Use and costs of nonrecommended tests during routine preventive health exams

Diagnosis of pathological conditions through electronic nose analysis of urine samples: a systematic review and meta-analysis

Currently available urinalysis methods are often applied for screening and monitoring of several pathologies. However, traditionally analyzed biomarkers in urinalysis still lack sensitivity and specificity to accurately diagnose some diseases. Several studies have proposed the use of electronic noses (eNoses) for the analysis of volatile organic compounds in urine samples that may, directly or indirectly, correlate with certain pathologies. Hence, the aim of this study was to perform a systematic review and meta-analysis of studies concerning the use of portable electronic noses for diagnosis or monitoring of pathologies through analysis of urine samples. A systematic review of the literature was held according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-four articles met the inclusion criteria and were included in the analysis. The results of the revised studies showed that there are various volatile organic compound profiles, identified through eNose analysis, that may be applied for diagnosis or monitoring of several diseases, such as diabetes, urinary tract infection, inflammatory bowel disease, and kidney disease. A meta-analysis was conducted taking into consideration the data of 10 of the initial 24 articles. The pooled sensitivity, specificity, and diagnostic odds ratio were 84% (95% CI, 0.72-0.92), 85% (95% CI, 0.75-0.91), and 24.17 (95% CI: 7.85-74.41), respectively. The area under the receiver operating characteristic curve was 0.897. These results suggest that eNose technology has adequate diagnostic accuracy for several pathologies and could be a promising screening tool for clinical settings. However, more studies are needed to reduce heterogeneity between results.

Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication

BACKGROUND

Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise.

METHODS

Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention.

RESULTS

Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse.

CONCLUSION

Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.

Shedding Light on the Main Characteristics and Perspectives of Romanian Medicinal Oxygen Market

Medicinal oxygen plays an important role in healthcare, being essential for the existence and maintenance of the health of millions of people, who depend on medicinal oxygen every day, both in hospitals and at home. Medicinal oxygen is the primary treatment administrated to the majority of patients suffering from respiratory problems and low levels of oxygen in the blood, and in the context of the actual health crisis caused by the new COVID-19, the challenge is represented by increasing the supply of medicinal oxygen while reducing cost so that it is accessible where it is needed most, free at the point of use. It will take increased investment and commitment to put oxygen at the center of strategies for universal health coverage. In this context, it becomes essential to investigate the main characteristics of the Romanian market of medicinal oxygen, highlighting top key players, market development, key driving factors, types of products, market perspectives as well as shedding light on the segmentation of this particular market based on considerations regarding regions, hospital competence class and hospital specialization. Also, the research aims to explore the regional disparities in the decision of using O93%medicinal oxygen, revealing the main factors related to the usage of this type of product among Romanian public hospitals. The research relies on the first quantitative survey regarding medicinal oxygen usage among 121 public hospital units from a total of 461 public hospitals in 2018, which meet the specific requirements: includes the entire population according to the list published on the website of the Ministry of Health, is the most recent data and does not show repetition. The sampling was of probabilistic stage-type stratification, with the following sampling layers: hospital county distribution, hospital competence class officially assigned by the Ministry of Health and also area of residence (urban/rural). In order to analyze the main characteristics of the Romanian oxygen market, the following methods have been used: analysis of variance (ANOVA) together with Kruskal-Wallis, Pearson correlation coefficient as well as Goodman and Kruskal gamma, Kendall's tau-b and Cramer's V, as well as multilevel logistic regression analysis using hierarchical data (hospitals grouped in regions). The Romanian market of medicinal oxygen is rather an oligopoly market characterized by the existence of a small number of producers and two types of products currently used for the same medical purpose and having a substitutable character: medicinal oxygen O99.5%, and medicinal oxygen O93%. An overwhelming proportion of public hospitals agree that both types of medicinal oxygen serve the same therapeutic purpose. The Romanian market of medicinal oxygen highlighted a significant segmentation on considerations based on regions, hospital competence class and hospital specialization. Regarding the main perspectives, the Romanian market of medical oxygen keeps the growth trend registered globally, with development perspectives for competitors. Exploring the regional disparities in the decision of using O93 medicinal oxygen, the empirical results acknowledged the important role of unitary price, hospital capacity and the relevance of this product seen as a medicine. Medicinal oxygen is vital in sustaining life, proving its utility mainly in the context of the actual health crisis. In this context, the Romanian local market exhibits prospects for further development, being characterized by an important segmentation depending on regions, hospital competence class and hospital specialization.

Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit

IMPORTANCE

For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care.

OBJECTIVE

To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020.

EXPOSURE

Receipt of a given test within 1 week before or after the AWV.

MAIN OUTCOMES AND MEASURES

Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed.

RESULTS

Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests.

CONCLUSIONS AND RELEVANCE

In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.

Reducing free thyroid hormone testing through multiple Plan-Do-Study-Act cycles

OBJECTIVES

Free thyroid hormones (fT4 and fT3) are one of the most commonly ordered laboratory tests and often ordered when not clinically meaningful. Based on this, many studies have sought to identify strategies to reduce inappropriate fT4 and fT3 testing. The goal of the current study was to implement a quality improvement (QI) framework to identify an optimal approach to reducing inappropriate free thyroid hormone testing through multiple change ideas and Plan-Do-Study-Act (PDSA) cycles. The aim was to reduce fT4 and fT3 30% from baseline at a large tertiary hospital within 12 months.

METHODS

The Model for Improvement Framework was used to implement a total of 3 change ideas in the first and second PDSA cycles. Change ideas included implementation and refinement of a free thyroid hormone forced function reflex system, modifications to test requisitions/order-entry interfaces, and a TSH-only option. Process and balancing measures were evaluated to fine-tune the change interventions. Data was continuously monitored pre and post interventions to assess progress, impact and potential errors.

RESULTS

In the first PDSA cycle, laboratory testing of fT4 was decreased by 24% and fT3 by 18%. Soliciting physician feedback and assessing balancing measures was important in refining the approach. In the second PDSA cycle, fT4 was decreased by an additional 16% and fT3 by 29%. An audit of the process showed that phone calls to the laboratory to add-on free thyroid hormones did not increase after the second PDSA, averaging 2 calls per month.

CONCLUSIONS

To achieve optimal reductions in free thyroid hormone testing, multiple PDSA cycles were required alongside assessing process and balancing measures. Overall, fT4 and fT3 testing was decreased by 39% and 47%, respectively.

Nationwide Epidemiological Study of Knowledge, Attitudes, and Practices Study of Greek General Practitioners Related to Screening

Background:

We aimed to assess general practitioners’ (GPs) knowledge, attitudes, and practices (KAPs) toward screening recommendation guidelines of the United States Preventive Services Task Force (USPSTF).

Methods:

The survey was conducted during a 6-month period in a stratified random sample of GPs, drawn from a national database of GPs in Greece. Participants were queried about their knowledge, attitudes, and self-reported practice patterns regarding screening in a primary care setting. Sociodemographic characteristics associated with vague screening practicing were identified using multivariable logistic regression models.

Results:

A total of 299 participants agreed and underwent telephonic survey (response rate: 78.2%). GPs agreed on the key role of population-based screening in improving patient care, and nine out of ten reported that their performance would be improved with the adoption of computer-based support systems in clinical practice. GPs, older than 50 years of age, those who those practicing for more than 15 years and GPs working in private sector, were less likely to comply with screening recommendations. Latent class analysis revealed that male physicians and those working in public sector were more likely to comply with USPSTF recommendations.

Conclusions:

Our findings highlight the need of educational intervention programs for GPs in order to promote the implementation of national evidence-based screening recommendation statements in clinical practice.

Effect of periodic health exam on provider management of preventive services

RATIONALE AND OBJECTIVE

To evaluate the relationship between receipt of annual physicals and the receipt of provider recommendation for preventive services, during a period when Medicare did not cover annual physicals (before 2011).

METHODS

Electronic medical records of patients aged 65 years and older from a US health care system were extracted for the 2001 to 2007 period. A fixed-effects logistic model was used to assess the relationship between receipt of periodic health examination (PHE) and receipt of provider recommendation for mammogram screening for 6466 female Medicare beneficiaries. Logistic regression models were used to assess the relationship between receipt of PHE and receipt of provider recommendation for colonoscopy screening and pneumococcal vaccination for 10 318 Medicare beneficiaries. Nine primary care providers from the network were also interviewed, selected by random sampling stratified by care model.

RESULTS

Electronic medical record analyses suggest that patients with a PHE were more likely to obtain provider recommendations for mammogram screening (OR = 2.17, P < 0.0001), colonoscopy screening (OR = 1.54, P < 0.0001), and pneumococcal vaccination (OR = 1.10, P < 0.0001). Providers suggested that prevention care quality improves with the PHE because certain screening measures (eg, skin cancer screening, breast exam) would be neglected without it, and healthy patients could miss recommended preventive services entirely. Without the PHE, some providers reported having tried to incorporate discussions of preventive services by scheduling more frequent follow-up chronic care visits than they would have otherwise, and some routinely charged Medicare for a more complex follow-up visit than they would have charged without the preventive service discussions.

CONCLUSION

Periodic health examination is important in connecting patients to recommended preventive services. Provider interviews suggested that, indirectly, Medicare ended up paying for the PHE via greater frequency of follow-up visits or higher visit charges from providers integrating the services with other visits.

Survey data on Vietnamese propensity to attend periodic general health examinations

As general living standards rise, so does the demand for periodic general health examinations (GHEs). Research on the subject, however, has reached opposing conclusions on the value of GHEs, although methodological limitations in previous works make these differences hard to resolve. Here, we present data from a socio-demographic survey of behaviours and tendencies concerning periodic GHE attendance in Vietnam. These data are shown to be suitable for evaluating the impact of demographic and socio-economic elements on regular health examinations. By presenting the methods used in this survey and by describing the enquiries mentioned in the dataset, this article aims to promote data-collecting methodologies that can help policy-makers and health communicators derive practical conclusions.

Multi-Center Benchmark Study Reveals Significant Variation in Thyroid Testing in United States

BACKGROUND

Studies show that a significant portion of laboratory testing is unnecessary. Thyroid tests are some of the most commonly ordered laboratory tests, yet little is known about practice patterns for laboratory testing for thyroid disease. The objective of this study was to collect data on practice patterns for thyroid testing in the United States.

METHODS

A survey was conducted to collect data on annual test volumes for thyroid stimulating hormone (TSH), free thyroxine (FT4), total thyroxine (TT4), free triiodothyronine (FT3), total triiodothyronine (TT3), triiodothyronine uptake (T3U), reverse triiodothyronine (rT3), and complete blood counts (CBC). Sites were also asked to provide data on laboratory utilization management activities. Thyroid workup rates were compared using the TSH/CBC ratio. Thyroid test selection patterns were compared using the ratio of order volumes for thyroid tests relative to TSH.

RESULTS

We obtained data from 82 sites. The thyroid workup rate (TSH/CBC) was higher for outpatients (0.26) than for inpatients (0.03). Based on median values, sites ordered 14 FT4, 3 TT4, 4 FT3, 2 TT3, 0.1 rT3, and 0.1 T3U for every 100 TSH orders. The majority (approximately 90%) of orders for T4 were for FT4 rather than TT4. Orders for T3 were almost evenly split between FT3 and TT3. There was significant practice variation in test selection for all tests. The highest variability was for the rT3/TSH and T3U/TSH ratios. Most organizations reported at least some laboratory utilization management activities. There was a weak relationship between utilization management initiatives and the quality of orders for thyroid tests.

CONCLUSIONS

There is considerable practice variation in thyroid testing which suggests a need for better guidance in test selection. Based on our sample, some organizations could significantly improve the quality of thyroid testing and reduce testing costs.

What Makes Vietnamese (Not) Attend Periodic General Health Examinations? A 2016 Cross-sectional Study

Objectives

General health examinations (GHE) have become an increasingly common measure for preventive medicine in Vietnam. However, little is known about the factors among Viet-namese people who attend or miss GHE. Budget or time constraints remain to be evaluated for better-informed policy making. This study investigates factors affecting behaviors in attending periodic GHE. The main objectives are as follows: (1) to explore empirical relationships between influencing factors and periodic GHE frequencies, and (2) to predict the probabilities of attending GHE under associated conditions.

Methods

The study used a 2,068-observational dataset, obtained from a Vietnamese survey in 2016. The analysis was then performed using the methods of baseline-category logits for establishing relationships between predictor and response variables.

Results

Significant relationships were found among the expenditure and time consumption, health priority and sensitivity to health data, insurance status, and frequency of GHE, with most p-values = 0.01.

Conclusion

Generally, people attended the GHE when they had the resources and health priorities (72.7% probability). Expenditure and time remain key obstacles to the periodic GHE. Health priority and health data are important in improving rates for GHEs. Health insurance should play a positive role in promoting the GHE.

Health communication, information technology and the public's attitude toward periodic general health examinations

Background: Periodic general health examinations (GHEs) are gradually becoming more popular as they employ subclinical screenings, as a means of early detection. This study considers the effect of information technology (IT), health communications and the public's attitude towards GHEs in Vietnam. Methods: A total of 2,068 valid observations were obtained from a survey in Hanoi and its surrounding areas. Results: In total, 42.12% of participants stated that they were willing to use IT applications to recognise illness symptoms, and nearly 2/3 of them rated the healthcare quality at average level or below. Discussion: The data, which was processed by the BCL model, showed that IT applications (apps) reduce hesitation toward GHEs; however, older people seem to have less confidence in using these apps. Health communications and government's subsidy also increased the likelihood of people attending periodic GHEs. The probability of early check-ups where there is a cash subsidy could reach approximately 80%.

Larger differences in utilization of rarely requested tests in primary care in Spain

INTRODUCTION

The study was performed to compare and analyze the inter-departmental variability in the request of rarely requested laboratory tests in primary care, as opposed to other more common and highly requested tests.

MATERIALS AND METHODS

Data from production statistics for the year 2012 from 76 Spanish laboratories was used. The number of antinuclear antibodies, antistreptolysin O, creatinine, cyclic citrullinated peptide antibodies, deaminated peptide gliadine IgA antibodies, glucose, protein electrophoresis, rheumatoid factor, transglutaminase IgA antibodies, urinalysis and uric acid tests requested was collected. The number of test requests per 1000 inhabitants was calculated. In order to explore the variability the coefficient of quartile dispersion was calculated.

RESULTS

The smallest variation was seen for creatinine, glucose, uric acid and urinalysis; the most requested tests. The tests that were least requested showed the greatest variability.

CONCLUSION

Our study shows through a very simplified approach, in a population close to twenty million inhabitants, how in primary care, the variability in the request of laboratory tests is inversely proportional to the request rate.

Race/Ethnicity and overuse of care: a systematic review

POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.

CONTEXT

The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.

METHODS

We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.

FINDINGS

We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.

CONCLUSIONS

Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.

Screening with urinary dipsticks for reducing morbidity and mortality

BACKGROUND

Urinary dipsticks are sometimes used for screening asymptomatic people, and for case-finding among inpatients or outpatients who do not have genitourinary symptoms. Abnormalities identified on screening sometimes lead to additional investigations, which may identify serious disease, such as bladder cancer and chronic kidney disease (CKD). Urinary dipstick screening could improve prognoses due to earlier detection, but could also lead to unnecessary and potentially invasive follow-up testing and unnecessary treatment.

OBJECTIVES

We aimed to quantify the benefits and harms of screening with urinary dipsticks in general populations and patients in hospitals.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 8 September 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials and other study types that compared urinary dipstick screening with no dipstick screening were eligible for inclusion. We searched for studies that investigated the use of urinary dipsticks for detecting haemoglobin, protein, albumin, albumin-creatinine ratio, leukocytes, nitrite, or glucose, alone or in any combination, and in any setting. We planned to exclude studies conducted in patients with urinary disorders.

DATA COLLECTION AND ANALYSIS

It was planned that two authors would independently extract data from included studies and assess risk of bias using the Cochrane risk of bias tool. However, no studies met our inclusion criteria.

MAIN RESULTS

Literature searches to 8 September 2014 yielded 4298 records, of which 4249 were excluded following title and abstract assessment. There were 49 records (44 studies) eligible for full text assessment; of these 18 studies were not RCTs and 26 studies compared interventions or controls that were not relevant to this review. Thus, no studies were eligible for inclusion.

AUTHORS' CONCLUSIONS

We found no evidence to assess the benefits and harms of screening with urinary dipsticks, which remain unknown.

Preventive health services implemented by family physicians in Portugal-a cross-sectional study based on two clinical scenarios

OBJECTIVES

To assess whether Portuguese family physicians perform preventive health services in accordance with scientific evidence, based on the recommendations of the United States Preventive Services Task Force (USPSTF).

DESIGN

Cross-sectional study.

SETTING

Primary healthcare, Portuguese National Health Service.

PARTICIPANTS

255 Portuguese family physicians selected by a stratified cluster sampling design were invited to participate in a computer-assisted telephone survey.

OUTCOMES

Prevalence of compliance with USPSTF recommendations for screening, given a male and female clinical scenario and a set of proposed medical interventions, including frequency of the intervention and performance in their own daily practice.

RESULTS

A response rate of 95.7% was obtained (n=244). 98-100% of family physicians answered according to the USPSTF recommendations in most interventions. In the male scenario, the lowest concordance was observed in the evaluation of prostate-specific antigen with 37% of family physicians answering according to the USPSTF recommendations. In the female scenario, the lowest concordance was for cholesterol testing with 2% of family physicians complying. Family physicians younger than 50 years had significantly better compliance scores than older ones (mean 77% vs 72%; p<0.001).

CONCLUSIONS

We found a high degree of agreement with USPSTF recommendations among Portuguese family physicians. However, we also found results suggesting excessive use of some medical interventions, raising concerns related to possible harm associated with overdiagnosis and overtreatment.

Low rate of non-attenders to primary care providers in Israel - a retrospective longitudinal study

Background

A model that combines reactive and anticipatory care within routine consultations has become recognized as a cost-effective means of providing preventive health care, challenging the need of the periodic health examination. As such, opportunistic screening may be preferable to organized screening. Provision of comprehensive preventive healthcare within the primary care system depends on regular attendance of the general population to primary care physicians (PCPs). Objectives: To assess the proportion of patients who do not visit a PCP even once during a four-year period, and to describe the characteristics of this population.

Methods

An observational study, based on electronic medical records of 421,012 individuals who were members of one district of Clalit Health Services, the largest health maintenance organization in Israel.

Results

The average annual number of visits to PCPs was 7.6 ± 8.7 to 8.3 ± 9.0 (median 5, 25%-75% interval 1–11) and 9.5 ± 10.0 to10.2 ± 10.4 (median 6, 25%-75% interval 1–14) including visits to direct access consultants) in the four years of the study. During the first year of the study 87.2% of the population visited a PCP. During the four year study period, only 1.5% did not visit a PCP even once.

In a multivariate analysis having fewer chronic diseases (for each additional chronic disease the OR, 95% CI was 0.40 (0.38¬0.42)), being a new immigrant (OR, 95% CI 2.46 (2.32¬2.62)), and being male (OR, 95% CI 1.66 (1.58¬1.75)) were the strongest predictors of being a non-attender to a PCP for four consecutive years.

Conclusions

The rate of nonattendance to PCPs in Israel is low. Other than new immigrant status, none of the characteristics identified for nonattendance suggest increased need for healthcare services.

Determinants of receipt of recommended preventive services: implications for the Affordable Care Act

OBJECTIVES

We examined preventive care use by nonelderly adults (aged 18-64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns.

METHODS

We used data from the 2005-2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income.

RESULTS

There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers.

CONCLUSIONS

Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.

Clinical preventive services in Guatemala: a cross-sectional survey of internal medicine physicians

BACKGROUND

Guatemala is currently undergoing an epidemiologic transition. Preventive services are key to reducing the burden of non-communicable diseases, and smoking counseling and cessation are among the most cost-effective and wide-reaching strategies. Internal medicine physicians are fundamental to providing such services, and their knowledge is a cornerstone of non-communicable disease control.

METHODS

A national cross-sectional survey was conducted in 2011 to evaluate knowledge of clinical preventive services for non-communicable diseases. Interns, residents, and attending physicians of the internal medicine departments of all teaching hospitals in Guatemala completed a self-administered questionnaire. Participants' responses were contrasted with the Guatemalan Ministry of Health (MoH) prevention guidelines and the US Preventive Services Task Force (USPSTF) recommendations. Analysis compared knowledge of recommendations within and between hospitals.

RESULTS

In response to simulated patient scenarios, all services were recommended by more than half of physicians regardless of MoH or USPSTF recommendations. Prioritization was adequate according to the MoH guidelines but not including other potentially effective services (e.g. colorectal cancer and lipid disorder screenings). With the exception of colorectal and prostate cancer screening, less frequently recommended by interns, there was no difference in recommendation rates by level.

CONCLUSION

Guatemalan internal medicine physicians' knowledge on preventive services recommendations for non-communicable diseases is limited, and prioritization did not reflect cost-effectiveness. Based on these data we recommend that preventive medicine training be strengthened and development of evidence-based guidelines for low-middle income countries be a priority.

Nonrecommended breast and colorectal cancer screening for young women: a vignette-based survey

BACKGROUND

Little is known about the prevalence of physicians offering nonrecommended breast or colorectal cancer screening for young women.

PURPOSE

The goal of the current paper was to examine the percentage of primary care physicians nationally who self-report offering breast or colorectal cancer screening tests for young women, and physician/practice characteristics associated with such recommendations.

METHODS

Analysis was performed in 2011 on data from a 2008 cross-sectional survey presenting a vignette of a health maintenance visit by an asymptomatic woman aged 35 years. This study included surveys sent to 1546 U.S. family physicians, general internists, and obstetrician-gynecologists aged <65 years, randomly selected from the AMA Physician Masterfile (60.6% response rate). Relevant respondent subsamples were used for the breast (n=505) and colorectal (n=721) cancer screening analyses. Responses were weighted to represent physicians nationally. The main outcome was physician self-report of offering breast or colorectal cancer screening tests.

RESULTS

75.3% (95% CI =71.0%, 79.2%) of physicians offered breast cancer screening tests; most commonly these physicians reported offering mammography alone (76.5%, 95% CI= 71.6%, 80.8%). A total of 39.3% (95% CI=35.5%, 43.2%) of physicians offered colorectal cancer screening tests; most commonly these physicians reported offering FOBT alone (43.3%, 95% CI=37.2%, 49.6%). In adjusted analysis, physician factors associated with offering breast and colorectal cancer screening tests were: estimating higher patient breast/colorectal cancer risk, and not listing the U.S. Preventive Services Task Force as a top influential organization.

CONCLUSIONS

A high percentage of physicians report offering nonrecommended breast or colorectal cancer screening tests for young women. Physicians' higher cancer-risk estimation accounted for some overscreening, but even physicians who estimated the patient to be at the same risk as the general population reported offering nonrecommended screening tests.

O perfil Brasileiro de propriedade intelectual em radiologia e diagnóstico por imagem em um contexto internacional, nos anos 2000-2009

OBJETIVO: Analisar a inovação tecnológica brasileira na área de radiologia e diagnóstico por imagem, em termos de indicadores de patentes. MATERIAIS E MÉTODOS: Este é um estudo analítico-exploratório de informações recuperadas por meio de consultas cruzadas nas bases de dados dos escritórios de propriedade intelectual do Brasil (Instituto Nacional da Propriedade Industrial - INPI), dos Estados Unidos (United States Patent and Trademark Office - USPTO) e da Europa (European Patent Office - EPO). RESULTADOS: Foram encontradas 277.057 patentes. Desse total, 7.800 foram registradas no INPI (3%), 65.428 (24%) registradas no EPO e 203.829 (73%) emitidas no USPTO. O Brasil é o país signatário em 1.732 patentes publicadas no INPI, 80 no EPO e 26 no escritório USPTO. Globalmente, 219.993 (79%) patentes referiam-se a dispositivos eletrônicos ligados a informática em saúde, ultrassonografia, ressonância magnética, tomografia computadorizada e procedimentos de geração, comunicação e arquivamento de imagens, e 57.064 (21%) das patentes tratavam das tecnologias relacionadas a radioproteção e dosimetria, física nuclear, eletroterapia, terapia magnética e radioterapia. CONCLUSÃO: Os resultados obtidos apontam para a fragilidade da produção nacional de inovação tecnológica registrada em patentes, no campo de radiologia e diagnóstico por Imagem.

Comparison between US Preventive Services Task Force recommendations and Medicare coverage

PURPOSE

The US Preventive Services Task Force (USPSTF) is authorized by the US government to review and disseminate the scientific evidence for clinical preventive services. The purpose of this study was to evaluate the alignment of Medicare preventive services coverage with the recommendations of the USPSTF before implementation of health reform.

METHODS

We recorded all Medicare coverage for preventive services as listed in the Medicare preventive services guide of 2007 (including the 2009 update) for all recommended (A-or B-rated) USPSTF and not recommended (D-rated) guidelines for preventive screening and counseling in adults aged 65 years and older. We analyzed 2 components of preventive care: preventive coordination (risk assessment, patient motivation, and arranging of preventive service) and the preventive service itself. The main outcome measure was the percentage of agreement between USPSTF recommendations and Medicare coverage.

RESULTS

The USPSTF recommended 15 preventive interventions for adults aged 65 years and older. Although Medicare partially reimbursed 93% of recommended services, full reimbursement for the preventive coordination, as well as the service, was available for only 7% of these services. This partial coverage is available mostly as part of the Welcome to Medicare Visit. Further, the USPSTF recommended against 16 preventive services; Medicare reimbursed clinicians for 44% of these services.

CONCLUSIONS

Medicare coverage for preventive services needs to be reassessed, with special focus on preventive coordination. Continuing previous practices will likely promote both inadequate and excessive delivery of preventive services. The new health care reform law has the potential to improve the provision of preventive services to Medicare beneficiaries.

Impact of periodic health examination on surgical treatment for uterine fibroids in Beijing: a case-control study

Background

During the past 2 decades, there has been a rapid proliferation of "health examination center (HEC)" across China. The effects of their services on public's health have not been systemically investigated. This study aimed to assess the impact of periodic health examination (PHE) at HEC on surgical treatment for uterine fibroids in Beijing residents.

Methods

We identified 224 patients with a primary diagnosis of uterine fibroids who had surgical treatment at four Level-1 general hospitals in Beijing, from June 1, 2009 to October 20, 2009. Controls were women who did not have surgery for uterine fibroids, matched (1:1 ratio) for age (within 2 years). A standard questionnaire was used to inquire about whether participants had PHE at HEC during the previous 2 years.

Results

PHE at HEC within 2 years were associated with surgical treatment for uterine fibroids. Odds ratios was 4.05 (95% CI, 2.61-6.29 P < 0.001), after adjustment for marital status, whether have children, annual family income, health insurance, education level and self-rated uterine fibroids-related symptom severity.

Conclusions

Our study showed PHE currently provided at HEC in China were associated with significantly increased use of surgical treatment for uterine fibroids in women. Further studies are needed to assess the effects of PHE on clinical as well as on broad societal outcomes in Chinese in contemporary medical settings.

The U.S. Preventive Services Task Force: an evidence-based prevention resource for nurse practitioners

PURPOSE

To describe the work of the U.S. Preventive Services Task Force and to encourage nurse practitioners (NPs) to use its evidence-based recommendations for clinical preventive services.

SOURCES

Evidence reports, recommendation statements, and journal articles published under the auspices of the U.S. Preventive Services Task Force since its establishment in 1984.

CONCLUSIONS

A core competency for NPs working in primary care is knowledge about and provision of appropriate preventive services for their patients. The U.S. Preventive Services Task Force, an independent panel of experts in prevention and primary care, is an important resource for NPs.

IMPLICATIONS FOR PRACTICE

NPs can use Task Force recommendations to guide their screening, counseling, and preventive medication decisions. They can also educate patients about the missed prevention opportunities related to underuse of effective services and the potential harms of overuse of inappropriate preventive services.

Comprehensive outpatient health assessment: a case-finding tool in 500 consecutive asymptomatic individuals

This study appraises the case-finding efficiency of a single-day outpatient program of a broad-based clinical evaluation and laboratory studies in asymptomatic adults. The same protocol, varied only according to age and sex, was used for 500 individuals encountered consecutively over 15 months, and an unanticipated new diagnosis or important clinical or laboratory finding was established for one-third of them. The diagnoses varied widely, consistent with the breadth of the observations, and most led to specific recommendations for care. These findings confirm the case-finding efficacy of comprehensive clinical assessments supported by basic laboratory studies and counter the notion that specific tests and/or portions of the review of systems and physical examination can be eliminated in establishing a reliable medical database for asymptomatic adults. In addition, such comprehensive data provide essential reference material for later comparisons.

Rearranging the deck chairs

In their efforts to make insurance premiums more affordable, employers and health plans are promoting consumer-directed health care as a consumer-friendly alternative that will cut costs and improve quality. In my view, consumer-directed care reflects health care providers' failure to deliver value and unrealistically assumes that consumers can make sound, cost-effective medical decisions. It also evades the fundamental question of how society defines the limits and obligations of health insurance, and it could stall meaningful action to hold all stakeholders accountable for an equitable, high-quality, and affordable system.

Routine screening: informed consent, stigma and the waning of HIV exceptionalism

The Centers for Disease Control and Prevention (CDC) recently recommended that HIV screening should become routine for all adults in the United States. Implicit in the CDC proposal is the notion that pre-test counseling would be more limited than at present, and that written informed consent to screening would no longer be required. If widely implemented, routine testing would mark a tremendous shift in the US HIV screening strategy. There are a number of considerations used to determine what screening tests should be routine, and HIV fits the bill in almost every regard. Yet the stigma associated with HIV infection remains, making the CDC's recommendation highly controversial. Will minimizing requirements for pre-test counseling and special written informed consent lead to unexpected or unwanted HIV testing, or do these stringent counseling and consent requirements needlessly scare people away? Will widespread and routine testing be associated with declining stigmatization, or will it drive some patients away from seeking desperately needed health care? These are high stakes questions, and we're about to find out the answers.