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Domeisen NK, Forte JE, Agwu VK, Allen SC, Mehran NA, Abubaker T, Patel NP, Keah NM, Shaw Y, Jones FS, Geer CP, Hiatt KD. The Radiology Scholars Certificate Program: A Medical Education Learning Tool. Acad Radiol 2022; 29:1739-1747. [PMID: 35090828 DOI: 10.1016/j.acra.2021.12.021] [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: 10/06/2021] [Revised: 12/17/2021] [Accepted: 12/22/2021] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES The Radiology Scholars Certificate Program (RSCP) is an extracurricular program created for preclinical medical students to address disparities in radiology education and exposure during medical school. MATERIALS AND METHODS The RSCP was designed as a year-long program for first- and second-year medical students. The 4 key components of the RSCP are: Exposure to radiology through shadowing, knowledge acquisition through self-paced case-based learning modules, knowledge application in interactive workshops, and completion of a scholarly project. Students are required to complete at least 3 hours of shadowing, attend at least 3 workshops, complete self-paced online modules, and complete a capstone project on a topic of their choosing. Pre- and post-program surveys were administered to assess trends in participants' perception of the field and imaging-related clinical knowledge. RESULTS In the first year of the RSCP, 55% of the matriculating class enrolled and of those, 84% completed the program. Approximately half of participants were female. Participants demonstrated significant improvement in radiology knowledge, with average scores improving from 52.8% to 68.6% (p < .001) on the knowledge-related survey questions. Significant improvements were also observed in student-reported confidence with ordering and interpreting imaging studies and in their perceptions of the field. CONCLUSION The RSCP is an effective tool for addressing deficits in radiology education and exposure during medical school. It is designed to be run by senior medical students under radiology resident and attending supervision. With motivated student and radiologist investment, the RSCP should be easily replicable in medical training programs worldwide.
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Affiliation(s)
- Natalie K Domeisen
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA.
| | - Jordan E Forte
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Victor K Agwu
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Samuel C Allen
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Nikki A Mehran
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Tebianne Abubaker
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Nishk P Patel
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Niobra M Keah
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Yolanda Shaw
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Frederick S Jones
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Carol P Geer
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
| | - Kevin D Hiatt
- Wake Forest School of Medicine (N.K.M., J.E.F., V.K.A., S.C.A., N.A.M., T.A., N.P.P., N.M.K., Y.S., F.S.J., C.P.G., K.D.H.), Winston-Salem, North Carolina, USA; Atrium Health Wake Forest Baptist, Department of Radiology (N.K.M., F.S.J., C.P.G., K.D.H.), Medical Center Blvd, Winston-Salem, North Carolina 27157, USA
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Meidani Z, Atoof F, Mobarak Z, Nabovati E, Daneshvar Kakhki R, Kouchaki E, Fakharian E, Nickfarjam AM, Holl F. Development of clinical-guideline-based mobile application and its effect on head CT scan utilization in neurology and neurosurgery departments. BMC Med Inform Decis Mak 2022; 22:106. [PMID: 35443649 PMCID: PMC9020029 DOI: 10.1186/s12911-022-01844-3] [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: 11/09/2021] [Accepted: 04/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background There is little evidence regarding the adoption and intention of using mobile apps by health care professionals (HCP) and the effectiveness of using mobile apps among physicians is still unclear. To address this challenge, the current study seeks two objectives: developing and implementing a head CT scan appropriateness criteria mobile app (HAC app), and investigating the effect of HAC app on CT scan order.
Methods A one arm intervention quasi experimental study with before/after analysis was conducted in neurology & neurosurgery (N&N) departments at the academic hospital. We recruited all residents' encounters to N&N departments with head CT scan to examine the effect of HAC app on residents' CT scan utilization. The main outcome measure was CT scan order per patient for seven months at three points, before the intervention, during the intervention, after cessation of the intervention -post-intervention follow-up. Data for CT scan utilization were collected by reviewing medical records and then analyzed using descriptive statistics, Kruskal-Wallis, and Mann-Whitney tests. A focus group discussion with residents was performed to review and digest residents' experiences during interaction with the HAC app. Results Sixteen residents participated in this study; a total of 415 N&N encounters with CT scan order, pre-intervention 127 (30.6%), intervention phase 187 (45.1%), and 101 (24.3%) in the post-intervention follow-up phase were included in this study. Although total CT scan utilization was statistically significant during three-time points of the study (P = 0.027), no significant differences were found for CT utilization after cessation of the intervention (P = 1). Conclusion The effect of mobile devices on residents' CT scan ordering behavior remains open to debate since the changes were not long-lasting. Further studies based on real interactive experiences with mobile devices is advisable before it can be recommended for widespread use by HCP.
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Affiliation(s)
- Zahra Meidani
- Health Information Management Research Center, Kashan University of Medical Sciences, Kashan, Iran. .,Department of Health Information Management and Technology, Faculty of Allied Medical Sciences, Kashan University of Medical Sciences, Kashan, Iran.
| | - Fatemeh Atoof
- Department of Biostatistics & Epidemiology, Faculty of Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Zohre Mobarak
- Department of Health Information Management and Technology, Faculty of Allied Medical Sciences, Kashan University of Medical Sciences, Kashan, Iran
| | - Ehsan Nabovati
- Health Information Management Research Center, Kashan University of Medical Sciences, Kashan, Iran.,Department of Health Information Management and Technology, Faculty of Allied Medical Sciences, Kashan University of Medical Sciences, Kashan, Iran
| | - Reza Daneshvar Kakhki
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Ebrahim Kouchaki
- Department of Neurology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Esmaeil Fakharian
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Ali Mohammad Nickfarjam
- Health Information Management Research Center, Kashan University of Medical Sciences, Kashan, Iran.,Department of Health Information Management and Technology, Faculty of Allied Medical Sciences, Kashan University of Medical Sciences, Kashan, Iran
| | - Felix Holl
- DigiHealth Institute, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany.,Institute for Medical Information Processing, Biometry, and Epidemiology, University of Munich, Munich, Germany
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Betrains A, Vanderschueren S. In reply to 'clinical biochemistry test eliminator providing cost-effectiveness with five algorithms': the Casablanca strategy. Acta Clin Belg 2021; 76:512-513. [PMID: 32421459 DOI: 10.1080/17843286.2020.1763672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In this journal, Ataman Gönel recently demonstrated that elimination of requested unnecessary tests by means of algorithms in an artificial intelligence program may contribute to the cost-effectiveness of medicine. However, test ordering is an essential part of clinical medicine and decision-making. Interns are responsible for a modest but significant excess in laboratory utilization and underestimate their control over laboratory testing. Even in the hands of experts, rational approaches to test ordering may be subverted by the Casablanca Strategy. Establishing a differential diagnosis and ordering only tests deemed necessary reflect the attainment of expertise in the clinical decision-making process. Residents and attendings in teaching roles should not underestimate the extent to which their clinical decision-making may be mimicked.
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Affiliation(s)
- Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disease, Leuven, Belgium,
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disease, Leuven, Belgium,
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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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Effectiveness of an automated feedback with dashboard on use of laboratory tests by neurology residents. INFORMATICS IN MEDICINE UNLOCKED 2021. [DOI: 10.1016/j.imu.2021.100767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Baranova K, Torti J, Goldszmidt M. Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:1922-1930. [PMID: 31567168 DOI: 10.1097/acm.0000000000002998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams. METHOD Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis. RESULTS The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover). CONCLUSIONS Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.
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Affiliation(s)
- Katherina Baranova
- K. Baranova is a fourth-year medical student, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. J. Torti is research consultant and education specialist, Centre for Education Research and Innovation, Western University, London, Ontario, Canada. M. Goldszmidt is research scientist and director (acting), Centre for Education Research and Innovation, and professor of medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Ambasta A, Pancic S, Wong BM, Lee T, McCaughey D, Ma IWY. Expert Recommendations on Frequency of Utilization of Common Laboratory Tests in Medical Inpatients: a Canadian Consensus Study. J Gen Intern Med 2019; 34:2786-2795. [PMID: 31385217 PMCID: PMC6854150 DOI: 10.1007/s11606-019-05196-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Repetitive inpatient laboratory testing in the face of clinical stability is a marker of low-value care. However, for commonly encountered clinical scenarios on medical units, there are no guidelines defining appropriate use criteria for laboratory tests. OBJECTIVE This study seeks to establish consensus-based recommendations for the utilization of common laboratory tests in medical inpatients. DESIGN This study uses a modified Delphi method. Participants completed two rounds of an online survey to determine appropriate testing frequencies for selected laboratory tests in commonly encountered clinical scenarios. Consensus was defined as agreement by at least 80% of participants. PARTICIPANTS Participants were 36 experts in internal medicine across Canada defined as internists in independent practice for ≥ 5 years with experience in medical education, quality improvement, or both. Experts represented 8 of the 10 Canadian provinces and 13 of 17 academic institutions. MAIN MEASURES Laboratory tests and clinical scenarios included were those that were considered common on medical units. The final survey contained a total of 45 clinical scenarios looking at the utilization of six laboratory tests (complete blood count, electrolytes, creatinine, urea, international normalized ratio, and partial thromboplastin time). The possible frequency choices were every 2-4 h, 6-8 h, twice a day, daily, every 2-3 days, weekly, or none unless there was specific diagnostic suspicion. These scenarios were reviewed by two internists with training in quality improvement and survey methods. KEY RESULTS Of the 45 initial clinical scenarios included, we reached consensus on 17 scenarios. We reached weak consensus on an additional 19 scenarios by combining two adjacent frequency categories. CONCLUSIONS A Canadian expert panel of internists has provided frequency recommendations on the utilization of six common laboratory tests in medical inpatients. These recommendations need validation in prospective studies to assess whether restrictive versus liberal laboratory test ordering impacts patient outcomes.
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Affiliation(s)
- Anshula Ambasta
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada. .,Ward of the 21st century, University of Calgary, Calgary, Alberta, Canada.
| | - Stefana Pancic
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Brian M Wong
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Center for Quality Improvement and Patient Safety, Toronto, Ontario, Canada
| | - Todd Lee
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Deirdre McCaughey
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Irene W Y Ma
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.,Ward of the 21st century, University of Calgary, Calgary, Alberta, Canada
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Meidani Z, Mousavi GA, Kheirkhah D, Benar N, Maleki MR, Sharifi M, Farrokhian A. Going beyond audit and feedback: towards behaviour-based interventions to change physician laboratory test ordering behaviour. J R Coll Physicians Edinb 2019. [PMID: 29537404 DOI: 10.4997/jrcpe.2017.407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Studies indicate there are a variety of contributing factors affecting physician test ordering behaviour. Identifying these behaviours allows development of behaviour-based interventions. Methods Through a pilot study, the list of contributing factors in laboratory tests ordering, and the most ordered tests, were identified, and given to 50 medical students, interns, residents and paediatricians in questionnaire form. The results showed routine tests and peer or supervisor pressure as the most influential factors affecting physician ordering behaviour. An audit and feedback mechanism was selected as an appropriate intervention to improve physician ordering behaviour. The intervention was carried out at two intervals over a three-month period. Findings There was a large reduction in the number of laboratory tests ordered; from 908 before intervention to 389 and 361 after first and second intervention, respectively. There was a significant relationship between audit and feedback and the meaningful reduction of 7 out of 15 laboratory tests including complete blood count (p = 0.002), erythrocyte sedimentation rate (p = 0.01), C-reactive protein (p = 0.01), venous blood gas (p = 0.016), urine analysis (p = 0.005), blood culture (p = 0.045) and stool examination (p = 0.001). Conclusion The audit and feedback intervention, even in short duration, affects physician ordering behaviour. It should be designed in terms of behaviour-based intervention and diagnosis of the contributing factors in physicians' behaviour. Further studies are required to substantiate the effectiveness of such behaviour-based intervention strategies in changing physician behaviour.
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Affiliation(s)
- Z Meidani
- D Kheirkhah, Infectious Diseases Research Centre, Kashan University of Medical Sciences, Kashan, Iran.
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Hollingsworth TD, Duszak R, Vijayasarathi A, Gelbard RB, Mullins ME. Trainee Knowledge of Imaging Appropriateness and Safety: Results of a Series of Surveys From a Large Academic Medical Center. Curr Probl Diagn Radiol 2019; 48:17-21. [DOI: 10.1067/j.cpradiol.2017.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/23/2017] [Indexed: 11/22/2022]
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Tchou MJ, Tang Girdwood S, Wormser B, Poole M, Davis-Rodriguez S, Caldwell JT, Shannon L, Hagedorn PA, Biondi E, Simmons J, Anderson J, Brady PW. Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods. Pediatrics 2018; 141:peds.2017-3187. [PMID: 29618583 PMCID: PMC7008632 DOI: 10.1542/peds.2017-3187] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.
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Affiliation(s)
- Michael J. Tchou
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | | | | | - Meifawn Poole
- Pediatric Residency Training Program, Cincinnati, Ohio
| | | | | | - Lauren Shannon
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Philip A. Hagedorn
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio
| | - Eric Biondi
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Jeffrey Simmons
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | - Jeffrey Anderson
- James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio;,Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W. Brady
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati, Ohio;,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
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Ellenbogen MI, O'Leary KJ. Reducing Routine Labs-Teaching Residents Restraint. J Hosp Med 2017; 12:781-782. [PMID: 28914290 DOI: 10.12788/jhm.2817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Michael I Ellenbogen
- Hospitalist Program, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Kevin J O'Leary
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Rudolf JW, Dighe AS, Coley CM, Kamis IK, Wertheim BM, Wright DE, Lewandrowski KB, Baron JM. Analysis of Daily Laboratory Orders at a Large Urban Academic Center: A Multifaceted Approach to Changing Test Ordering Patterns. Am J Clin Pathol 2017; 148:128-135. [PMID: 28898984 DOI: 10.1093/ajcp/aqx054] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to address concerns regarding recurring inpatient laboratory test order practices (daily laboratory tests) through a multifaceted approach to changing ordering patterns. METHODS We engaged in an interdepartmental collaboration to foster mindful test ordering through clinical policy creation, electronic clinical decision support, and continuous auditing and feedback. RESULTS Annualized daily order volumes decreased from approximately 25,000 to 10,000 during a 33-month postintervention review. This represented a significant change from preintervention order volumes (95% confidence interval, 0.61-0.64; P < 10-16). Total inpatient test volumes were not affected. CONCLUSIONS Durable changes to inpatient order practices can be achieved through a collaborative approach to utilization management that includes shared responsibility for establishing clinical guidelines and electronic decision support. Our experience suggests auditing and continued feedback are additional crucial components to changing ordering behavior. Curtailing daily orders alone may not be a sufficient strategy to reduce in-laboratory costs.
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Affiliation(s)
| | - Anand S Dighe
- Departments of Pathology
- Harvard Medical School, Boston, MA
| | - Christopher M Coley
- Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Irina K Kamis
- Information Systems, Partners HealthCare, Boston, MA
| | - Bradley M Wertheim
- Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Douglas E Wright
- Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, MA
| | | | - Jason M Baron
- Departments of Pathology
- Harvard Medical School, Boston, MA
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Rudolf J, Jackson BR, Wilson AR, Smock KJ, Schmidt RL. Organizational Benchmarks for Test Utilization Performance: An Example Based on Positivity Rates for Genetic Tests. Am J Clin Pathol 2017; 147:382-389. [PMID: 28340161 DOI: 10.1093/ajcp/aqx019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Health care organizations are under increasing pressure to deliver value by improving test utilization management. Many factors, including organizational factors, could affect utilization performance. Past research has focused on the impact of specific interventions in single organizations. The impact of organizational factors is unknown. The objective of this study is to determine whether testing patterns are subject to organizational effects, ie, are utilization patterns for individual tests correlated within organizations. METHODS Comparative analysis of ordering patterns (positivity rates for three genetic tests) across 659 organizations. Hierarchical regression was used to assess the impact of organizational factors after controlling for test-level factors (mutation prevalence) and hospital bed size. RESULTS Test positivity rates were correlated within organizations. CONCLUSIONS Organizations have a statistically significant impact on the positivity rate of three genetic tests.
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Affiliation(s)
- Joseph Rudolf
- From the Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston
| | - Brian R Jackson
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
| | - Andrew R Wilson
- School of Nursing, University of Utah Health Sciences Center, Salt Lake City
| | - Kristi J Smock
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
| | - Robert L Schmidt
- Center for Effective Medical Testing, Department of Pathology, University of Utah, Salt Lake City
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Wertheim BM, Aguirre AJ, Bhattacharyya RP, Chorba J, Jadhav AP, Kerry VB, Macklin EA, Motyckova G, Raju S, Lewandrowski K, Hunt DP, Wright DE. An Educational and Administrative Intervention to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service. Am J Med 2017; 130:47-53. [PMID: 27619354 PMCID: PMC6598201 DOI: 10.1016/j.amjmed.2016.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/30/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Overuse of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily implemented intervention to promote rational laboratory use without compromising resident education or patient care. METHODS The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring laboratory orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized "general medicine" was duplicated during 2 consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, Massachusetts. The primary outcome was the total number of commonly used laboratory tests per patient day during 2 months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient day, adverse events, and resident and nursing satisfaction. RESULTS A total of 5392 patient days were captured. The intervention produced a 9% decrease in aggregate laboratory use (rate ratio, 0.91; P = .021; 95% confidence interval, 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm. CONCLUSIONS A bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in laboratory use. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study.
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Affiliation(s)
- Bradley M Wertheim
- Department of Medicine, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, Mass.
| | - Andrew J Aguirre
- Department of Medicine, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, Mass
| | - Roby P Bhattacharyya
- Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Massachusetts General Hospital, Boston
| | - John Chorba
- Department of Medicine, Massachusetts General Hospital, Boston
| | | | - Vanessa B Kerry
- Harvard Medical School, Boston, Mass; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Eric A Macklin
- Biostatistics Center, Massachusetts General Hospital, Boston
| | | | - Shveta Raju
- Department of Medicine, Massachusetts General Hospital, Boston; Georgia Regents University/Medical College of Georgia, Augusta
| | - Kent Lewandrowski
- Harvard Medical School, Boston, Mass; Department of Pathology, Massachusetts General Hospital, Boston
| | - Daniel P Hunt
- Department of Medicine, Massachusetts General Hospital, Boston; Emory University School of Medicine, Atlanta, Ga
| | - Douglas E Wright
- Department of Medicine, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, Mass
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Sedrak MS, Patel MS, Ziemba JB, Murray D, Kim EJ, Dine CJ, Myers JS. Residents' self-report on why they order perceived unnecessary inpatient laboratory tests. J Hosp Med 2016; 11:869-872. [PMID: 27520384 DOI: 10.1002/jhm.2645] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/25/2016] [Accepted: 06/28/2016] [Indexed: 11/09/2022]
Abstract
Resident physicians routinely order unnecessary inpatient laboratory tests. As hospitalists face growing pressures to reduce low-value services, understanding the factors that drive residents' laboratory ordering can help steer resident training in high-value care. We conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center to describe the frequency of perceived unnecessary ordering of inpatient laboratory tests, factors contributing to that behavior, and potential interventions to change it. The sample comprised 57.0% of IM and 54.4% of GS residents. Among respondents, perceived unnecessary inpatient laboratory test ordering was self-reported by 88.2% of IM and 67.7% of GS residents, occurring on a daily basis by 43.5% and 32.3% of responding IM and GS residents, respectively. Across both specialties, residents attributed their behaviors to the health system culture, lack of transparency of the costs associated with health care services, and lack of faculty role models that celebrate restraint. Journal of Hospital Medicine 2015;11:869-872. © 2015 Society of Hospital Medicine.
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Affiliation(s)
- Mina S Sedrak
- Department of Medical Oncology, Therapeutics Research, City of Hope, Duarte, California
| | - Mitesh S Patel
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Justin B Ziemba
- Department of Urology, John Hopkins Hospital, Baltimore, Maryland
| | - Dana Murray
- Department of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Esther J Kim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - C Jessica Dine
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer S Myers
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Vijayasarathi A, Duszak R, Gelbard RB, Mullins ME. Knowledge of the Costs of Diagnostic Imaging: A Survey of Physician Trainees at a Large Academic Medical Center. J Am Coll Radiol 2016; 13:1304-1310. [DOI: 10.1016/j.jacr.2016.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/03/2016] [Accepted: 05/09/2016] [Indexed: 02/04/2023]
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Delfiner MS, Martinez LR, Pavia CS. A Gram Stain Hands-On Workshop Enhances First Year Medical Students' Technique Competency in Comprehension and Memorization. PLoS One 2016; 11:e0163658. [PMID: 27711118 PMCID: PMC5053596 DOI: 10.1371/journal.pone.0163658] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/12/2016] [Indexed: 11/19/2022] Open
Abstract
Background Laboratory diagnostic tests have an essential role in patient care, and the increasing number of medical and health professions schools focusing on teaching laboratory medicine to pre-clinical students reflects this importance. However, data validating the pedagogical methods that best influence students’ comprehension and interpretation of diagnostic tests have not been well described. The Gram stain is a simple yet significant and frequently used diagnostic test in the clinical setting that helps classify bacteria into two major groups, Gram positive and negative, based on their cell wall structure. Methods and Findings We used this technique to assess which educational strategies may improve students’ learning and competency in medical diagnostic techniques. Hence, in this randomized controlled study, we compared the effectiveness of several educational strategies (e.g. workshop, discussion, or lecture) in first year medical students’ competency in comprehension and interpretation of the Gram stain procedure. We demonstrated that a hands-on practical workshop significantly enhances students’ competency in memorization and overall comprehension of the technique. Interestingly, most students irrespective of their cohort showed difficulty in answering Gram stain-related analytical questions, suggesting that more emphasis should be allocated by the instructors to clearly explain the interpretation of the diagnostic test results to students in medical and health professional schools. Conclusion This proof of principle study highlights the need of practical experiences on laboratory medical techniques during pre-clinical training to facilitate future medical doctors’ and healthcare professionals’ basic understanding and competency in diagnostic testing for better patient care.
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Affiliation(s)
- Matthew S. Delfiner
- Department of Biomedical Sciences, NYIT College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY, United States of America
| | - Luis R. Martinez
- Department of Biomedical Sciences, NYIT College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY, United States of America
- * E-mail: (LRM); (CSP)
| | - Charles S. Pavia
- Department of Biomedical Sciences, NYIT College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY, United States of America
- * E-mail: (LRM); (CSP)
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Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs. J Hosp Med 2016; 11:348-54. [PMID: 26843272 DOI: 10.1002/jhm.2552] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/15/2015] [Accepted: 01/04/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inappropriate laboratory testing is a contributor to waste in healthcare. OBJECTIVE To evaluate the impact of a multifaceted laboratory reduction intervention on laboratory costs. DESIGN A retrospective, controlled, interrupted time series (ITS) study. SETTING University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah. POPULATION All patients 18 years or older admitted to the hospital to a service other than obstetrics, rehabilitation, or psychiatry. INTERVENTION Multifaceted quality-improvement initiative in a hospitalist service including education, process change, cost feedback, and financial incentive. MEASUREMENTS Primary outcomes of lab cost per day and per visit. Secondary outcomes of number of basic metabolic panel (BMP), comprehensive metabolic panel (CMP), complete blood count (CBC), and prothrombin time/international normalized ratio tests per day; length of stay (LOS); and 30-day readmissions. RESULTS A total of 6310 hospitalist patient visits (intervention group) were compared to 25,586 nonhospitalist visits (control group). Among the intervention group, the unadjusted mean cost per day was reduced from $138 before the intervention to $123 after the intervention (P < 0.001), and the unadjusted mean cost per visit decreased from $618 to $558 (P = 0.005). The ITS analysis showed significant reductions in cost per day, cost per visit, and the number of BMP, CMP, and CBC tests per day (P = 0.034, 0.02, <0.001, 0.004, and <0.001). LOS was unchanged and 30-day readmissions decreased in the intervention group. CONCLUSION A multifaceted approach to laboratory reduction demonstrated a significant reduction in laboratory cost per day and per visit, as well as common tests per day at a major academic medical center. Journal of Hospital Medicine 2016;11:348-354. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Peter M Yarbrough
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah Medical Center, Salt Lake City, Utah
- Department of Internal Medicine, Division of General Medicine, George E. Whalen Veteran Affairs Medical Center, Salt Lake City, Utah
| | - Polina V Kukhareva
- Department of Biomedical Informatics, University of Utah, University of Utah Medical Center, Salt Lake City, Utah
| | - Devin Horton
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah Medical Center, Salt Lake City, Utah
| | - Karli Edholm
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah Medical Center, Salt Lake City, Utah
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, University of Utah Medical Center, Salt Lake City, Utah
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Padia R, Thomas A, Alt J, Gale C, Meier JD. Hospital cost of pediatric patients with complicated acute sinusitis. Int J Pediatr Otorhinolaryngol 2016; 80:17-20. [PMID: 26746605 DOI: 10.1016/j.ijporl.2015.11.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/15/2015] [Accepted: 11/18/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Review costs for pediatric patients with complicated acute sinusitis. METHODS A retrospective case series of patients in a pediatric hospital was created to determine hospital costs using a standardized activity-based accounting system for inpatient treatment between November 2010 and December 2014. Children less than 18 years of age who were admitted for complicated acute sinusitis were included in the study. Demographics, length of stay, type of complication and cost of care were determined for these patients. RESULTS The study included 64 patients with a mean age of 10 years. Orbital cellulitis (orbital/preseptal/postseptal cellulitis) accounted for 32.8% of patients, intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 29.7%, orbital abscesses (subperiosteal/intraorbital abscesses) for 25.0%, potts puffy tumor for 7.8%, and other (including facial abscess and dacryocystitis) for 4.7%. The average length of stay was 5.7 days. The mean cost per patient was $20,748. Inpatient floor costs (31%) and operating room costs (18%) were the two greatest expenditures. The major drivers in variation of cost between types of complications included pediatric intensive care unit stays and pharmacy costs. CONCLUSION Although complicated acute sinusitis in the pediatric population is rare, this study demonstrates a significant financial impact on the health care system. Identifying ways to reduce unnecessary costs for these visits would improve the value of care for these patients.
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Affiliation(s)
- Reema Padia
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Andrew Thomas
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jeremiah Alt
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Craig Gale
- Intermountain Healthcare, Surgical Services Clinical Program, Murray, UT, United States
| | - Jeremy D Meier
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States.
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Smith BR, Kamoun M, Hickner J. Laboratory Medicine Education at U.S. Medical Schools: A 2014 Status Report. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91. [PMID: 26200574 PMCID: PMC5480607 DOI: 10.1097/acm.0000000000000817] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE To assess the current state of laboratory medicine education at U.S. medical schools. METHOD From 2013 to 2014, the authors surveyed the appropriate dean, department chair, or undergraduate education director at each U.S. medical school accredited by the Liaison Committee on Medical Education about the state of laboratory medicine education, curriculum and competency assessment, and barriers to education at his or her institution. The authors used descriptive statistics to analyze the results. RESULTS The authors received 98 (75%) responses. Eighty-two schools (84%) offered course work in laboratory medicine; 76 (78%) required it. The median number of hours of required course work was 12.5, with 8.0 devoted to lectures and 4.5 to small-group, problem-based learning and/or laboratory sessions. Only 8 schools required training in a clinical setting. Fewer than half reported regular, formal review of the laboratory medicine curriculum. The assessment of students' competency in laboratory medicine was rare (8 schools), and only half of respondents were aware of published curriculum guidelines. Barriers to teaching laboratory medicine included lack of sufficient time in the preclinical curriculum (86; 88%) or clinical curriculum (84; 86%), lack of knowledge of best laboratory practices by residents (70; 72%), lack of student interest (62; 63%), and lack of knowledge by attending physicians (58; 59%). Half of respondents were likely to use a national standardized examination to assess competency in laboratory medicine, if one was available. CONCLUSIONS Significant opportunities exist to improve laboratory medicine education, including in the proper use and interpretation of clinical laboratory testing.
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Affiliation(s)
- Brian R Smith
- B.R. Smith is professor and chair, Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut. M. Kamoun is professor, Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. J. Hickner is head, Department of Family Clinical Medicine, University of Illinois College of Medicine, Chicago, Illinois
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Ryskina KL, Dine CJ, Kim EJ, Bishop TF, Epstein AJ. Effect of Attending Practice Style on Generic Medication Prescribing by Residents in the Clinic Setting: An Observational Study. J Gen Intern Med 2015; 30:1286-93. [PMID: 26173522 PMCID: PMC4539316 DOI: 10.1007/s11606-015-3323-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite increased emphasis on cost-consciousness in graduate medical training, there is little empirical evidence of the role of attending physician supervision on resident practice in this area. OBJECTIVE To study whether the prescribing practices of attendings influence residents' prescribing of brand-name statin medications in the ambulatory clinic setting. DESIGN AND PARTICIPANTS A retrospective study of statin prescriptions by residents at two internal medicine residency programs, using electronic medical record data from July 2007 through November 2011. MAIN MEASURES We estimated multivariable hierarchical logistic regression models to assess the independent effect of the supervising attending's rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin. KEY RESULTS The sample included 342 residents and 58 attendings, accounting for 10,151 initial statin prescriptions, including 3,942 by residents. Brand-name statins were prescribed in about one-fourth of encounters. After adjusting for patient-, physician-, and practice-level factors, the supervising attendings' brand-name prescribing rate in the quarter preceding the encounter was positively associated with a postgraduate year (PGY)-1 resident's prescribing a brand-name statin, but not for PGY-2 or PGY-3 residents. For PGY-1 residents, the adjusted probability of a resident prescribing a brand-name statin ranged from 22.6 % (95 % CI 17.3-28.0 %, p < 0.001) for residents supervised by an attending who prescribed < 20 % brand-name statins in the previous quarter to 41.6 % (95 % CI 24.6-58.5 %, p < 0.001) for residents supervised by an attending who prescribed at least 80 % brand-name statins in the previous quarter. A higher PGY level was associated with brand-name prescribing (aOR 2.07, 95 % CI 1.28-3.35, p = 0.003 for PGY-2; aOR 2.15, 95 % CI 1.31-3.55, p = 0.003 for PGY-3, vs. PGY-1). CONCLUSIONS Supervising attendings' prescribing of brand-name medications may have a significant influence on PGY-1 residents' prescribing of brand-name medications, but not on prescribing by more senior residents.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, 13-30B4 13th Floor Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA,
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Appropriateness of expectorated sputum cultures in the hospital setting. Diagn Microbiol Infect Dis 2015; 83:74-6. [PMID: 26032431 DOI: 10.1016/j.diagmicrobio.2015.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 04/29/2015] [Accepted: 05/16/2015] [Indexed: 11/23/2022]
Abstract
We assessed whether expectorated sputum samples are ordered according to national guidelines and the impact of culture results on patient management. Overall, guidelines for ordering sputum samples were followed for 23% (18/78) of patients. Results affected treatment in 18% (14/79) of cases. Reducing inappropriate sputum cultures may have significant economic savings in the hospital system.
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Ryskina KL, Pesko MF, Gossey JT, Caesar EP, Bishop TF. Brand Name Statin Prescribing in a Resident Ambulatory Practice: Implications for Teaching Cost-Conscious Medicine. J Grad Med Educ 2014; 6:484-8. [PMID: 26279773 PMCID: PMC4535212 DOI: 10.4300/jgme-d-13-00412.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/07/2014] [Accepted: 03/17/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Several national initiatives aim to teach high-value care to residents. While there is a growing body of literature on cost impact of physicians' therapeutic decisions, few studies have assessed factors that influence residents' prescribing practices. OBJECTIVE We studied factors associated with intensive health care utilization among internal medicine residents, using brand name statin prescribing as a proxy for higher-cost care. METHODS We conducted a retrospective, cross-sectional analysis of statin prescriptions by residents at an urban academic internal medicine program, using electronic health record data between July 1, 2010, and June 30, 2011. RESULTS For 319 encounters by 90 residents, patients were given a brand name statin in 50% of cases. When categorized into quintiles, the bottom quintile of residents prescribed brand name statins in 2% of encounters, while the top quintile prescribed brand name statins in 98% of encounters. After adjusting for potential confounders, including patient characteristics and supervising attending, being in the primary care track was associated with lower odds (odds ratio [OR], 0.38; P = .02; 95% confidence interval [CI], 0.16-0.86), and graduating from a medical school with an above-average hospital care intensity index was associated with higher odds of prescribing brand name statins (OR, 1.70; P = .049; 95% CI, 1.003-2.88). CONCLUSIONS We found considerable variation in brand name statin prescribing by residents. Medical school attended and residency program type were associated with resident prescribing behavior. Future interventions should raise awareness of these patterns in an effort to teach high-value, cost-conscious care to all residents.
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Variation in diagnostic testing in ICUs: a comparison of teaching and nonteaching hospitals in a regional system. Crit Care Med 2014; 42:9-16. [PMID: 24145835 DOI: 10.1097/ccm.0b013e3182a63887] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore variation in the use of diagnostic testing in ICUs, with emphasis on differences between teaching and nonteaching ICUs. DESIGN Retrospective review of a prospective clinical ICU database. SETTING Five teaching and four nonteaching ICUs in Winnipeg, Canada, during 2006-2010. PATIENTS All adults admitted to the nine ICUs during the study period were eligible. After excluding subgroups restricted to teaching ICUs, inter-ICU transfers, prior ICU admission within 90 days, ICU length of stay less than 12 hours, and missing death dates, 10,262 patients were evaluated. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Our primary outcome variable (TotalTesting) was the cumulative number of nine common laboratory tests, three radiologic tests, and electrocardiograms performed in each ICU. We used multivariable median regression to identify factors associated with TotalTesting, including length of stay, demographics, admission details, type and severity of acute illness, and specific medical interventions. We estimated the predictive power of variables as the decline in pseudo-R2 (a goodness-of-fit measure for median regression) when omitting those variables from the model. Median (interquartile range) TotalTesting was 27 (18-49) in teaching ICUs and 20 (13-36) in nonteaching units. With multivariable adjustment, median TotalTesting was 7.1 higher (95% CI, 6.6-7.7) in teaching ICUs. The most influential variable was length of stay, accounting for almost half of the variation. ICU teaching status was the second most important factor, greater than the degree of physiologic derangement and details of medical management. CONCLUSIONS After adjustment for confounding variables, patients in teaching ICUs had slightly but significantly more diagnostic tests done than those in nonteaching ICUs. In addition to increasing costs, prior studies have shown that excessive testing can cause harm in various ways and does not improve outcomes. Interventions to reduce testing should be directed to all caregivers with responsibility for ordering diagnostic tests, in both teaching and nonteaching institutions.
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Teaching and practicing cost-awareness in the intensive care unit: A TARGET to aim for. J Crit Care 2014; 29:107-11. [DOI: 10.1016/j.jcrc.2013.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 08/16/2013] [Accepted: 08/18/2013] [Indexed: 11/20/2022]
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Vidyarthi AR, Hamill T, Green AL, Rosenbluth G, Baron RB. Changing resident test ordering behavior: a multilevel intervention to decrease laboratory utilization at an academic medical center. Am J Med Qual 2014; 30:81-7. [PMID: 24443317 DOI: 10.1177/1062860613517502] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hospital laboratory test volume is increasing, and overutilization contributes to errors and costs. Efforts to reduce laboratory utilization have targeted aspects of ordering behavior, but few have utilized a multilevel collaborative approach. The study team partnered with residents to reduce unnecessary laboratory tests and associated costs through multilevel interventions across the academic medical center. The study team selected laboratory tests for intervention based on cost, volume, and ordering frequency (complete blood count [CBC] and CBC with differential, common electrolytes, blood enzymes, and liver function tests). Interventions were designed collaboratively with residents and targeted components of ordering behavior, including system changes, teaching, social marketing, academic detailing, financial incentives, and audit/feedback. Laboratory ordering was reduced by 8% cumulatively over 3 years, saving $2 019 000. By involving residents at every stage of the intervention and targeting multiple levels simultaneously, laboratory utilization was reduced and cost savings were sustained over 3 years.
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Affiliation(s)
- Arpana R Vidyarthi
- Duke-NUS Graduate Medical School, Singapore Healthcare Leadership College, Singapore SingHealth Pvt Ltd, Singapore
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Sommers BD, Desai N, Fiskio J, Licurse A, Thorndike M, Katz JT, Bates DW. An educational intervention to improve cost-effective care among medicine housestaff: a randomized controlled trial. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2012; 87:719-728. [PMID: 22534589 DOI: 10.1097/acm.0b013e31825373b3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE High medical costs create significant burdens. Research indicates that doctors have little awareness of costs. This study tested whether a brief educational intervention could increase residents' awareness of cost-effectiveness and reduce costs without negatively affecting patient outcomes. METHOD The authors conducted a clustered randomized controlled trial of 33 teams (96 residents) at an internal medicine residency program (2009-2010). The intervention was a 45-minute teaching session; residents reviewed the hospital bill of a patient for whom they had cared and discussed reducing unnecessary costs. Primary outcomes were laboratory, pharmacy, radiology, and total hospital costs per admission. Secondary measures were length of stay (LOS), intensive care unit (ICU) admission, 30-day readmission, and 30-day mortality. Multivariate adjustment controlled for patient demographics and health. A follow-up survey assessed resident attitudes three months later. RESULTS Among 1,194 patients, there were no significant cost differences between intervention and control groups. In the intervention group, 30-day readmission was higher (adjusted odds ratio 1.51, P = .010). There was no effect on LOS or the composite outcome of readmission, mortality, and ICU transfer. In a subgroup analysis of 835 patients newly admitted during the study, the intervention group incurred $163 lower adjusted lab costs per admission (P = .046). The follow-up survey indicated persistent differences in residents' exposure to concepts of cost-effectiveness (P = .041). CONCLUSIONS A brief intervention featuring a discussion of hospital bills can fill a gap in resident education and reduce laboratory costs for a subset of patients, but may increase readmission risk.
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Affiliation(s)
- Benjamin D Sommers
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
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Croskerry P. Commentary: Lowly interns, more is merrier, and the Casablanca Strategy. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:8-10. [PMID: 21191201 DOI: 10.1097/acm.0b013e318200281a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Test ordering is an integral part of clinical decision making. Variation in test-ordering behavior appears to reflect uncertainty in the clinical reasoning and decision-making process. Among decision makers, novices function mostly in the analytic mode of reasoning, experiencing high levels of uncertainty and, therefore, account for the most variance. While less discriminate test ordering has both economical and clinical downsides, it nevertheless remains a rite of passage along the road toward expertise. In response to the article by Iwashyna and colleagues, the author of this commentary reflects on the implications of test-ordering behavior in the academic medicine setting. The process of ordering tests can serve purposes other than the obvious, not the least of which allows the decision maker additional time for reflection in the decision-making process, perhaps leading to a less mindless and more mindful approach. The author observes that test-ordering behavior of novitiates might be optimized through a variety of strategies that improve both active and passive learning in the clinical environment. In addition to specific education around costs, as well as Bayesian considerations, active learning importantly requires exposure to those processes that may subvert clinical reasoning, notably cognitive biases. Passive learning is enhanced in supportive environments. Throughout, those who supervise and teach should provide effective models.
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Affiliation(s)
- Pat Croskerry
- Department of Emergency Medicine and Division of Medical Education, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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