesthesiology and Critical Care Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ulrich Bauer
- Intensive Care Unit, Cancer Center Jean Perrin, Clermont-Ferrand, France
| | - Philippe Verdier
- Intensive Care Unit, Centre Hospitalier de Montluçon, Montluçon, France
| | - Ramin Ravan
- Intensive Care Unit, Centre Hospitalier Jacques Lacarin, Vichy, France
| | | | - Charline Mourgues
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Intensive Care Unit, Cancer Center Jean Perrin, Clermont-Ferrand, France.
- Intensive Care Medicine, CHU Clermont-Ferrand,Intensive Care Unit, Cancer Centre Jean Perrin, Clermont-Ferrand, 54 rue Montalembert BP69, Cedex 1, 63003, France.
- LMGE (Laboratoire Micro-organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France.
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Eberlein TR, Knudsen J, Lylloff L, Markussen MS, Nielsen P, Mose FH. Reversing a trend towards overtesting in a department of internal medicine in Denmark. BMJ Open Qual 2023; 12:e001934. [PMID: 38123472 DOI: 10.1136/bmjoq-2022-001934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/29/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
| | - Judith Knudsen
- Department of Medicine, Gødstrup Hospital, Herning, Denmark
| | - Louise Lylloff
- Department of Clinical Biochemistry, Gødstrup Hospital, Herning, Denmark
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Sznol JA, Becher R, Maung AA, Bhattacharya B, Davis K, Schuster KM. Routine post-operative labs and healthcare system burden in acute appendicitis. Am J Surg 2023; 226:571-577. [PMID: 37291012 DOI: 10.1016/j.amjsurg.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management. METHODS A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected. RESULTS A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient. CONCLUSIONS In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.
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Affiliation(s)
- Joshua A Sznol
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Robert Becher
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Adrian A Maung
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Bishwajit Bhattacharya
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kimberly Davis
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kevin M Schuster
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
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Moriates C. How can we finally reduce repetitive routine laboratory tests for hospitalised patients? BMJ Qual Saf 2023; 32:498-501. [PMID: 37328268 DOI: 10.1136/bmjqs-2023-016315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Christopher Moriates
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
- Executive Director, Costs of Care, Boston, Massachusetts, USA
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Spoyalo K, Lalande A, Rizan C, Park S, Simons J, Dawe P, Brown CJ, Lillywhite R, MacNeill AJ. Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients. BMJ Open Qual 2023; 12:e002316. [PMID: 37402596 DOI: 10.1136/bmjoq-2023-002316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
OBJECTIVE To characterise the extent of unnecessary care in general surgery inpatients using a triple bottom line approach. DESIGN Patients with uncomplicated acute surgical conditions were retrospectively evaluated for unnecessary bloodwork according to the triple bottom line, quantifying the impacts on patients, healthcare costs and greenhouse gas emissions. The carbon footprint of common laboratory investigations was estimated using PAS2050 methodology, including emissions generated from the production, transport, processing and disposal of consumable goods and reagents. SETTING Single-centre tertiary care hospital. PARTICIPANTS Patients admitted with acute uncomplicated appendicitis, cholecystitis, choledocholithiasis, gallstone pancreatitis and adhesive small bowel obstruction were included in the study. 304 patients met inclusion criteria and 83 were randomly selected for in-depth chart review. MAIN OUTCOME MEASURES In each patient population, the extent of over-investigation was determined by comparing ordered laboratory investigations against previously developed consensus recommendations. The quantity of unnecessary bloodwork was measured by number of phlebotomies, tests and blood volume in addition to healthcare costs and greenhouse gas emissions. RESULTS 76% (63/83) of evaluated patients underwent unnecessary bloodwork resulting in a mean of 1.84 phlebotomies, 4.4 blood vials, 16.5 tests and 18 mL of blood loss per patient. The hospital and environmental cost of these unnecessary activities was $C5235 and 61 kg CO2e (974 g CO2e per person), respectively. The carbon footprint of a common set of investigations (complete blood count, differential, creatinine, urea, sodium, potassium) was 332 g CO2e. Adding a liver panel (liver enzymes, bilirubin, albumin, international normalised ratio/partial thromboplastin time) resulted in an additional 462 g CO2e. CONCLUSIONS We found considerable overuse of laboratory investigations among general surgery patients admitted with uncomplicated acute surgical conditions resulting in unnecessary burden to patients, hospitals and the environment. This study identifies an opportunity for resource stewardship and exemplifies a comprehensive approach to quality improvement.
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Affiliation(s)
- Karina Spoyalo
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Annie Lalande
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Chantelle Rizan
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Sophia Park
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet Simons
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Philip Dawe
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Carl J Brown
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Lillywhite
- School of Life Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrea J MacNeill
- Department of Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
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de Carle M, Macnab B, Utainrat J, Herkes-Deane J, Attia J, de Malmanche T, Teber E, Palazzi K, Scowen C, Hure A. Does an electronic pathology ordering system change the volume and pattern of routine testing in hospital? An interrupted time series analysis. J Clin Pathol 2023:jcp-2023-208850. [PMID: 37085324 DOI: 10.1136/jcp-2023-208850] [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: 02/21/2023] [Accepted: 03/31/2023] [Indexed: 04/23/2023]
Abstract
AIMS Identifying and reducing low-value care is a vital issue in Australia, with pathology test ordering a common focus in this field. This study builds on previous research and aimed to quantify the impact of the implementation of an electronic ordering (e-ordering) system on the volume of pathology testing, compared with manual (paper based) ordering. METHODS An audit and analysis of pathology test data were conducted, using an interrupted time series design to investigate the impact of the e-ordering system on pathology ordering patterns. All medical and surgical adult inpatients at a tertiary referral hospital in Newcastle, Australia, were included over a 3-year period. RESULTS Overall, there were no statistically significant differences in the volume of orders due to the implementation of the e-ordering system. There was a slight increase in the aggregated volume (tests per admission and tests per bed day) of tests ordered across the entire study period, reflecting a secular trend. CONCLUSIONS Despite providing greater visibility and tracking of orders, we conclude that the implementation of an e-ordering system does not, in and of itself, reduce ordering volume. Efforts to identify and reduce low-value care will require intentional effort and specifically designed educational programmes or hard-wired algorithms.
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Affiliation(s)
- Madeleine de Carle
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Brooke Macnab
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Jenewa Utainrat
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Jessica Herkes-Deane
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Theo de Malmanche
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- John Hunter Hospital, NSW Health Pathology, New Lambton Heights, New South Wales, Australia
| | - Erdahl Teber
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Kerrin Palazzi
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Craig Scowen
- John Hunter Hospital, NSW Health Pathology, New Lambton Heights, New South Wales, Australia
| | - Alexis Hure
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Rabbani N, Ma SP, Li RC, Winget M, Weber S, Boosi S, Pham TD, Svec D, Shieh L, Chen JH. Targeting repetitive laboratory testing with electronic health records-embedded predictive decision support: A pre-implementation study. Clin Biochem 2023; 113:70-77. [PMID: 36623759 PMCID: PMC9936847 DOI: 10.1016/j.clinbiochem.2023.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/07/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Unnecessary laboratory testing contributes to patient morbidity and healthcare waste. Despite prior attempts at curbing such overutilization, there remains opportunity for improvement using novel data-driven approaches. This study presents the development and early evaluation of a clinical decision support tool that uses a predictive model to help providers reduce low-yield, repetitive laboratory testing in hospitalized patients. METHODS We developed an EHR-embedded SMART on FHIR application that utilizes a laboratory test result prediction model based on historical laboratory data. A combination of semi-structured physician interviews, usability testing, and quantitative analysis on retrospective laboratory data were used to inform the tool's development and evaluate its acceptability and potential clinical impact. KEY RESULTS Physicians identified culture and lack of awareness of repeat orders as key drivers for overuse of inpatient blood testing. Users expressed an openness to a lab prediction model and 13/15 physicians believed the tool would alter their ordering practices. The application received a median System Usability Scale score of 75, corresponding to the 75th percentile of software tools. On average, physicians desired a prediction certainty of 85% before discontinuing a routine recurring laboratory order and a higher certainty of 90% before being alerted. Simulation on historical lab data indicates that filtering based on accepted thresholds could have reduced ∼22% of repeat chemistry panels. CONCLUSIONS The use of a predictive algorithm as a means to calculate the utility of a diagnostic test is a promising paradigm for curbing laboratory test overutilization. An EHR-embedded clinical decision support tool employing such a model is a novel and acceptable intervention with the potential to reduce low-yield, repetitive laboratory testing.
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Affiliation(s)
- Naveed Rabbani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA.
| | - Stephen P Ma
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ron C Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Marcy Winget
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Susan Weber
- Technology and Digital Solutions, Stanford University School of Medicine, Stanford, CA, USA
| | - Srinivasan Boosi
- Technology and Digital Solutions, Stanford University School of Medicine, Stanford, CA, USA
| | - Tho D Pham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - David Svec
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Shieh
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA; Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
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9
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Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. Method A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. Results The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. Conclusions Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01247-y.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
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Aslam F, Mahboob U, Zahra Q, Zohra S, Malik R, Khan RA. The Drudgery of a Doctor's Disciple: Exploring the effects of Negative Role Modelling on medical students' professional development. MEDICAL TEACHER 2022; 45:1-7. [PMID: 36272400 DOI: 10.1080/0142159x.2022.2133690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Role modelling is considered an essential component of teaching in various educational settings and impact students' professional development. Most studies found in the literature have explored the influence of positive role models and limited data is available about the negative role modelling. This study explores the effects of negative role modelling of teachers on the professional development of future doctors. METHODS A qualitative exploratory study was done in three medical colleges of Lahore, Pakistan. Fifteen, telephonic, semi-structured interviews were done with fifth-year MBBS students. A thematic analysis was done through manual coding of transcribed interviews. RESULTS A total of 374 codes were generated in the first cycle of coding, that was merged to 42 in the second cycle. These codes led to 4 subthemes that finally emerged as two themes. The first theme was "Students & patients: In the same boat" highlighting the damaging effects of negative role modelling. The second theme was "Taking the bad with the good" focusing on the ambivalent response of students towards the unprofessional behaviours of their role models. CONCLUSION Negative role modelling exponentially affects the attitude and behaviour of medical students especially in informal settings and have detrimental effects on patient care. Students lose some degree of humanism while unconsciously observing the unethical behaviours, to become a part of hospital culture whereas some students show determination to channelize their resentment to reforms.
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Affiliation(s)
- Fatima Aslam
- Department of Psychiatry & Behavioural Sciences, Avicenna Medical College & Hospital, Lahore, Pakistan
| | - Usman Mahboob
- Institute of Health Professions Education (IHPE&R), Khyber Medical University, Peshawar, Pakistan
| | - Qundeel Zahra
- Department of Ophthalmology, Azra Naheed Medical College & Hospital, Lahore, Pakistan
| | | | - Rabia Malik
- Department of Medical Education, Muhammad Islam Medical & Dental College, Gujranwala, Pakistan
| | - Rehan Ahmed Khan
- Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan
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11
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Verkerk EW, Van Dulmen SA, Born K, Gupta R, Westert GP, Kool RB. Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands. Int J Health Policy Manag 2022; 11:1514-1521. [PMID: 34273925 PMCID: PMC9808325 DOI: 10.34172/ijhpm.2021.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 04/30/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. METHODS We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. RESULTS The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy. CONCLUSION Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.
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Affiliation(s)
- Eva W. Verkerk
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simone A. Van Dulmen
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karen Born
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Reshma Gupta
- University of California Health, Sacramento, CA, USA
| | - Gert P. Westert
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rudolf B. Kool
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Ambasta A. Ten Years Since the Choosing Wisely Campaign: Are We Ordering Laboratory Tests More Wisely in Our Hospitalized Patients? Jt Comm J Qual Patient Saf 2022; 48:500-502. [DOI: 10.1016/j.jcjq.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Gabarin N, Trinkaus M, Selby R, Goldberg N, Hanif H, Sholzberg M. Coagulation test understanding and ordering by medical trainees: Novel teaching approach. Res Pract Thromb Haemost 2022; 6:S2475-0379(22)01240-7. [PMID: 35755855 PMCID: PMC9204395 DOI: 10.1002/rth2.12746] [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: 02/04/2022] [Revised: 03/15/2022] [Accepted: 04/05/2022] [Indexed: 11/09/2022] Open
Abstract
Background Coagulation testing provides a prime opportunity to make an impact on the reduction of unnecessary laboratory test ordering, as there are clear indications for testing. Despite the prothrombin time/international normalized ratio and activated partial thromboplastin time being validated for specific clinical indications, they are frequently ordered as screening tests and often ordered together, suggesting a gap in understanding of coagulation. Methods Based on a needs assessment, we developed an online educational module on coagulation for trainees, incorporating education on testing cost, specificity, and sensitivity. Fifty participating resident physicians and medical students completed a validated premodule quiz, postmodule quiz after completion of the module, and a latent quiz 3 to 6 months after to assess longer‐term knowledge retention. Trainees provided responses regarding their subjective laboratory test‐ordering practices before and after module completion. Results The median premodule quiz score was 67% (n = 50; range, 24%‐86%) with an increase of 24% to a median postmodule quiz score of 91% (n = 50; range, 64%‐100%). There was evidence of sustained knowledge acquisition with a latent quiz median score of 89% (n = 40; range, 67%–100%). Trainees were more likely to consider the sensitivity, specificity, and cost of laboratory investigations before ordering them following completion of the educational module. Conclusions Using the expertise of medical educators and incorporating trainee feedback, we employed a novel approach to the teaching of coagulation to maximize its approachability and clinical relevance. We found sustained knowledge retention regarding coagulation and appropriate coagulation test ordering, and a subjective change to trainee ordering habits following participation in our educational intervention.
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Affiliation(s)
- Nadia Gabarin
- Department of Medicine, Michael G. DeGroote School of Medicine McMaster University Hamilton Ontario Canada
| | - Martina Trinkaus
- Department of Medicine St. Michael's Hospital University of Toronto Toronto Ontario Canada.,Division of Hematology, Department of Medicine, St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Rita Selby
- Department of Laboratory Medicine & Pathobiology and Department of Medicine University Health Network and Sunnybrook Health Sciences Centre, University of Toronto Toronto Ontario Canada
| | - Nicola Goldberg
- Department of Medicine St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Hina Hanif
- Department of Laboratory Medicine & Pathobiology St. Michael's Hospital University of Toronto Toronto Ontario Canada
| | - Michelle Sholzberg
- Department of Medicine St. Michael's Hospital University of Toronto Toronto Ontario Canada.,Division of Hematology, Department of Medicine, St. Michael's Hospital University of Toronto Toronto Ontario Canada.,Department of Laboratory Medicine & Pathobiology St. Michael's Hospital University of Toronto Toronto Ontario Canada
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14
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Tran A, Hudoba M, Markin T, Roland K. Sustainable Laboratory-Driven Method to Decrease Repeat, Same-Day WBC Differentials at a Tertiary Care Center. Am J Clin Pathol 2022; 157:561-565. [PMID: 34617986 DOI: 10.1093/ajcp/aqab146] [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: 05/26/2021] [Accepted: 07/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES A CBC with WBC differential is often ordered when a CBC alone would be sufficient for patient care. Performing unnecessary WBC differentials adds to costs in the laboratory. Our objective was to implement a laboratory middleware algorithm to cancel repeat, same-day WBC differentials to achieve lasting improvements in laboratory resource allocation. METHODS Repeat same-day WBC differentials were first canceled only on intensive care unit samples; after a successful trial period, the algorithm was applied hospital-wide. We retrospectively reviewed CBC with differential orders from pre- and postimplementation periods to estimate the reduction in WBC differentials and potential cost savings. RESULTS The algorithm led to a monthly WBC differential cancellation rate of 5.40% for a total of 10,195 canceled WBC differentials during the cumulative postimplementation period (September 25, 2019, to December 31, 2020). Nearly all (99.94%) differentials remained canceled. Most patients only had one WBC differential canceled (range, 1-38). Savings estimates showed savings of $0.99 CAD per canceled differential and 1,060 minutes (17.7 hours) of technologist time. CONCLUSIONS A middleware algorithm to cancel repeat, same-day WBC differentials is a simple and sustainable way to achieve lasting improvements in laboratory utilization.
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Affiliation(s)
- Ann Tran
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Monika Hudoba
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Todd Markin
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Kristine Roland
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
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15
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Deimplementation of Polycythemia Screening in Asymptomatic Infants in a Level 1 Nursery. Pediatr Qual Saf 2022; 7:e533. [PMID: 35369422 PMCID: PMC8970080 DOI: 10.1097/pq9.0000000000000533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/04/2021] [Indexed: 11/28/2022] Open
Abstract
Polycythemia (venous hematocrit >65%) is rare in healthy newborns (incidence: 0.4%–5%), with serious outcomes (stroke, bowel ischemia) of unknown incidence in asymptomatic infants. No national guidelines address screening or management of asymptomatic infants with polycythemia. Our nursery screened “high risk” (HR) newborns (small for gestational age, large for gestational age, twin, infant of diabetic mother) with poor adherence and low yield. We aimed to decrease polycythemia screening of asymptomatic HR infants by 80% within 6 months.
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Seltz LB, Nathaniel E, Ball A, Jimenez S, Tchou M. Pediatric Residents' Experiences With High-Value Care at an Academic Children's Hospital. J Grad Med Educ 2022; 14:80-88. [PMID: 35222825 PMCID: PMC8848867 DOI: 10.4300/jgme-d-21-00665.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/28/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education mandates residents incorporate cost considerations into patient care. However, resident experiences with high-value care (HVC) in the clinical setting have not been well described. OBJECTIVE To explore pediatric residents' experiences with HVC and its facilitators and barriers. METHODS We performed a qualitative study with a grounded theory epistemology of pediatric residents recruited by email at a large academic children's hospital. We conducted focus groups (n=3) and interviews (n=7) between February and September 2020 using a semi-structured guide. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into thematic categories. Sampling continued until saturation was reached. RESULTS Twenty-two residents participated. Residents' value-based health care decisions occurred in a complex learning environment. Due to limited experience, residents feared missing diagnoses, which contributed to perceived overtesting. Resident autonomy, with valuable experiential learning, supported and hindered HVC. Informal teaching occurred through patient care discussions; however, cost information was lacking. Practice of HVC varied by clinical setting with greater challenges on high acuity and subspecialty services. For children with medical complexity, identifying family concerns and goals of care improved value. Family experience/demands influenced resident health care decisions, contributing to high- and low-value care. Effective collaboration among health care team members was crucial; residents often felt pressured following perceived low-value recommendations from consultants. CONCLUSIONS Resident HVC learning and practice is influenced by multiple factors in a complex clinical learning environment.
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Affiliation(s)
- L. Barry Seltz
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- L. Barry Seltz, MD, is a Pediatric Hospitalist and Associate Residency Program Director
| | - Emma Nathaniel
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Emma Nathaniel, MD, was a PGY-3 Resident at the time of the study and is now Pediatric Hospitalist
| | - Alexis Ball
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Alexis Ball, MD, was a PGY-2 Resident at the time of the study and is now a General Pediatrician
| | - Sheilah Jimenez
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Sheilah Jimenez, is a Professional Research Assistant
| | - Michael Tchou
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Michael Tchou, MD, MSc, is a Pediatric Hospitalist
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Oncu S, Baskurt A, Senturk B, Aslan O, Kume T, Ucku R, Gelal A. Educational intervention to improve appropriate digoxin therapeutic drug monitoring: a quasi-experimental study. Eur J Hosp Pharm 2021; 28:320-324. [PMID: 34697048 DOI: 10.1136/ejhpharm-2019-002078] [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: 08/28/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Our previous retrospecive study evaluating the appropriateness of serum digoxin concentration (SDC) measurements revealed errors in the timing of blood specimen collection in 98% of the tests. The aim of this study is to evaluate the appropriateness of the SDC measurements and the factors involved in inappropriate test-ordering, after training health personnel in digoxin therapeutic drug monitoring. METHODS This is a training-based quasi-experimental study. The residents and nurses of the Cardiology Clinic were trained first in December 2017, and refresher training courses were carried out every month throughout the study. The medical data of the inpatients receiving digoxin therapy were recorded prospectively, between January and December 2018. The appropriateness of the physicians' orders for SDC measurement was evaluated according to the criteria of the right indication and right timing of blood collection. The results are presented by descriptive statistics, Student's t-test and χ2 analysis. RESULTS A total of 232 SDC tests were ordered for 121 patients (age: 71.0±12.6 years, 56.2% women). Of these orders,129 (55.6%) were considered appropriate: 205 (88.4%) for indication and 129 (62.9%) for blood collection timing. There was a significant correlation between inappropriate order for SDC test and the age of the patient, female gender, impairment of renal function tests, high levels of serum BNP and the number of medications used (P<0.005). CONCLUSIONS Approximately a one-half decrease in inappropriate tests compared with our previous study results imply that education has a positive effect on physician behaviour. However, physicians' concerns due to increased risk factors for the patient still play a role in inappropriate test-ordering.
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Affiliation(s)
- Seyma Oncu
- Department of Medical Pharmacology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Anil Baskurt
- Department of Cardiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Bihter Senturk
- Department of Cardiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Ozgur Aslan
- Department of Cardiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Tuncay Kume
- Department of Biochemistry, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Reyhan Ucku
- Department of Public Health, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Ayse Gelal
- Department of Medical Pharmacology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
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The role of electronic versus written order sets in inappropriate laboratory testing among hospitalized medical patients. Int J Med Inform 2021; 153:104546. [PMID: 34391017 DOI: 10.1016/j.ijmedinf.2021.104546] [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: 04/23/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 11/22/2022]
Abstract
IMPORTANCE Reducing inappropriate blood tests has been highlighted by Choosing Wisely as a key area of focus. Computer physician order entry is one modifiable contributor, but little is known about how computer ordering compares to paper methods when it comes to low-value laboratory testing. OBJECTIVE To determine which method of order entry is associated with a greater amount of appropriate lab testing. Furthermore, to identify ordering patterns for more targeted interventions in future. DESIGN We conducted a retrospective observational cohort study of inpatients discharged at two hospitals (one site uses paper order sets, while the other uses electronic order sets). SETTING General internal medicine wards at two Canadian teaching hospitals. PARTICIPANTS At site 1 (electronic orders), all general internal medicine discharges from May 2015 and February 2016. At site 2 (paper orders), all general internal medicine discharges from April 15, 2015 to May 26, 2015. MAIN OUTCOME(S) AND MEASURE(S) Main outcome was the percentage of inpatient discharges at each site with orders for daily laboratory tests for three days on admission. Secondary measures include proportion of tests with appropriate indications and rates of discontinuation of daily laboratory tests. RESULTS We reviewed 395 discharges with a mean patient age of 69.5 ± 18.9 years and mean length of stay of 12.1 days. Daily laboratory tests were more common with paper orders (site 2) compared to electronic order sets (site 1) for complete blood count (CBC) (90.8% vs. 68.5%, p < 0.001), electrolytes (93.8% vs 71.5%, p < 0.001), and creatinine (93.8% vs 70.0%, p < 0.001) testing. However, paper orders for daily laboratory tests were more often appropriate, both in CBC (76.3% vs. 38.9%, p < 0.001) and electrolyte/creatinine (80.3% vs 44.2%, p < 0.001) testing. Discontinuation of daily labs occurred more often with paper orders (35.4% vs. 6.7%, p < 0.001). CONCLUSIONS AND RELEVANCE Compared to written orders, daily laboratory testing using electronic ordering was associated with higher rates of inappropriate indications and lower rates of discontinuation. Our results support interventions aimed at ensuring electronic order sets incorporate appropriate indications and a mechanism for discontinuation of daily lab orders. Further studies aimed at understanding how the process of completing paper or electronic orders influence appropriateness of daily laboratory orders are needed to further minimize inappropriate testing.
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Mathura P, Boettger C, Hagtvedt R, Suranyi Y, Kassam N. Does admission order form design really matter? A reduction in urea blood test ordering. BMJ Open Qual 2021; 10:bmjoq-2020-001330. [PMID: 34210669 PMCID: PMC8252868 DOI: 10.1136/bmjoq-2020-001330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/22/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Laboratory blood testing is one of the most high-volume medical procedures and continues to increase steadily with instances of inappropriate testing resulting in significant financial implications. Studies have suggested that the design of a standard hospital admission order form and laboratory request forms influence physician test ordering behaviour, reducing inappropriate ordering and promoting resource stewardship. Aim/method To redesign the standard medicine admission order form-laboratory request section to reduce inappropriate blood urea nitrogen (BUN) testing. Results A redesign of the standard admission order form used by general internal medicine physicians and residents in two large teaching hospitals in one health zone in Alberta, Canada led to a significant step reduction in the ordering of the BUN test on hospital admission. Conclusions Redesigning the standard medicine admission order form-laboratory request section can have a beneficial effect on the reduction in BUN ordering altering physician ordering patterns and behaviour.
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Affiliation(s)
- Pamela Mathura
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cole Boettger
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- Alberta School of Business, University of Alberta, Edmonton, Alberta, Canada
| | - Yvonne Suranyi
- Emergency Department, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Narmin Kassam
- Medicine, University of Alberta, Edmonton, Alberta, Canada
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20
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Adhikari AN, Beck MD, Wykes JJ, Ashford BG. Targeted ordering of investigations reduces costs of treatment for surgical inpatients. Int J Qual Health Care 2021; 33:6275450. [PMID: 33987666 DOI: 10.1093/intqhc/mzab083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/25/2021] [Accepted: 05/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Laboratory testing forms an important part of diagnostic investigation in modern medicine; however, the overuse of 'routine blood tests' can result in significant potential harm and financial cost to the patient and the healthcare system. In 2018, a new protocol targeting the ordering of investigations was implemented within the General Surgical Teams of Wollongong Hospital in New South Wales, an Australian tertiary referral hospital, to reduce the number of 'routine blood tests' as a quality improvement initiative. OBJECTIVE To identify whether there was a reduction in the number of 'routine blood tests' and associated costs following implementation of the new protocol. METHODS The protocol involved regular review of the laboratory investigations being ordered for the following day with a senior team member. The medical records of all patients admitted under the general surgery service at Wollongong Hospital were retrospectively reviewed over two 10-week periods in 2017 and 2018 (control and study, respectively). The casemix was categorized into Minor, Intermediate, Major or Unscored, depending on case complexity coding. RESULTS A total of 838 patients were identified during the control period (2017) and 805 patients were identified during the study period (2018). Ten thousand and thirty tests were included in the control period, compared to 8610 over the study period, resulting in a 16% (or greater) reduction in 'routine blood tests' per patient, per day of admission and a 6% reduction in costs in the study group (P < 0.001). CONCLUSION Targeted ordering of investigations with personalized education and feedback to junior staff during review of clinical status of each patient as a part of normal workflow can reduce inappropriate ordering of 'routine blood tests' and associated costs to the patient and the healthcare system.
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Affiliation(s)
- Ashim Nath Adhikari
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia
| | - Matthew Dylan Beck
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia
| | - James Justin Wykes
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia
| | - Bruce Graham Ashford
- Department of Surgery, Wollongong Public Hospital, 252 Loftus Street, Wollongong, NSW 2500, Australia.,Department of Surgery, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia
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21
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Doi D, do Vale RR, Monteiro JMC, Plens GCM, Ferreira Junior M, Fonseca LAM, Perazzio SF, Besen BAMP, Lichtenstein A, Taniguchi LU, Sumita NM, Corá AP, Eisencraft AP, Duarte AJDS. Perception of usefulness of laboratory tests ordering by internal medicine residents in ambulatory setting: A single-center prospective cohort study. PLoS One 2021; 16:e0250769. [PMID: 33974629 PMCID: PMC8112663 DOI: 10.1371/journal.pone.0250769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 04/13/2021] [Indexed: 11/29/2022] Open
Abstract
The demand for high value health care uncovered a steady trend in laboratory tests ordering and inappropriate testing practices. Residents’ training in laboratory ordering practice provides an opportunity for quality improvement. We collected information on demographics, the main reason for the appointment, preexisting medical conditions and presence of co-morbidities from first-visit patients to the internal medicine outpatient service of our university general hospital. We also collected information on all laboratory tests ordered by the attending medical residents. At a follow-up visit, we recorded residents’ subjective perception on the usefulness of each ordered laboratory test for the purposes of diagnosis, prognosis, treatment or screening. We observed that 17.3% of all ordered tests had no perceived utility by the attending resident. Tests were usually ordered to exclude differential diagnoses (26.7%) and to help prognosis estimation (19.1%). Age and co-morbidity influenced the chosen category to legitimate usefulness of tests ordering. This study suggests that clinical objectives (diagnosis, prognosis, treatment or prevention) as well as personalization to age and previous health conditions should be considered before test ordering to allow a more appropriate laboratory tests ordering, but further studies are necessary to examine this framework beyond this medical training scenario.
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Affiliation(s)
- Dimitria Doi
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Romulo Ribeiro do Vale
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jean Michell Correia Monteiro
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Glauco Cabral Marinho Plens
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Mario Ferreira Junior
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Augusto Marcondes Fonseca
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Bruno Adler Maccagnan Pinheiro Besen
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Arnaldo Lichtenstein
- Department of Internal Medicine, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Leandro Utino Taniguchi
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nairo Massakazu Sumita
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- * E-mail:
| | - Aline Pivetta Corá
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Adriana Pasmanik Eisencraft
- Emergency Department, Children’s Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alberto José da Silva Duarte
- Central Laboratory Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Shirazi M, Masoudian Y, Feizabad E, Golshahi F, Ghaemi M. Creating a novel strategy to reduce unnecessary laboratory testing based on healthcare cost analysis in high-risk pregnancies and delivery ward. J Clin Lab Anal 2021; 35:e23759. [PMID: 33745154 PMCID: PMC8128318 DOI: 10.1002/jcla.23759] [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: 01/04/2021] [Revised: 02/02/2021] [Accepted: 02/25/2021] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Inappropriate request for laboratory tests is a challenging problem and an important cause for additional healthcare costs. Indeed, it may have further ambiguity for the clinicians. This study aimed to design an education-based program to reduce unnecessary laboratory testing orders and the associated costs. MATERIALS AND METHODS In this interventional prospective study that took place in an educational hospital, the type and frequency of selected laboratory testing requested by gynecology, and obstetrics residents in the patients with gestational diabetes mellitus, preeclampsia, preterm labor, and premature preterm rupture of the membrane as well as cesarean section and normal vaginal delivery were analyzed periodically in a 1-year interval. At the same time, continuous educational supports and monitoring were performed. The results were compared before and after interventions. RESULTS The educational intervention regardless of the etiologies of the admission, decreased the requested laboratory testing significantly (p < 0.001), except for CBC. Indeed, no near misses or delays in treatment were observed. Cost analysis showed a 31.3% reduction of expenses per inpatient day due to the decrease in the number of daily laboratory testing ordered. CONCLUSIONS Appropriate education and continuous monitoring of the residents could reduce the unrequired laboratory testing as well as healthcare costs.
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Affiliation(s)
- Mahboobeh Shirazi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Maternal, Fetal & Neonatal Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Yusuf Masoudian
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Feizabad
- Maternal, Fetal & Neonatal Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Golshahi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghaemi
- Vali-e-Asr Reproductive Health Research Center, (VRHRC), Tehran University of Medical Sciences, Tehran, Iran
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Augustsson H, Ingvarsson S, Nilsen P, von Thiele Schwarz U, Muli I, Dervish J, Hasson H. Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implement Sci Commun 2021; 2:13. [PMID: 33541443 PMCID: PMC7860215 DOI: 10.1186/s43058-021-00110-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION The review has not been registered.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
| | - Irene Muli
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Jessica Dervish
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
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Shashar S, Ellen M, Codish S, Davidson E, Novack V. Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years. Ann Fam Med 2021; 19:30-37. [PMID: 33431388 PMCID: PMC7800753 DOI: 10.1370/afm.2627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/14/2020] [Accepted: 07/24/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services. METHODS We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models. RESULTS The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: rs = (-0.58), P = .03 and rs = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95). CONCLUSIONS Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.
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Affiliation(s)
- Sagi Shashar
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Moriah Ellen
- Department of Health Services Management, Guilford Glazer Faculty of Business and Management, Ben Gurion University of the Negev, Be'er-Sheva, Israel.,Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
| | - Shlomi Codish
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel-Aviv, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
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25
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Jutras C, Charlier J, François T, Du Pont-Thibodeau G. <p>Anemia in Pediatric Critical Care</p>. INTERNATIONAL JOURNAL OF CLINICAL TRANSFUSION MEDICINE 2020. [DOI: 10.2147/ijctm.s229764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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26
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Nagle SJ, Aakhus E. Preparing Trainees to Deliver High-Value and Cost-Conscious Care in Hematology. Curr Hematol Malig Rep 2020; 15:248-253. [PMID: 32632656 DOI: 10.1007/s11899-020-00595-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW Despite national-level directives to reduce healthcare waste and promote high-value care (HVC), clinical educators struggle to equip trainees with the knowledge and skills needed to practice value-based care. In this review, we analyze ongoing efforts in graduate medical education (GME) to enhance trainee competence in delivery of high-value and cost-conscious care. RECENT FINDINGS Surveys of residents and program directors have shown that while many training programs want to offer formal training in high-value care delivery, few succeed. Although several studies suggest that trainees model stewardship behaviors after clinical preceptors, there remains a shortage of faculty role models skilled in providing HVC. Preparing future hematologist-oncologists to provide cost-conscious care will require significant cultural change at the institutional and program levels and will depend heavily on the development of skilled clinical role models.
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Affiliation(s)
- Sarah J Nagle
- Knight Cancer Institute, Oregon Health & Sciences University, Portland, OR, USA
| | - Erin Aakhus
- Department of Medicine, Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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27
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Mohammed-Ali Z, Brinc D, Kulasingam V, Selvaratnam R. Defining appropriate utilization of AST testing. Clin Biochem 2020; 79:75-77. [DOI: 10.1016/j.clinbiochem.2020.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/08/2020] [Accepted: 02/11/2020] [Indexed: 12/13/2022]
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28
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Stammen LA, Driessen EW, Notermans CC, Scheele F, Stassen LP, Stalmeijer RE. How Do Attending Physicians Prepare Residents to Deliver High-Value, Cost-Conscious Care? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:764-770. [PMID: 31688032 PMCID: PMC7185052 DOI: 10.1097/acm.0000000000003051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE An estimated 20% of health care expenditures are wasteful. Educational interventions aimed at reducing waste by delivering high-value, cost-conscious care (HV3C) often focus on the role of the physician. This study sought to understand how attending physicians, who have a central role in the workplace, prepare residents to provide HV3C. METHOD Researchers from Maastricht University in Maastricht, the Netherlands, conducted semistructured interviews between September 2016 and August 2017 with 12 attending physicians who supervise residents in the workplace. Participants were purposefully sampled from 5 institutions throughout the Netherlands to include surgical and nonsurgical attending physicians and hospital- and nonhospital-based physicians. Data collection and analysis were iterative, using principles of grounded theory. RESULTS The attending physician's approach to providing HV3C was an important factor in preparing residents in the workplace. Three differences became apparent: priority of HV3C training, feedback on HV3C, and obstacles to HV3C delivery. Results indicate that attending physicians use 3 teaching methods to teach HV3C delivery: Socratic questioning, role modeling, and setting limits. Training was often implicit and ad hoc. CONCLUSIONS How attending physicians deal with HV3C themselves influences how they prepare residents in the workplace. To optimize resident training, it may be important to create a supportive environment for HV3C delivery and training. Delivery could be supported by making HV3C a shared goal for attending physicians and residents, thereby providing insight into clinical practice behavior and minimizing the influence of obstacles. Training could be optimized by supporting a variety of teaching methods suitable for daily teaching to stimulate continuous learning in residents.
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Affiliation(s)
- Lorette A. Stammen
- L.A. Stammen is a family medicine resident and PhD candidate in the field of medical education, School of Health Professions Education, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands; ORCID: https://orcid.org/0000-0003-1528-546X
| | - Erik W. Driessen
- E.W. Driessen is professor of medical education, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands; ORCID: https://orcid.org/0000-0001-8115-261X
| | - Celine C.V.I. Notermans
- C.C.V.I. Notermans is a master student in the medicine program, Faculty of Health, Medicine and Life Sciences, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands
| | - Fedde Scheele
- F. Scheele is professor of health systems innovation and medical education, Athena Institute, VU School of Medical Sciences, Amsterdam UMC, and gynecologist at the OLVG Hospital Amsterdam, Amsterdam, the Netherlands; ORCID: https://orcid.org/0000-0001-9593-257X
| | - Laurents P.S. Stassen
- L.P.S. Stassen is professor of medical education and gastrointestinal surgeon, Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; ORCID: https://orcid.org/0000-0002-3383-9035
| | - Renée E. Stalmeijer
- R.E. Stalmeijer is assistant professor and qualitative researcher, School of Health Professions Education, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands; ORCID: https://orcid.org/0000-0001-8690-5326
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CJEM Debate Series: #ChoosingWisely - The Choosing Wisely campaign will not impact physician behaviour and choices. CAN J EMERG MED 2020. [PMID: 29534784 DOI: 10.1017/cem.2017.402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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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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Vrijsen B, Naaktgeboren C, Vos L, van Solinge W, Kaasjager H, ten Berg M. Inappropriate laboratory testing in internal medicine inpatients: Prevalence, causes and interventions. Ann Med Surg (Lond) 2020; 51:48-53. [PMID: 32082564 PMCID: PMC7021522 DOI: 10.1016/j.amsu.2020.02.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/22/2020] [Accepted: 02/03/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND To reduce overutilization of laboratory testing many interventions have been tried, but selecting the most effective intervention for a given setting is challenging. To be sustainable, interventions need to align with healthcare providers' needs and daily practices. This study aimed to assess the extent of overutilization and the perspectives of healthcare providers, which may be used to guide the choice of intervention. METHODS The extent of inappropriate laboratory testing in internal medicine inpatients was evaluated using a database. Surveys and focus groups were used to investigate healthcare providers' perceptions on its causes and solutions. RESULTS On average, patients had 5.7 laboratory orders done during the first week of admission, whereas guidelines advise performing laboratory testing no more than twice per week. Repeat testing of normal test results occurred in up to 85% of patients. The frequency of laboratory testing was underestimated by survey responders, even though the majority of responders (78%) thought that laboratory tests are ordered too frequently. Residents were considered to be most responsible for laboratory test ordering.The primary causes of overutilization discussed were personal factors, such as a lack of awareness and knowledge, as well as feelings of insecurity. Regarding possible solutions, residents generally recommended educational interventions, whereas specialists tended to favour technical solutions such as lockouts. CONCLUSION Inappropriate laboratory testing is common in internal medicine. The most important causes are a lack of awareness and knowledge, especially in residents. The intervention most favoured by residents is education, suggesting educational interventions may be most applicable.
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Affiliation(s)
- B.E.L. Vrijsen
- University Medical Center Utrecht, Department of Internal Medicine, Utrecht, the Netherlands
- Corresponding author.
| | - C.A. Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L.M. Vos
- University Medical Center Utrecht, Department of Internal Medicine, Utrecht, the Netherlands
| | - W.W. van Solinge
- University Medical Center Utrecht, Laboratory of Clinical Chemistry and Haematology, Utrecht, the Netherlands
| | - H.A.H. Kaasjager
- University Medical Center Utrecht, Department of Internal Medicine, Utrecht, the Netherlands
| | - M.J. ten Berg
- University Medical Center Utrecht, Laboratory of Clinical Chemistry and Haematology, Utrecht, the Netherlands
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Lee B, Hershey D, Patel A, Pierce H, Rhee KE, Fisher E. Reducing Unnecessary Testing in Uncomplicated Skin and Soft Tissue Infections: A Quality Improvement Approach. Hosp Pediatr 2020; 10:129-137. [PMID: 31941651 DOI: 10.1542/hpeds.2019-0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Skin and soft tissue infections are common pediatric diagnoses with substantial costs. Recent studies suggest blood cultures are not useful in management of uncomplicated skin and soft tissue infections (uSSTIs). Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein are also of questionable value. We aimed to decrease these tests by 25% for patients with uSSTIs admitted to the pediatric hospital medicine service within 3 months. METHODS An interdisciplinary team led a quality improvement (QI) project. Baseline assessment included review of the literature and 12 months of medical records. Key stakeholders identified drivers that informed the creation of an electronic order set and development of a pediatric hospital medicine-emergency department collaborative QI project. The primary outcome measure was mean number of tests per patient encounter. Balancing measures included unplanned readmissions and missed diagnoses. RESULTS Our baseline-year rate was 3.4 tests per patient encounter (573 tests and 169 patient encounters). During the intervention year, the rate decreased by 35% to 2.2 tests per patient encounter (286 tests and 130 patient encounters) and was sustained for 14 months postintervention. There were no unplanned readmissions or missed diagnoses for the study period. Order set adherence was 80% (83 out of 104) during the intervention period and sustained at 87% postintervention. CONCLUSIONS Our interdisciplinary team achieved our aim, reducing unnecessary laboratory testing in patients with an uSSTI without patient harm. Awareness of local culture, creation of an order set, defining appropriate patient selection and testing indications, and implementation of a collaborative QI project helped us achieve our aim.
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Affiliation(s)
- Begem Lee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Daniel Hershey
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Aarti Patel
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Heather Pierce
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Kyung E Rhee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Erin Fisher
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
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Mummadi SR, Mishra R. Effectiveness of provider price display in computerized physician order entry (CPOE) on healthcare quality: a systematic review. J Am Med Inform Assoc 2019; 25:1228-1239. [PMID: 29982523 DOI: 10.1093/jamia/ocy076] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/24/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To study the association between Electronic Health Record (EHR)/Computerized Physician Order Entry (CPOE) provider price display, and domains of healthcare quality (efficiency, effective care, patient centered care, patient safety, equitable care, and timeliness of care). Methods Randomized and non-randomized studies assessing the relationship between healthcare quality domains and EHR/CPOE provider price display published between 1/1/1980 to 2/1/2018 were included. MEDLINE, Web of Science, and Embase were searched. Assessment of internal validity of the included studies was performed with a modified Downs-Black checklist. Results Screening of 1118 abstracts was performed resulting in selection of 41 manuscripts for full length review. A total of 13 studies were included in the final analysis. Thirteen studies reported on efficiency domain, one on effectiveness and one on patient safety. Studies assessing relationship between provider price display and patient centered, equitable and timely care domains were not retrieved. Quality of the studies varied widely (Range 6-12 out of a maximum possible score of 13). Provider price display in electronic health record environment did not consistently influence domains of healthcare quality such as efficiency, effectiveness and patient safety. Conclusions Published evidence suggests that price display tools aimed at ordering providers in EHR/CPOE do not influence the efficiency domain of healthcare quality. Scant published evidence suggests that they do not influence the effectiveness and patient safety domains of healthcare quality. Future studies are needed to assess the relationship between provider price display and unexplored domains of healthcare quality (patient centered, equitable, and timely care). Registration PROSPERO registration: CRD42018082227.
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Affiliation(s)
- Srinivas R Mummadi
- Department of Pulmonary and Critical Care Medicine, Metro Health-University of Michigan Health, Wyoming, MI, USA.,Department of Clinical Informatics, Metro Health-University of Michigan Health Innovation Center, Wyoming, MI, USA
| | - Raghavendra Mishra
- Department of Hospital Medicine & Clinical Informatics, SCL Good Samaritan Hospital, Lafayette, CO, USA.,Department of Hospital Medicine & Clinical Informatics, Kaiser Permanente, Englewood, CO, USA
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Soong C, Shojania KG. Education as a low-value improvement intervention: often necessary but rarely sufficient. BMJ Qual Saf 2019; 29:353-357. [PMID: 31843878 DOI: 10.1136/bmjqs-2019-010411] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 12/27/2022]
Affiliation(s)
| | - Kaveh G Shojania
- Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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Xu S, Hom J, Balasubramanian S, Schroeder LF, Najafi N, Roy S, Chen JH. Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests. JAMA Netw Open 2019; 2:e1910967. [PMID: 31509205 PMCID: PMC6739729 DOI: 10.1001/jamanetworkopen.2019.10967] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Laboratory testing is an important target for high-value care initiatives, constituting the highest volume of medical procedures. Prior studies have found that up to half of all inpatient laboratory tests may be medically unnecessary, but a systematic method to identify these unnecessary tests in individual cases is lacking. OBJECTIVE To systematically identify low-yield inpatient laboratory testing through personalized predictions. DESIGN, SETTING, AND PARTICIPANTS In this retrospective diagnostic study with multivariable prediction models, 116 637 inpatients treated at Stanford University Hospital from January 1, 2008, to December 31, 2017, a total of 60 929 inpatients treated at University of Michigan from January 1, 2015, to December 31, 2018, and 13 940 inpatients treated at the University of California, San Francisco from January 1 to December 31, 2018, were assessed. MAIN OUTCOMES AND MEASURES Diagnostic accuracy measures, including sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUROC), of machine learning models when predicting whether inpatient laboratory tests yield a normal result as defined by local laboratory reference ranges. RESULTS In the recent data sets (July 1, 2014, to June 30, 2017) from Stanford University Hospital (including 22 664 female inpatients with a mean [SD] age of 58.8 [19.0] years and 22 016 male inpatients with a mean [SD] age of 59.0 [18.1] years), among the top 20 highest-volume tests, 792 397 were repeats of orders within 24 hours, including tests that are physiologically unlikely to yield new information that quickly (eg, white blood cell differential, glycated hemoglobin, and serum albumin level). The best-performing machine learning models predicted normal results with an AUROC of 0.90 or greater for 12 stand-alone laboratory tests (eg, sodium AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 98%; specificity, 35%; PPV, 66%; NPV, 93%; lactate dehydrogenase AUROC, 0.93 [95% CI, 0.93-0.94]; sensitivity, 96%; specificity, 65%; PPV, 71%; NPV, 95%; and troponin I AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 88%; specificity, 79%; PPV, 67%; NPV, 93%) and 10 common laboratory test components (eg, hemoglobin AUROC, 0.94 [95% CI, 0.92-0.95]; sensitivity, 99%; specificity, 17%; PPV, 90%; NPV, 81%; creatinine AUROC, 0.96 [95% CI, 0.96-0.97]; sensitivity, 93%; specificity, 83%; PPV, 79%; NPV, 94%; and urea nitrogen AUROC, 0.95 [95% CI, 0.94, 0.96]; sensitivity, 87%; specificity, 89%; PPV, 77%; NPV 94%). CONCLUSIONS AND RELEVANCE The findings suggest that low-yield diagnostic testing is common and can be systematically identified through data-driven methods and patient context-aware predictions. Implementing machine learning models appear to be able to quantify the level of uncertainty and expected information gained from diagnostic tests explicitly, with the potential to encourage useful testing and discourage low-value testing that incurs direct costs and indirect harms.
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Affiliation(s)
- Song Xu
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Jason Hom
- Division of Hospital Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Santhosh Balasubramanian
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Lee F. Schroeder
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor
| | - Nader Najafi
- Department of Medicine, University of California, San Francisco
| | - Shivaal Roy
- Department of Computer Science, Stanford University, Stanford, California
| | - Jonathan H. Chen
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
- Division of Hospital Medicine, Department of Medicine, Stanford University, Stanford, California
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Hure A, Palazzi K, Peel R, Geraghty D, Collard P, De Malmanche T, Tran H, Reeves P, Searles A, Jorm L, Attia J. Identifying low value pathology test ordering in hospitalised patients: a retrospective cohort study across two hospitals. Pathology 2019; 51:621-627. [PMID: 31472983 DOI: 10.1016/j.pathol.2019.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/27/2019] [Accepted: 06/26/2019] [Indexed: 11/30/2022]
Abstract
The push to identify low value care has led to scrutiny of pathology test re-ordering. The objective of this study was to identify the patterns of ordering pathology tests among inpatients in teaching hospitals and model strategies to reduce unnecessary testing. This was a retrospective cohort study of all adult medical and surgical inpatients admitted to one major teaching hospital and one rural hospital in the same health district over 2 years. Obstetric, gynaecological, intensive care, elective/day procedures and dialysis admissions were excluded. Orders for electrolytes, urea and creatinine (EUC), full blood count (FBC), thyroid stimulating hormone (TSH), glycated haemoglobin (HbA1c), vitamin D, and troponin, date of order, and value of the resulting test, were obtained from a health district data warehouse. Pathology results were mapped to each inpatient day. EUC and FBC constituted over 90% of all inpatient pathology requests for these six tests. Between 40-45% of inpatients had EUC and/or FBC performed daily. After the first couple of tests, the retest interval was consistently around 24 hours, regardless of the previous value of the test, consistent with a culture of routine ordering. This was less pronounced in the rural hospital compared to the urban teaching hospital. Lockouts (applied when previous tests normal) or minimum retest intervals (applied to previously normal and abnormal tests) of various lengths were tested on the data to find optimal combinations that reduced unnecessary tests without missing too many very abnormal tests. A lockout of 48 hours for EUC and 48 hour lockout combined with a 12 hour minimum retest interval for FBC appear optimal to reduce over ordering and could save approximately AU$400/inpatient bed per year at a single teaching hospital. There is evidence of low value re-ordering of EUC and FBC pathology tests. Implementation of a computerised physician order entry system with inbuilt prompts to restrict unnecessary re-ordering of pathology tests may be a practical solution.
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Affiliation(s)
- Alexis Hure
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Kerrin Palazzi
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Roseanne Peel
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - David Geraghty
- Applications Development ICT Services Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Phillip Collard
- Applications Development ICT Services Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Theo De Malmanche
- New South Wales Health Pathology, Immunology, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Huy Tran
- New South Wales Health Pathology, Immunology, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Penny Reeves
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Andrew Searles
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Louisa Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia.
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Stammen L, Slootweg I, Stalmeijer R, Janssen L, Stassen L, Scheele F, Driessen E. The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care. TEACHING AND LEARNING IN MEDICINE 2019; 31:402-411. [PMID: 30909747 DOI: 10.1080/10401334.2019.1583566] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Phenomenon: Rising healthcare expenditures threaten the accessibility and affordability of healthcare systems. Research has demonstrated that teaching (junior) physicians to deliver high-value, cost-conscious care can be effective when learning is situated in a supportive environment. This study aims to offer insight into how residents learn to provide high-value, cost-conscious care in the workplace and how the postgraduate training environment influences this learning. Approach: Six homogeneous focus groups were held between August 2015 and July 2016 with 36 residents from six residency programs (dermatology, n = 5; elderly care, n = 8; family medicine, n = 5; internal medicine, n = 6; orthopedic surgery, n = 6; surgery, n = 6). An iterative grounded theory approach was used to analyze the qualitative data. Findings: Influential factors in learning of high-value, cost-conscious care delivery operated on three levels: individual resident, training program, and the workplace. On the individual level, we discerned three types of beliefs regarding HV3C. At the training program level, perceived determinants of learning included resident-supervisor interactions, involvement in decision-making over time, and exposure to variation in care delivery. At the workplace level, learning depended on the availability of professional healthcare expertise and the presence of institutional policy. Insights: Residents struggle to seize high-value, cost-conscious care learning opportunities in the workplace setting. Both residency training programs and workplaces can contribute to creating these learning opportunities. An important starting point is being aware of the different personal beliefs of residents and the approaches to high-value, cost-conscious care on the level of the training program and workplace.
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Affiliation(s)
- Lorette Stammen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Irene Slootweg
- b Department of Public Health and Primary Care, Leiden University Medical Centre , Leiden , The Netherlands
| | - Renée Stalmeijer
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Linda Janssen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Laurents Stassen
- c Department of Surgery, Maastricht University Medical Center , Maastricht , The Netherlands
| | - Fedde Scheele
- d VU School of Medical Sciences, Amsterdam UMC, Athena Institute , Amsterdam , The Netherlands
- e OLVG Amsterdam , Amsterdam , The Netherlands
| | - Erik Driessen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
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Beck J, Wignall J, Jacob-Files E, Tchou MJ, Schroeder A, Henrikson NB, Desai AD. Parent Attitudes and Preferences for Discussing Health Care Costs in the Inpatient Setting. Pediatrics 2019; 144:peds.2018-4029. [PMID: 31270139 DOI: 10.1542/peds.2018-4029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To explore parent attitudes toward discussing their child's health care costs in the inpatient setting and to identify strategies for health care providers to engage in cost discussions with parents. METHODS Using purposeful sampling, we conducted semistructured interviews between October 2017 and February 2018 with parents of children with and without chronic disease who received care at a tertiary academic children's hospital. Researchers coded the data using applied thematic analysis to identify salient themes and organized them into a conceptual model. RESULTS We interviewed 42 parents and identified 2 major domains. Categories in the first domain related to factors that influence the parent's desire to discuss health care costs in the inpatient setting, including responsibility for out-of-pocket expenses, understanding their child's insurance coverage, parent responses to financial stress, and their child's severity of illness on hospital presentation. Categories in the second domain related to parent preference regarding the execution of cost discussions. Parents felt these discussions should be optional and individualized to meet the unique values and preferences of families. They highlighted concerns regarding physician involvement in these discussions; their preference instead was to explore financial issues with a financial counselor or social worker. CONCLUSIONS Parents recommended that cost discussions in the inpatient setting should be optional and based on the needs of the family. Families expressed a desire for physicians to introduce rather than conduct cost discussions. Specific recommendations from parents for these discussions may be used to inform the initiation and improvement of cost discussions with families during inpatient encounters.
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Affiliation(s)
- Jimmy Beck
- Department of Pediatrics, University of Washington, Seattle, Washington;
| | - Julia Wignall
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington
| | | | - Michael J Tchou
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Alan Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Nora B Henrikson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington
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Hoody DG. Capsule Commentary on Hunderfund et al., Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity. J Gen Intern Med 2019; 34:1290. [PMID: 31011968 PMCID: PMC6614230 DOI: 10.1007/s11606-019-04905-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Daniel G Hoody
- Academic Hospital, Hennepin Healthcare, Minneapolis, MN, USA.
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Tchou MJ, Hall M, Shah SS, Johnson DP, Schroeder AR, Antoon JW, Genies MC, Quinonez R, Miller CW, Shah SP, Brady PW. Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses. Pediatrics 2019; 144:e20181644. [PMID: 31171587 PMCID: PMC6615522 DOI: 10.1542/peds.2018-1644] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts. METHODS We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing. RESULTS In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis. CONCLUSIONS Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio;
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Samir S Shah
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - James W Antoon
- Children's Hospital, University of Illinois, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Marquita C Genies
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Christopher W Miller
- Division of Pediatric Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Snehal P Shah
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Leep Hunderfund AN, Starr SR, Dyrbye LN, Baxley EG, Gonzalo JD, Miller BM, George P, Morgan HK, Allen BL, Hoffman A, Fancher TL, Mandrekar J, Reed DA. Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity. J Gen Intern Med 2019; 34:1131-1138. [PMID: 30756307 PMCID: PMC6614293 DOI: 10.1007/s11606-019-04828-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 10/25/2018] [Accepted: 12/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Physician behaviors are important to high-value care, and the learning environment medical students encounter on clinical clerkships may imprint their developing practice patterns. OBJECTIVES To explore potential imprinting on clinical rotations by (a) describing high- and low-value behaviors among medical students and (b) examining relationships with regional healthcare intensity (HCI). DESIGN Multisite cross-sectional survey PARTICIPANTS: Third- and fourth-year students at nine US medical schools MAIN MEASURES: Survey items measured high-value (n = 10) and low-value (n = 9) student behaviors. Regional HCI was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data (ratio of physician visits per decedent compared with the US average, hospital care intensity index, ratio of medical specialty to primary care physician visits per decedent). Associations between regional HCI and student behaviors were examined using unadjusted and adjusted (controlling for age, sex, and year in school) logistic regression analyses, using median item ratings to summarize reported engagement in high- and low-value behaviors. KEY RESULTS Of 2623 students invited, 1304 (50%) responded. Many reported trying to determine healthcare costs (1085/1234, 88%), but only 45% (571/1257) reported including cost details in case presentations. Students acknowledged suggesting tests solely to anticipate what their supervisor would want (1143/1220, 94%), show off their ability to generate a broad differential diagnosis (1072/1218, 88%), satisfy curiosity (958/1217, 79%), protect the team from liability (938/1215, 77%), and build clinical experience (533/1217, 44%). Students in higher intensity regions reported significantly more low-value behaviors: each one-unit increase in the ratio of physician visits per decedent increased the odds of reporting low-value behaviors by 20% (OR 1.20, 95% CI 1.04-1.38; P = 0.01). CONCLUSIONS Third- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Bradley L Allen
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ari Hoffman
- University of California, San Francisco, San Francisco, CA, USA
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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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Shen JZ, Hill BC, Polhill SR, Evans P, Galloway DP, Johnson RB, Reddy VVB, Bosarge PL, Rice-Jennings LA, Lorenz RG. Optimization of Laboratory Ordering Practices for Complete Blood Count With Differential. Am J Clin Pathol 2019; 151:306-315. [PMID: 30357374 DOI: 10.1093/ajcp/aqy146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives To investigate the utilization of CBC and CBC with differential (CBC w/diff) tests at University of Alabama at Birmingham Hospital, and to determine if a reduction in CBC w/diff tests could be achieved without negatively impacting patient care. Methods The quantity of testing and distribution of repeated tests before, during, and after an educational intervention were compared. Results CBC w/diff tests were ordered 10-fold more frequently than CBC tests. The trauma burn intensive care unit ordered the most CBC w/diff tests, with repeat tests done every 4 or 12 hours. The educational intervention reduced the number of CBC w/diff tests ordered and tests repeated every 12 hours. Conclusions The educational intervention changed the ordering practices of CBC w/diff and CBC tests. This was sustained after the intervention and no negative effects on patient care were noted. Similar interventions may lead to optimization of ordering practices of other laboratory tests.
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Affiliation(s)
- Jeffrey Z Shen
- Departments of Pathology, University of Alabama at Birmingham
| | - Benjamin C Hill
- Department of Pathology, Children’s Hospital of Alabama, Birmingham
| | | | | | - David P Galloway
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Alabama, Birmingham
| | - Robert B Johnson
- Department of Respiratory Care, University of Alabama at Birmingham Hospital
| | | | | | | | - Robin G Lorenz
- Departments of Pathology, University of Alabama at Birmingham
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Faisal A, Andres K, Rind JAK, Das A, Alter D, Subramanian J, Koehler TJ, Parker J, Bernicchi N. Reducing the number of unnecessary routine laboratory tests through education of internal medicine residents. Postgrad Med J 2019; 94:716-719. [DOI: 10.1136/postgradmedj-2018-135784] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 11/24/2018] [Accepted: 12/01/2018] [Indexed: 11/03/2022]
Abstract
IntroductionThe Choosing Wisely guidelines advise against ordering routine blood tests for hospitalised patients unless they change management. Unnecessary testing can lead to adverse effects (eg, iatrogenic anaemia, poor sleep quality, risk for infections and increased cost of care).MethodsAn 8-week quality initiative aimed at reducing unnecessary blood tests was implemented in three internal medicine resident inpatient services. The initiative included a 30 min educational session, reminders prior to rotation and midrotation and posters in work areas that displayed lab pricing and urged judicious testing. Residents were encouraged to justify the purpose of ordering tests in their daily progress notes. Attending physicians were made aware of the initiative. Preintervention and postintervention time points were used to compare key metrics. A >10% decrease between time periods was used as an evaluation criterion.ResultsThere were 293 patient records reviewed in the preintervention period and 419 in the postintervention period. The two groups were similar in terms of age and gender. Median blood test count (complete blood count/basic metabolic profile/comprehensive metabolic profile) decreased from 4 to 2 tests per patient per day (50 % decrease) after the intervention. The median length of hospital stay decreased from 4.9 to 3.9 days (21% decrease). A decreased percentage of people requiring transfusions was also noted (2016: 6.1%, 2017: 2.9%).ConclusionThe frequency of unnecessary routine blood tests ordered in the hospital can be decreased by educating resident physicians, making them cost conscious and aware of the indications for ordering routine labs. Frequent reminders are needed to sustain the educational benefit.
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Huang MZ, Rhee KE, Gist L, Fisher ES. Barriers to Minimizing Respiratory Viral Testing in Bronchiolitis: Physician Perceptions on Testing Practices. Hosp Pediatr 2019; 9:79-86. [PMID: 30647087 DOI: 10.1542/hpeds.2018-0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess pediatric providers' perceptions on viral testing and to determine barriers to minimizing respiratory viral testing (RVT) in bronchiolitis. METHODS A single-center, cross-sectional study was conducted and included 6 focus group discussions with pediatric providers. Questions were focused on identifying factors associated with obtaining RVT. Focus group discussions were transcribed verbatim and coded for emergent themes. RESULTS Clinicians report that they themselves do not typically obtain RVT in otherwise healthy patients with bronchiolitis. The most commonly cited reasons for not obtaining RVT is that it does not aid medical decision-making and that it is used as an educational opportunity for trainees. However, clinicians tend to obtain RVT when they are directed by another clinician, when they desire reassurance, when RVT is perceived as "doing something," and when there are knowledge gaps on institutional cohorting policies. CONCLUSIONS Clinician medical decision-making is influenced by multiple internal and external factors. Intended behaviors do not always correlate with actual actions because of these influences. Developing interventions in which some of these factors are addressed may help reduce unnecessary RVT among healthy patients with bronchiolitis and could be considered for broader application beyond this patient population.
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Affiliation(s)
| | | | - Lauren Gist
- Developmental-Behavioral Pediatrics, Department of Pediatrics, School of Medicine, University of California, San Diego, San Diego, California
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Perez R, Aizenberg D, Davis T, Ryskina KL. Seeking a stable foundation to build on: 1 st-Year residents' views of high-value care teaching. EDUCATION FOR HEALTH (ABINGDON, ENGLAND) 2019; 32:11-17. [PMID: 31512587 DOI: 10.4103/efh.efh_189_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND United States (US) residency programs have been recently mandated to teach the concept of high-value care (HVC) defined as care that balances the benefits of interventions with their harms and costs. We know that reflective practice is a key to successful learning of HVC; however, little is known about resident perceptions of HVC learning. To better inform HVC teaching in graduate medical education, we asked 1st-year residents to reflect on their HVC learning. METHODS We conducted three focus groups (n = 36) and online forum discussion (n = 13) of 1st-year internal medicine residents. A constructivist grounded theory approach was used to assess transcripts for recurrent themes to identify the perspectives of residents shared about HVC learning. RESULTS Residents perceived their learning of HVC as limited by cultural and systemic barriers that included limited time, fear of missing a diagnosis, perceived expectations of attending physicians, and poor cost transparency. While the residents reported considerable exposure to the construct of HVC, they desired a more consistent framework that could be applied in different situations. In particular, residents reported frustration with variable incentives, objectives, and definitions pertaining to HVC. Suggestions for improvement in HVC teaching outlined three main needs for: (1) a generalizable framework to systematically approach each case that could be later adapted to independent practice; (2) objective real-time data on costs, benefits, and harms of medical interventions; and (3) standardized approach to assess resident competency in HVC. DISCUSSION As frontline clinicians and the intended target audience for HVC education, 1st-year residents are in a unique position to provide feedback to improve HVC teaching in residency. Our findings highlight the learners' desire for a more systematic approach to HVC teaching that includes the development of a stable generalizable framework for decision-making, objective data, and standardized assessment. These findings contrast current educational interventions in HVC that aim at reducing the overuse of specific practices.
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Affiliation(s)
- Rey Perez
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Aizenberg
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Trocon Davis
- Department of Family Medicine and Community Health, Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Korenstein D, Husain S, Gennarelli RL, White C, Masciale JN, Roman BR. Impact of Clinical Specialty on Attitudes Regarding Overuse of Inpatient Laboratory Testing. J Hosp Med 2018; 13:844-847. [PMID: 29964278 PMCID: PMC6265055 DOI: 10.12788/jhm.2978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Routine laboratory testing is common among hospitalized patients, with associated harm. Attitudes toward testing and drivers across clinical specialties have not been described. We performed a cross-sectional study and anonymously surveyed inpatient clinicians (nurses, advanced practice providers, and physicians) at a tertiary cancer center regarding attitudes toward unnecessary laboratory testing and its drivers across clinical specialties. A total of 837 providers completed surveys (response rate 53%). Most respondents agreed with daily testing of hospitalized patients and that daily labs generally enhance safety, and those from pediatric and surgical specialties generally valued testing less than others. Participants most commonly indentified habit and institutional culture as important drivers of unnecessary testing. There were differences in other drivers across specialties, with pediatric clinicians identifying family pressure more commonly and fear of litigation less commonly compared to others. Future interventions to reduce unnecessary inpatient laboratory testing should acknowledge different attitudes based on specialty and tailor interventions accordingly.
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Affiliation(s)
- Deborah Korenstein
- Memorial Sloan Kettering Cancer Center, Department of Medicine, New York, New York, USA.
- Memorial Sloan Kettering Cancer Center, Center for Health Policy and Outcomes, New York, New York, USA
| | - Solomon Husain
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Head & Neck Division, New York, New York, USA
| | - Renee L Gennarelli
- Memorial Sloan Kettering Cancer Center, Center for Health Policy and Outcomes, New York, New York, USA
| | - Cilian White
- Morristown Medical Center, Department of Medicine, Morristown, New Jersey, USA
| | - James N Masciale
- Memorial Sloan Kettering Cancer Center, Department of Quality and Safety, New York, New York, USA
| | - Benjamin R Roman
- Memorial Sloan Kettering Cancer Center, Center for Health Policy and Outcomes, New York, New York, USA
- Memorial Sloan Kettering Cancer Center, Department of Surgery, Head & Neck Division, New York, New York, USA
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49
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Ryskina K, Jessica Dine C, Gitelman Y, Leri D, Patel M, Kurtzman G, Lin LY, Epstein AJ. Effect of Social Comparison Feedback on Laboratory Test Ordering for Hospitalized Patients: A Randomized Controlled Trial. J Gen Intern Med 2018; 33:1639-1645. [PMID: 29790072 PMCID: PMC6153251 DOI: 10.1007/s11606-018-4482-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/14/2018] [Accepted: 05/04/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Social comparison feedback is an increasingly popular strategy that uses performance report cards to modify physician behavior. Our objective was to test the effect of such feedback on the ordering of routine laboratory tests for hospitalized patients, a practice considered overused. METHODS This was a single-blinded randomized controlled trial. Between January and June 2016, physicians on six general medicine teams at the Hospital of the University of Pennsylvania were cluster randomized with equal allocation to two arms: (1) those e-mailed a summary of their routine laboratory test ordering vs. the service average for the prior week, linked to a continuously updated personalized dashboard containing patient-level details, and snapshot of the dashboard and (2) those who did not receive the intervention. The primary outcome was the count of routine laboratory test orders placed by a physician per patient-day. We modeled the count of orders by each physician per patient-day after the intervention as a function of trial arm and the physician's order count before the intervention. The count outcome was modeled using negative binomial models with adjustment for clustering within teams. RESULTS One hundred and fourteen interns and residents participated. We did not observe a statistically significant difference in adjusted reduction in routine laboratory ordering between the intervention and control physicians (physicians in the intervention group ordered 0.14 fewer tests per patient-day than physicians in the control group, 95% CI - 0.56 to 0.27, p = 0.50). Physicians whose absolute ordering rate deviated from the peer rate by more than 1.0 laboratory test per patient-day reduced their laboratory ordering by 0.80 orders per patient-day (95% CI - 1.58 to - 0.02, p = 0.04). CONCLUSIONS Personalized social comparison feedback on routine laboratory ordering did not change targeted behavior among physicians, although there was a significant decrease in orders among participants who deviated more from the peer rate. TRIAL REGISTRATION Clinicaltrials.gov registration: #NCT02330289.
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Affiliation(s)
- Kira Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - C Jessica Dine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yevgeniy Gitelman
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Damien Leri
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Mitesh Patel
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Gregory Kurtzman
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lisa Y Lin
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew J Epstein
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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50
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Ryskina KL, Smith CD, Arora VM, Zaas AK, Halvorsen AJ, Weissman A, Wahi-Gururaj S. Relationship Between Institutional Investment in High-Value Care (HVC) Performance Improvement and Internal Medicine Residents' Perceptions of HVC Training. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:1517-1523. [PMID: 29697425 PMCID: PMC6442932 DOI: 10.1097/acm.0000000000002257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE To measure the association between institutional investment in high-value care (HVC) performance improvement and resident HVC experiences. METHOD The authors analyzed data from two 2014 surveys assessing institutions' investments in HVC performance improvement as reported by program directors (PDs) and residents' perceptions of the frequency of HVC teaching, participation in HVC-focused quality improvement (QI), and views on HVC topics. The authors measured the association between institutional investment and resident-reported experiences using logistic regression, controlling for program and resident characteristics. RESULTS The sample included 214 programs and 9,854 residents (59.3% of 361 programs, 55.2% of 17,851 residents surveyed). Most PDs (158/209; 75.6%) reported some support. Residents were more likely to report HVC discussions with faculty at least a few times weekly if they trained in programs that offered HVC-focused faculty development (odds ratio [OR] = 1.19; 95% confidence interval [CI] 1.04-1.37; P = .01), that supported such faculty development (OR = 1.21; 95% CI 1.04-1.41; P = .02), or that provided physician cost-of-care performance data (OR = 1.19; 95% CI 1.03-1.39; P = .02). Residents were more likely to report participation in HVC QI if they trained in programs with a formal HVC curriculum (OR = 1.83; 95% CI 1.48-2.27; P < .001) or with HVC-focused faculty development (OR = 1.46; 95% CI 1.15-1.85; P = .002). CONCLUSIONS Institutional investment in HVC-related faculty development and physician feedback on costs of care may increase the frequency of HVC teaching and resident participation in HVC-related QI.
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Affiliation(s)
- Kira L Ryskina
- K.L. Ryskina is assistant professor of medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-3379-6394. C.D. Smith is vice president, Clinical Programs, American College of Physicians, and adjunct associate professor of medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-1910-9546. V.M. Arora is associate professor and director, Graduate Medical Education Clinical Learning Environment Innovation, Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois; ORCID: https://orcid.org/0000-0002-4745-7599. A.K. Zaas is associate professor, Division of Infectious Diseases and International Health, and program director, Duke Internal Medicine Residency, Duke University School of Medicine, Duke University, Durham, North Carolina. A.J. Halvorsen is assistant professor of medicine, Office of Educational Innovations, Internal Medicine Residency Program, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-1272-616X. A. Weissman is director, Research Center, American College of Physicians, Philadelphia, Pennsylvania. S. Wahi-Gururaj is associate professor of medicine, Section of General Internal Medicine, and program director, Internal Medicine Residency, Department of Internal Medicine, University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada
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