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Liu DS, Murray MM, Bae DS, May CJ. Pediatric and Adolescent Distal Radius Fractures: Current Concepts and Treatment Recommendations. J Am Acad Orthop Surg 2024:00124635-990000000-01010. [PMID: 38833725 DOI: 10.5435/jaaos-d-23-01233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/27/2024] [Indexed: 06/06/2024] Open
Abstract
Distal radius fractures are the most common skeletal injuries requiring intervention in children. These injuries are classified by fracture pattern, location, displacement, and angulation. While each unique fracture pattern warrants slightly modified treatment plans and follow-up, the goals of treatment remain constant. Successful outcomes depend on restoration of motion and function, and attaining acceptable sagittal and coronal alignment is a necessary first step. For displaced fractures, closed reduction is often necessary to restore alignment; well-molded cast application is important to maintain fracture alignment. Fractures with bayonet apposition, if well aligned, may not need formal reduction in some patients. Special attention should be paid to the physis-not only for physeal-involving fractures but also for all distal radius fractures-given that the proximity to the physis and amount of remaining skeletal growth help guide treatment decisions. Casting technique is essential in optimizing the best chance in maintaining fracture reduction. Surgical intervention may be indicated for a subset of fractures when acceptable alignment is not achieved or is lost at subsequent follow-up. Even among experts in the field, there is little consensus as to the optimal treatment of displaced metaphyseal fractures, illustrating the need for prospective, randomized studies to establish best practices.
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Affiliation(s)
- David S Liu
- From the Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
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Lin TJ. Editorial Commentary: There Is No Standard for or Standardization of Postoperative Rehabilitation Protocols After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2023; 39:590-591. [PMID: 36740283 DOI: 10.1016/j.arthro.2022.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 02/07/2023]
Abstract
The anterior cruciate ligament (ACL) is the most studied ligament in the knee and one of the most studied topics in orthopaedics, with little consensus on best options for surgical technique or graft choice. While there is little question that physical rehabilitation is one of the most important variables in the episode of care before and after ACL reconstruction (ACLR), recent research surveying orthopaedic surgeons demonstrates no consensus of how to rehab ACLR patients and how to get them to return to sport safely and quickly. Seventy-two percent of surgeons prescribe "pre-hab" prior to ACLR, and 83% of surgeons use postoperative bracing, with most (55%) bracing for 3 to 6 weeks postoperatively. Patient-reported outcome measures (35%) and assessments of psychological readiness (23%) are not commonly used to progress patients through the stages of rehab. When asked what they believe is the single most important factor in unrestricted return to sport, 52% of surgeons stated functional testing scores were most important, while 38% stated time since surgery, and 5% stated muscle strength. As for average time to return to full activity, 50% of surgeons waited until 9+ months for full return, and 42% allowed return within 6 to 8 months. Reductions in practice variability have been shown in orthopaedic surgery and other fields to reduce costs of care delivery and improve patient outcomes, and with so much variability in ACLR rehabilitation protocols, the orthopaedic community would be wise to strive for more consensus focused on evidence-based recommendations for rehabilitation and to fill in knowledge gaps with focused, high-quality research where needed.
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Effect of a Protocol to Reduce Radiographic Imaging in Pediatric Patients With Suspected Fractures. J Pediatr Orthop 2023; 43:61-64. [PMID: 36084624 DOI: 10.1097/bpo.0000000000002262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Children with suspected fractures are typically evaluated with multiple x-rays. This approach can add time, discomfort, and radiation exposure without clinical benefit. The purpose of this study was to determine whether a focused radiographic protocol could reduce the number of x-rays performed without missing any fractures. METHODS Pediatric patients presenting at 2 sites within an academic medical center [urgent care (UC) and the emergency department(ED)] for a suspected fracture were identified. There were 495 patients (UC, 409; ED, 86) over a 3-month period. A retrospective chart review was performed to characterize the standard x-rays performed. Using this data, a simplified protocol was developed and distributed. Subsequently, 333 patients (UC, 259; ED, 74) were evaluated over the same period 1-year later. The main outcome measures included the final diagnosis, the total number of x-rays, the number of anatomic areas imaged, visit length, and the time for additional trips to radiology. Charts were reviewed to identify any missed injuries. Welch 2-sample t tests and Fisher exact tests were used for statistical analysis. RESULTS After implementing the radiographic protocol, there was a significant reduction in the number of x-ray views, 3.4 versus 5.1 ( P <0.001). There was a decrease in imaging of multiple anatomic areas with the largest reduction occurring in patients presenting with elbow injuries (9% vs. 44%, P <0.001). No difference was found in the rate of patients sent back to radiology (6% vs. 7%, P =0.67). However, among patients presenting with outside imaging, significantly fewer were sent to radiology for additional x-rays (29% vs. 50%, P <0.01). CONCLUSION A simple radiographic protocol for evaluating pediatric patients with suspected fractures safely led to a decrease in the overall number of x-rays without missing any injuries. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Abstract
BACKGROUND Distal radius buckle fractures (DRBFx) represent nearly half of the pediatric wrist injuries. DRBFx are stable injury patterns that can typically be successfully managed with brief immobilization. The purpose of this study was to evaluate opinions and preferences of pediatric orthopaedic specialists regarding the management of DRBFx. METHODS The POSNA Trauma Quality, Safety, and Value Initiative (QSVI) Committee developed a 20-question survey regarding the treatment of DRBFx in children. The survey was sent twice to all active and candidate POSNA members in June 2020 (n=1487). Questions focused on various aspects of treatment, including type and length of immobilization, follow-up, and radiographs and on potential concerns regarding patient/family satisfaction and pain control, medicolegal concerns, misdiagnosis, and mismanagement. RESULTS A total of 317 participants completed the survey (response rate=21.3%). In all, 69% of all respondents prefer to use a removable wrist splint, with 76% of those in practice <20 years preferring removable wrist splints compared with 51% of those in practice >20 years (χ 2 =21.7; P <0.01). Overall, 85% of participants utilize shared decision-making in discussing management options with patients and their families. The majority of participants felt that the risk of complications associated with DRBFx was very low, but concern for misdiagnosis and mismanagement have required some respondents to perform closed or open reductions. CONCLUSIONS In 2020, the majority of respondents treat DRBFx with removable splints (69%) for 3 or fewer weeks (55%), minimal follow-up (85%), and no reimaging (64%). This marks a dramatic shift from the 2012 POSNA survey when only 29% of respondents used removable splinting for DRBFx. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sarah E Lindsay
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR
| | - Stephanie Holmes
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California, San Francisco, Oakland, CA
| | - Matthew Halsey
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR
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Xu AL, Prasad N, Lee RJ. The Financial Burden of Nonoperatively Treated Pediatric Distal Radius Fractures: Medical Debt in Privately Versus Publicly Insured Patients. J Pediatr Orthop 2022; 42:65-69. [PMID: 34995256 DOI: 10.1097/bpo.0000000000002021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with public health insurance have greater difficulty obtaining orthopaedic care than their privately insured counterparts because of lower reimbursements. However, the relationship between insurance status and financial burden for patients and treating institutions is unknown. We compared patient medical debt and uncompensated hospital costs by insurance type for pediatric patients who received nonoperative treatment for distal radius fractures (DRFs). METHODS We reviewed medical records of 100 pediatric patients (above 18 y) treated nonoperatively at our US academic hospital for DRFs from 2016 to 2020. Patients were grouped according to insurance type at the time of treatment: preferred-provider organization (PPO), n=30; health maintenance organization (HMO), n=29; Medicaid, n=28; and uninsured, n=13. These groups were matched by number of encounters, total original charge, and total number of charges. The primary outcomes were patient medical debt and uncompensated costs to the hospital, comprising unpaid balance, uncollectible debt, and self-adjustments offered by the hospital. χ2 tests and analysis of variance were used to compare financial outcomes among subgroups (alpha=0.05). RESULTS Patient medical debt (ie, uncollectible debt) was generated by 20% of PPO, 7.7% of uninsured, and 6.9% of HMO patients (P=0.06). Medicaid patients generated no patient medical debt, whereas PPO patients generated a mean (±SD) of $15±$39 and HMO patients generated $26±$130, which was not significantly different than that of uninsured patients ($25±$89) (P<0.0001). Uncompensated costs were generated by 54% of uninsured, 20% of PPO, 6.9% of HMO, and 0% of Medicaid patients (P<0.0001). Uncompensated costs were the same as uncollectible debt for privately insured and Medicaid patients, whereas uninsured patients generated an additional $550±$600 from self-adjustments (P<0.0001). CONCLUSION Unlike the Medicaid group, the privately insured and uninsured groups incurred patient medical debt and uncompensated costs after nonoperative DRF treatment. Thus, orthopaedic providers should be cost conscious with privately insured patients, while publicly insured patients may provide more consistent-albeit lower-reimbursement for the hospital. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amy L Xu
- Department of Orthopaedics, The Johns Hopkins University, Baltimore, MD
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, Alberta T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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Perry DC, Gibson P, Roland D, Messahel S. What level of immobilisation is necessary for treatment of torus (buckle) fractures of the distal radius in children? BMJ 2021; 372:m4862. [PMID: 33414102 DOI: 10.1136/bmj.m4862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Daniel C Perry
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Alder Hey Children's Hospital, Liverpool, UK
- Alder Hey Children's Hospital, Liverpool, UK
| | - Phoebe Gibson
- Alder Hey Clinical Research Facility Parent Carer Forum, Liverpool, UK
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Mayers A, Dunleavy ML, Chau MM, Hennrikus W. The Vacuum-Assisted Closure Device Increases Value in the Treatment of Gustilo Grade IIIb Open Tibia Fractures in Children. Cureus 2020; 12:e10194. [PMID: 33033672 PMCID: PMC7532879 DOI: 10.7759/cureus.10194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Wound management associated with Gustilo grade IIIb open tibia fractures in children often requires muscle flaps, skin grafts, and amputations. The purpose of this study is to report the outcomes and complications of vacuum-assisted closure (VAC) treatment, as well as discuss its role in optimizing value when treating these injuries. Methods A retrospective review of medical records and imaging studies was performed from 2008-2015. Six pediatric patients with Gustilo grade IIIb fractures managed with the VAC were identified. The time to treatment, frequency of VAC changes, VAC size, and closure attempts, including muscle flaps and skin grafts, were documented. Fracture fixation methods, the incidence of delayed union or nonunion, as well as the occurrence of deep tissue infection and compartment syndrome were detailed. Results Five patients were male and one was female with an average age of 12 years (range 8-15 years). All patients sustained a Gustilo IIIb open tibia fracture and were treated with irrigation, debridement, intravenous (IV) antibiotics, fixation, and a VAC as a wound care adjunct. Three patients required both a muscle flap and a skin graft. One patient required a skin graft. There was one case of deep tissue infection. Three patients were treated successfully with the VAC alone and did not require any flap procedures. Conclusions Wound care for Gustilo grade IIIb open tibia fractures in children traditionally involved potentially painful twice-daily dressing changes with solutions such as dilute bleach or iodine. The implementation of VAC markedly reduced the frequency of dressing changes every three days. In the current study, the open wound gradually closed with only a VAC in 50% of Gustilo grade IIIb open pediatric tibia fractures. In summary, the VAC is an adjunct that increases value in the care of pediatric patients with Gustilo grade IIIb open tibia fractures (Value = Outcomes/Cost). Level of evidence Therapeutic level IV
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Affiliation(s)
- Alex Mayers
- Orthopaedics, Geisinger Medical Center, Danville, USA
| | - Mark L Dunleavy
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Michael M Chau
- Orthopaedics, University of Minnesota School of Medicine, Minneapolis, USA
| | - William Hennrikus
- Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Maggio LA, Aakre CA, Del Fiol G, Shellum J, Cook DA. Impact of Clinicians' Use of Electronic Knowledge Resources on Clinical and Learning Outcomes: Systematic Review and Meta-Analysis. J Med Internet Res 2019; 21:e13315. [PMID: 31359865 PMCID: PMC6690166 DOI: 10.2196/13315] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 05/12/2019] [Accepted: 06/18/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinicians use electronic knowledge resources, such as Micromedex, UpToDate, and Wikipedia, to deliver evidence-based care and engage in point-of-care learning. Despite this use in clinical practice, their impact on patient care and learning outcomes is incompletely understood. A comprehensive synthesis of available evidence regarding the effectiveness of electronic knowledge resources would guide clinicians, health care system administrators, medical educators, and informaticians in making evidence-based decisions about their purchase, implementation, and use. OBJECTIVE The aim of this review is to quantify the impact of electronic knowledge resources on clinical and learning outcomes. METHODS We searched MEDLINE, Embase, PsycINFO, and the Cochrane Library for articles published from 1991 to 2017. Two authors independently screened studies for inclusion and extracted outcomes related to knowledge, skills, attitudes, behaviors, patient effects, and cost. We used random-effects meta-analysis to pool standardized mean differences (SMDs) across studies. RESULTS Of 10,811 studies screened, we identified 25 eligible studies published between 2003 and 2016. A total of 5 studies were randomized trials, 22 involved physicians in practice or training, and 10 reported potential conflicts of interest. A total of 15 studies compared electronic knowledge resources with no intervention. Of these, 7 reported clinician behaviors, with a pooled SMD of 0.47 (95% CI 0.27 to 0.67; P<.001), and 8 reported objective patient effects with a pooled SMD of 0.19 (95% CI 0.07 to 0.32; P=.003). Heterogeneity was large (I2>50%) across studies. When compared with other resources-7 studies, not amenable to meta-analytic pooling-the use of electronic knowledge resources was associated with increased frequency of answering questions and perceived benefits on patient care, with variable impact on time to find an answer. A total of 2 studies compared different implementations of the same electronic knowledge resource. CONCLUSIONS Use of electronic knowledge resources is associated with a positive impact on clinician behaviors and patient effects. We found statistically significant associations between the use of electronic knowledge resources and improved clinician behaviors and patient effects. When compared with other resources, the use of electronic knowledge resources was associated with increased success in answering clinical questions, with variable impact on speed. Comparisons of different implementation strategies of the same electronic knowledge resource suggest that there are benefits from allowing clinicians to choose to access the resource, versus automated display of resource information, and from integrating patient-specific information. A total of 4 studies compared different commercial electronic knowledge resources, with variable results. Resource implementation strategies can significantly influence outcomes but few studies have examined such factors.
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Affiliation(s)
- Lauren A Maggio
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Christopher A Aakre
- Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jane Shellum
- Center for Translational Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, United States
| | - David A Cook
- Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
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Abstract
BACKGROUND Distal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost. METHODS We retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression. RESULTS We identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs. CONCLUSIONS Closed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices. LEVEL OF EVIDENCE Level III-therapeutic.
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Hiscock H, Neely RJ, Warren H, Soon J, Georgiou A. Reducing Unnecessary Imaging and Pathology Tests: A Systematic Review. Pediatrics 2018; 141:peds.2017-2862. [PMID: 29382686 DOI: 10.1542/peds.2017-2862] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2017] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Unnecessary imaging and pathology procedures represent low-value care and can harm children and the health care system. OBJECTIVE To perform a systematic review of interventions designed to reduce unnecessary pediatric imaging and pathology testing. DATA SOURCES We searched Medline, Embase, Cinahl, PubMed, Cochrane Library, and gray literature. STUDY SELECTION Studies we included were: reports of interventions to reduce unnecessary imaging and pathology testing in pediatric populations; from developed countries; written in the English language; and published between January 1, 1996, and April 29, 2017. DATA EXTRACTION Two researchers independently extracted data and assessed study quality using a Cochrane group risk of bias tool. Level of evidence was graded using the Oxford Centre for Evidence-Based Medicine grading system. RESULTS We found 64 articles including 44 before-after, 14 interrupted time series, and 1 randomized controlled trial. More effective interventions were (1) multifaceted, with 3 components (mean relative reduction = 45.0%; SD = 28.3%) as opposed to 2 components (32.0% [30.3%]); or 1 component (28.6%, [34.9%]); (2) targeted toward families and clinicians compared with clinicians only (61.9% [34.3%] vs 30.0% [32.0%], respectively); and (3) targeted toward imaging (41.8% [38.4%]) or pathology testing only (48.8% [20.9%]), compared with both simultaneously (21.6% [29.2%]). LIMITATIONS The studies we included were limited to the English language. CONCLUSIONS Promising interventions include audit and feedback, system-based changes, and education. Future researchers should move beyond before-after designs to rigorously evaluate interventions. A relatively novel approach will be to include both clinicians and the families they manage in such interventions.
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Affiliation(s)
- Harriet Hiscock
- Health Services Research Unit, The Royal Children's Hospital, Parkville, Australia; .,Community Health Services Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Pediatrics, The University of Melbourne, Melbourne, Australia
| | - Rachel Jane Neely
- Health Services Research Unit, The Royal Children's Hospital, Parkville, Australia.,Community Health Services Research, Murdoch Children's Research Institute, Parkville, Australia
| | - Hayley Warren
- Community Health Services Research, Murdoch Children's Research Institute, Parkville, Australia
| | - Jason Soon
- Policy and Advocacy, Royal Australasian College of Physicians, Sydney, Australia; and
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Sydney, Australia
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