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Walsh NE, Halls S, Thomas R, Berry A, Liddiard C, Cupples ME, Gage H, Jackson D, Cramp F, Stott H, Kersten P, Jagosh J, Foster D, Williams P. First contact physiotherapy: an evaluation of clinical effectiveness and costs. Br J Gen Pract 2024:BJGP.2023.0560. [PMID: 38429110 PMCID: PMC11325442 DOI: 10.3399/bjgp.2023.0560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/22/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND First contact physiotherapy practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis, and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation. AIM To determine the clinical effectiveness and costs of FCPP models compared with GP-led models of care. DESIGN AND SETTING Multiple site case-study design of general practices in the UK. METHOD General practice sites were recruited representing the following three models: 1) GP-led care; 2) FCPPs who could not prescribe or inject (FCPPs-standard [St]); and 3) FCPPs who could prescribe and/or inject (FCPPs-additional qualifications [AQ]). Patient participants from each site completed outcome data at baseline, 3 months, and 6 months. The primary outcome was the SF-36 Physical Component Summary (PCS) score. Healthcare usage was collected for 6 months. RESULTS In total, 426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF-36 PCS) across all three arms at 6 months (P = 0.667). At 3 months, a significant difference in numbers improving was seen between arms: 54.7% (n = 47) GP consultees, 72.4% (n = 71) FCPP-St, and 66.4% (n = 101) FCPP-AQ (P = 0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%, n = 42), compared with FCPP-St (18.4%, n = 21) and FCPP-AQ (24.7%, n = 40) (P<0.001). NHS costs (initial consultation and over 6-month follow-up) were significantly higher in the GP-led model (median £105.5 per patient) versus FCPP-St (£41.0 per patient) and FCPP-AQ (£44.0 per patient) (P<0.001). CONCLUSION FCPP-led models of care provide safe, clinically effective patient management, with cost-benefits and reduced opioid use in this cohort.
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Affiliation(s)
- Nicola E Walsh
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Serena Halls
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Rachel Thomas
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Alice Berry
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Cathy Liddiard
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | | | - Heather Gage
- Surrey Health Economics Centre, University of Surrey, Guildford, UK
| | - Daniel Jackson
- Surrey Health Economics Centre, University of Surrey, Guildford, UK
| | - Fiona Cramp
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Hannah Stott
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Paula Kersten
- Health and Social Care, Canterbury Christ Church University, Canterbury, UK
| | - Justin Jagosh
- Director for the Centre for Advancement in Realist Evaluation and Synthesis, Canada
| | - Dave Foster
- Department of Mathematics, University of Surrey, Guildford, UK
| | - Peter Williams
- Department of Mathematics, University of Surrey, Guildford, UK
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Schumacher MR, Karl KA, Stich MA, Dean CR, Lawson SR, Hogan JL. Identifying physical therapists' attitudes, beliefs, and barriers toward diagnostic imaging referral: a mixed-methods study. J Man Manip Ther 2024:1-9. [PMID: 38676667 DOI: 10.1080/10669817.2024.2346957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVE Ten states, including the District of Columbia, have laws that currently permit physical therapists (PTs) to directly order diagnostic imaging (DI) in the United States. Military and civilian PTs order DI judiciously and appropriately demonstrating optimal patient outcomes and satisfaction when compared to other medical professionals. However, no studies have explored perceived attitudes, beliefs, and barriers to PT DI referral specific to North Dakota (ND). Therefore, the purpose of this mixed-methods study was to identify ND PTs' attitudes, beliefs, and barriers toward DI referral. METHODS A total of 147 participants completed an online survey with a subset of 17 participants agreeing to an interview. Frequency counts of demographic data and perceived barriers were completed. A binary logistic regression was run on demographic data. One-on-one interviews were conducted with a thematic coding process completed within a qualitative analysis. RESULTS Seventy-four percent of PTs reported not currently referring for DI, although 71% felt that it would improve their patient outcomes. PTs with post-professional training (OR = 4.59), a doctorate degree (OR = 3.84), practicing in an orthopaedic or sports setting (OR = 3.55), and practicing within an urban setting of ND (OR = 3.01) were more likely to refer for DI. The main barriers identified in the survey included: (1) the logistics of performing a DI referral, (2) DI referrals only privileged to other medical providers, (3) provider/work relationship dynamics, (4) the cost of continuing education (CE), (5) and the inability to identify CE. One-on-one interviews further identified five main themes related to DI referral. DISCUSSION/CONCLUSION Several barriers identified resulted in 74.1% of PTs not directly referring for DI, although certain characteristics (post-professional training, doctorate degree, orthopaedic/sports setting, practicing in an urban area in ND) were more likely to refer for DI. This study may help improve future adoption and implementation of DI referral in current and future states.
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Affiliation(s)
| | - Kendra A Karl
- Doctor of Physical Therapy Program, University of Mary, Bismarck, USA
| | - Mattias A Stich
- Doctor of Physical Therapy Program, University of Mary, Bismarck, USA
| | | | - Sara R Lawson
- Doctor of Physical Therapy Program, University of Mary, Bismarck, USA
| | - Jason L Hogan
- Doctor of Physical Therapy Program, University of Mary, Bismarck, USA
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Cockburn L, Baer G, Rhodes J. Level of diagnostic agreement in musculoskeletal shoulder diagnosis between remote and face-to-face consultations: A retrospective service evaluation. Health Sci Rep 2024; 7:e2060. [PMID: 38650721 PMCID: PMC11033340 DOI: 10.1002/hsr2.2060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/22/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
Background and Aims To determine the level of diagnostic agreement between remote and face-to-face consultation in assessing shoulder complaints. Methods A retrospective service evaluation with three groups of patient data; those assessed only face-to-face (group 1), remotely then face-to-face (group 2), remotely only (group 3). Patient data were extracted from 6 secondary care shoulder Advanced Physiotherapy Practitioner's (APPs) records, covering six sites. Three-hundred-and-fifty-nine sets of patient data were included in the final evaluation. The main outcome measure was the percentage of agreement between diagnosis at initial and follow-up consultation, when assessed by APPs across the three groups. A Pearson χ 2 test was used to assess the relationship between the method of consultation and the level of diagnostic agreement. Diagnoses were categorized as either the same, similar, or different by an independent APP. Secondary outcome measures investigated whether age or the length of time between appointments had any effect in determining the level of diagnostic concordance. Results There was exact agreement of 77.05% and 85.52% for groups 1 and 3, respectively, compared with 34.93% for patient data in group 2. Similar clinical impressions across both initial and follow-up were seen 16.39% of the time in group 1, 7.24% of the time in group 3, and 36.99% in group 2. Lastly, the percentage of times a diagnosis was changed between initial and review appointments occurred in only 6.56% of group 1 contacts, 7.24% of group 3 contacts, but 28.08% of the time in group 2. Conclusion There was a large mismatch in the diagnosis of musculoskeletal shoulder complaints, when patients are initially assessed remotely and then followed-up in-person. This has implications for the future provision of shoulder assessment in physiotherapy.
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Affiliation(s)
- Louise Cockburn
- Division of Dietetics Nutrition Biological Sciences Physiotherapy Podiatry and RadiographyQueen Margaret UniversityMusselburghUK
| | - Gill Baer
- Division of Dietetics Nutrition Biological Sciences Physiotherapy Podiatry and RadiographyQueen Margaret UniversityMusselburghUK
| | - Jenna Rhodes
- Division of Dietetics Nutrition Biological Sciences Physiotherapy Podiatry and RadiographyQueen Margaret UniversityMusselburghUK
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Hofmann B, Håvik V, Andersen ER, Brandsæter IØ, Kjelle E. Low-value MRI of the knee in Norway: a register-based study to identify the proportion of potentially low-value MRIs and estimate the related costs. BMJ Open 2024; 14:e081860. [PMID: 38485174 PMCID: PMC10941154 DOI: 10.1136/bmjopen-2023-081860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES The objective of this study is to investigate the proportion of potentially low-value knee MRI in Norway and to provide an estimate of the related costs. DESIGN Register study based on conditional data extraction and analysis of data from Control and Reimbursement of Healthcare Claims registry in Norway. SETTING MRI in public specialist healthcare with universal health coverage (Norway). PARTICIPANTS 48 212 MRIs for 41 456 unique patients and 45 946 reimbursement claims. OUTCOME MEASURES Proportion of MRIs of the knee that (1) did not have a relevant tentative diagnosis prior to the knee MRI, (2) did not have a relevant alternative image of the knee before the MRI or (3) did not have a relevant code from the specialist care within 6 months after the MRI, and those that had combinations of 1, 2 and 3. Estimated costs for those that had combinations of 1, 2 and 3. RESULTS Very few patients (6.4%) had a relevant diagnosis code or prior imaging examination when having the MRI and only 14.6% got a knee-related diagnosis code from the specialist care within 6 months after the MRI. 21.8% of the patients had knee X-ray, CT or ultrasound within 6 months before the MRI. Between 58% and 85% of patients having knee MRIs in Norway have no relevant examinations or diagnoses six months prior to or after the MRI examination. These examinations are unlikely to benefit patients and they correspond to between 24 108 and 35 416 MRIs at a cost of €6.7-€9.8 million per year. CONCLUSION A substantial proportion of MRIs of the knee in Norway have no relevant examinations or diagnoses before or after the MRI and are potentially of low value. Reducing low-value MRIs could free resources for high-value imaging, reduce waiting times, improve the quality of care and increase patient safety and professional integrity.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Norway, Oslo, Norway
| | - Vegard Håvik
- Department for Medical Reimbursement, Norwegian Directorate of Health, Oslo, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
| | - Ingrid Øfsti Brandsæter
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
| | - Elin Kjelle
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
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Farabaugh R, Hawk C, Taylor D, Daniels C, Noll C, Schneider M, McGowan J, Whalen W, Wilcox R, Sarnat R, Suiter L, Whedon J. Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review. Chiropr Man Therap 2024; 32:8. [PMID: 38448998 PMCID: PMC10918856 DOI: 10.1186/s12998-024-00533-4] [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: 08/14/2023] [Accepted: 02/08/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain. METHODS A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators. RESULTS The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures. CONCLUSION Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.
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Affiliation(s)
- Ronald Farabaugh
- American Chiropractic Association, 2008 St. Johns Avenue, Highland Park, Illiois. 60035, Arlington, VA, USA.
| | - Cheryl Hawk
- Texas Chiropractic College, 5912 Spencer Highway, Pasadena, TX, 77505, USA
| | - Dave Taylor
- Texas Chiropractic College, 5912 Spencer Highway, Pasadena, TX, 77505, USA
| | - Clinton Daniels
- VA Puget Sound Health Care System, 9600 Veterans Drive Southwest Tacoma, Tacoma, WA, 98493-0003, USA
| | - Claire Noll
- Texas Chiropractic College, 5912 Spencer Highway, Pasadena, TX, 77505, USA
| | - Mike Schneider
- University of Pittsburgh, 100 Technology Drive, Suite 500, Pittsburgh, PA, 15219, USA
| | - John McGowan
- Saint Louis University, 3674 Lindell Blvd, St. Louis, MO, 63108, USA
| | - Wayne Whalen
- Clinical Compass-Past Chairman, 9570 Cuyamaca St Ste 101, Santee, CA, 92071, USA
| | - Ron Wilcox
- Private Practice, 204 Pinehurst Dr. SW, Suite 103, Tumwater, 9850, USA
| | - Richard Sarnat
- LP AMI Group, AMI Group, LP; 2008 St. Johns Avenue, Highland Park, IL, 60035, USA
| | - Leonard Suiter
- Clinical Compass-Past Chairman, 9570 Cuyamaca St Ste 101, Santee, CA, 92071, USA
| | - James Whedon
- Southern California University of Health Sciences, 16200 Amber Valley Drive, Whittier, CA, 90604, USA
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O'Callaghan ME, Fawsitt R, Gao J, Broughan J, McCombe G, Phelan A, Quinlan D, Collins C, Stanley F, Cullen W. Irish general practitioner (GP) perspectives on impact of direct access radiology on patient care in the community: results from a mixed-methods study. Ir J Med Sci 2024; 193:425-434. [PMID: 37354242 PMCID: PMC10808218 DOI: 10.1007/s11845-023-03419-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/26/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Since winter 2020/21, general practitioners (GPs) in the Republic of Ireland (RoI) have been granted access to diagnostic imaging studies on a new publicly funded pathway, expediting access to services previously obtained via hospital-based doctors. AIMS Outline GP perspectives on imaging studies obtained via the new "GP Access to Community Diagnostics" initiative. METHODS A mixed-methods design was employed. Referrals over the first six months of 2019 and 2021 were collated by a private imaging provider, and a randomly selected subset of 2021 studies (maximum 30 referrals per GP) was returned to participating GPs to provide detail on the impact on each patient's care. In-depth qualitative interviews were also conducted with participating GPs. RESULTS Eleven GPs supplied detailed information on 81 studies organized through the new initiative. GPs reported that the initiative had led to a large proportion of cases being managed solely in general practice, with an 81% reduction in referrals to acute hospital settings and a 58% reduction in referrals to secondary care clinics. GPs felt imaging studies improved patient care in 86% of cases and increased GP workload in 58% of cases. GP qualitative interviews revealed four key themes: improved patient care, increased GP workload, reduction in hospital referrals, and opinions on ongoing management of such initiatives, including guidelines. CONCLUSIONS GPs felt enhancing access to diagnostics improved patient care by expediting diagnosis, decision-making, and treatment and by reducing hospital referrals. GPs were generally positive about the initiative and made some suggestions on future management of the initiative.
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Affiliation(s)
- Michael Edmund O'Callaghan
- Irish College of General Practitioners (ICGP), Dublin, Ireland.
- School of Medicine, University of Limerick (UL), Dublin, Ireland.
| | - Ronan Fawsitt
- Ireland East Hospital Group (IEHG) GP Research Network, University College Dublin/Ireland, Dublin, Ireland
| | - Jiaran Gao
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - John Broughan
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - Geoff McCombe
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - Amy Phelan
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | | | - Claire Collins
- Irish College of General Practitioners (ICGP), Dublin, Ireland
| | - Fintan Stanley
- Irish College of General Practitioners (ICGP), Dublin, Ireland
| | - Walter Cullen
- Ireland East Hospital Group (IEHG) GP Research Network, University College Dublin/Ireland, Dublin, Ireland
- School of Medicine, University College Dublin (UCD), Dublin, Ireland
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Murphy J, Malik R, Lau B, Conway SJ, Johnson PT. Refocusing the Lens: Adding Downstream Value to the Radiology Quality Equation. J Am Coll Radiol 2024; 21:88-92. [PMID: 37690537 DOI: 10.1016/j.jacr.2023.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Jacob Murphy
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rubab Malik
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn Lau
- Department of Radiology & Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah J Conway
- Chief Medical Officer, Johns Hopkins Clinical Alliance, Baltimore, Maryland; Assistant Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pamela T Johnson
- Vice President of Care Transformation, Johns Hopkins Health System, Baltimore, Maryland; Vice Chair of Quality, Safety and Value, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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Panchal S, Hendrick P. The lived experiences of musculoskeletal physiotherapists managing patient expectations for diagnostic imaging: A qualitative study using a phenomenological analysis. Musculoskelet Sci Pract 2023; 67:102833. [PMID: 37672861 DOI: 10.1016/j.msksp.2023.102833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/29/2023] [Accepted: 07/21/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES Unnecessary diagnostic imaging for musculoskeletal presentations is a pervasive phenomenon, placing a substantial weight on healthcare resources. Their overuse can lead to iatrogenic consequences associated with overdiagnosis and overtreatment. Factors which contribute to inappropriate imaging are multifactorial. Clinician-patient beliefs, behaviours, and expectations have been identified as central drivers. Physiotherapists play an important role in the utilisation of diagnostic imaging for musculoskeletal presentations throughout healthcare settings. This study aims to explore the lived experiences of physiotherapists managing patient expectations for diagnostic imaging. DESIGN A qualitative study using an interpretative phenomenological analysis. Five participants were purposefully recruited and took part in semi-structured individual interviews. RESULTS The central themes identified were expectations for diagnostic imaging, managing expectations, communicating imaging findings, imaging as a therapeutic tool, and risk and uncertainty. CONCLUSION The findings from this study gives new insights into how musculoskeletal physiotherapists manage expectations for diagnostic imaging, the associated complexities, and the challenges encountered.
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Jermini-Gianinazzi I, Blum M, Trachsel M, Trippolini MA, Tochtermann N, Rimensberger C, Liechti FD, Wertli MM. Management of acute non-specific low back pain in the emergency department: do emergency physicians follow the guidelines? Results of a cross-sectional survey. BMJ Open 2023; 13:e071893. [PMID: 37541755 PMCID: PMC10407374 DOI: 10.1136/bmjopen-2023-071893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVES Clinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED). SETTING We invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations. RESULTS In total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions. CONCLUSION Management of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.
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Affiliation(s)
- Ilaria Jermini-Gianinazzi
- Emergency Department, Ospedale Regionale di Bellinzona e Valli Bellinzona, Bellinzona, Ticino, Switzerland
| | - Manuel Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria Trachsel
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maurizio Alen Trippolini
- School of Health Professions, Berne University of Applied Sciences, Bern, Switzerland
- Evidence-based Insurance Medicine (EbIM), Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nicole Tochtermann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Caroline Rimensberger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Dominik Liechti
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, Kantonsspital Baden AG, Baden, Aargau, Switzerland
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Rudisill KE, Ratnasamy PP, Joo PY, Rubin LE, Grauer JN. Magnetic Resonance Imaging in the Year Prior to Total Knee Arthroplasty: A Potential Overutilization of Healthcare Resources. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00019. [PMID: 37205731 PMCID: PMC10566819 DOI: 10.5435/jaaosglobal-d-22-00262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common procedure for late-stage degenerative changes, a situation for which magnetic resonance imaging (MRI) is typically not considered useful. In an era attempting to contain healthcare expenditures, the rate, timing, and predictors for MRI before TKA were assessed in a large, national, administrative data set. METHODS The 2010 to Q3 2020 MKnee PearlDiver data set was used to identify patients undergoing TKA for osteoarthritis. Those with lower extremity MRI for knee indications within 1 year before TKA were then defined. Patient age, sex, Elixhauser Comorbidity Index, region in the country, and insurance plan were characterized. Predictors of having had an MRI were assessed by univariate and multivariate analyses. The costs and timing of the obtained MRIs were also assessed. RESULTS Of 731,066 TKAs, MRI was obtained within 1 year prior for 56,180 (7.68%) with 28,963 (51.9%) within the 3 months of TKA. Independent predictors of having had an MRI included younger age (odds ratio [OR], 0.74 per decade increase), female sex (OR, 1.10), higher Elixhauser Comorbidity Index (OR, 1.15), region of the country (relative to South, Northeast OR, 1.08, West OR, 1.22, Midwest OR, 1.36), and insurance (relative to Medicare, Medicaid OR, 1.36 and Commercial OR, 1.35) with P < 0.0001 for each. The total cost of MRIs among patients who received a TKA is $44,686,308. CONCLUSION Noting that TKA is typically done for advanced degenerative changes, MRI should rarely be indicated in the preoperative period for this procedure. Nonetheless, this study found that MRI was done within the year before TKA for 7.68% of the study cohort. In an era striving for evidence-based medicine, the almost $45 million dollars spent on MRI in the year before TKA may represent overutilization.
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Affiliation(s)
- Katelyn E. Rudisill
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Philip P. Ratnasamy
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Peter Y. Joo
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E. Rubin
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N. Grauer
- From the Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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12
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Olivares-Tirado P, Zanga R. Waste in health care spending: A scoping review. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2023. [DOI: 10.1080/20479700.2023.2185580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Affiliation(s)
- Pedro Olivares-Tirado
- Research and Development Department of the Superintendency of Health of Chile, Santiago, Chile
- Adjunct researcher at Health Service Development Research Center, University of Tsukuba, Tsukuba, Japan
| | - Rosendo Zanga
- Research and Development Department of the Superintendency of Health of Chile, Santiago, Chile
- School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile
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13
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Baiguissova D, Laghi A, Rakhimbekova A, Fakhradiyev I, Mukhamejanova A, Battalova G, Tanabayeva S, Zharmenov S, Saliev T, Kausova G. An economic impact of incorrect referrals for MRI and CT scans: A retrospective analysis. Health Sci Rep 2023; 6:e1102. [PMID: 36923371 PMCID: PMC10009910 DOI: 10.1002/hsr2.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/12/2023] [Accepted: 01/29/2023] [Indexed: 03/14/2023] Open
Abstract
Background and Aims Up to date, no research on the economic efficacy of diagnostic modalities, such as magnetic resonance imaging (MRI) and computerized tomography (CT), has been done in Central Asia. The aim of this study was to analyse the inappropriate appointments of MRI and CT scanning procedures in Kazakhstan. Methods We used the imaging diagnostic reports and medical records from 9725 planned outpatient CT and MRI exams performed in two major hospitals in Almaty. The study period was for the period 2014-2019. The independent experts-radiologists evaluated the MRI and CT exams for validity using the ACR® compliance standards and RCR recommendations. Results The results showed that the combined costs of MRI and CT scans increased by $17.982 between 2014 ($22.537) and 2019 ($40.519), p = 0.002. The highest rate of MRI examinations was observed in 2019, with a rate of 6.9 per 10,000 people. It was determined that in 2019 the highest rate for men who undertook CT was equal to 12.4 per 10,000 people, while for women it was equivalent to 5.7 per 10,000 patients. The majority of non-corresponding imaging examinations (n = 1304) were referred for MRI and CT scans by general practitioners. We detected the irrational referrals for head and neck radiological examinations in n = 178 (13.7%) cases, and the abdominal cavity checks in n = 249 (19.1%) cases (p = 0.001). The main portion of erroneously unreasonable referrals for examination of the abdominal organs was made by surgeons in n = 43 (3.3%) cases. Conclusion The findings indicated an increase in the number of referrals for unnecessary CT and MRI tests over the research period (2014-2019). It had a substantial impact on the rise in healthcare system expenses. The results demonstrate the need for the education of GPs and improving the approaches for diagnostics.
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Affiliation(s)
- Dinara Baiguissova
- S.D. Asfendiyarov Kazakh National Medical University Almaty Kazakhstan.,National Scientific Center of Surgery A.N.Syzganov Almaty Kazakhstan.,Kazakhstan School of Public Health Kazakhstan's Medical University Almaty Kazakhstan
| | - Andrea Laghi
- Department of Medical Surgical Sciences and Translational Medicine Sapienza University of Rome - Sant'Andrea University Hospital Rome Italy
| | | | - Ildar Fakhradiyev
- S.D. Asfendiyarov Kazakh National Medical University Almaty Kazakhstan
| | | | - Galina Battalova
- National Scientific Center of Surgery A.N.Syzganov Almaty Kazakhstan
| | - Shynar Tanabayeva
- S.D. Asfendiyarov Kazakh National Medical University Almaty Kazakhstan
| | - Samat Zharmenov
- Kazakhstan School of Public Health Kazakhstan's Medical University Almaty Kazakhstan
| | - Timur Saliev
- S.D. Asfendiyarov Kazakh National Medical University Almaty Kazakhstan
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Andersen ER, Brandsæter IØ, Hofmann BM, Kjelle E. The use of low-value imaging: the role of referral practice and access to imaging services in a representative area of Norway. Insights Imaging 2023; 14:29. [PMID: 36746848 PMCID: PMC9902580 DOI: 10.1186/s13244-023-01375-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/20/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Even though imaging is essential to modern medicine, some examinations are of low value as they do not lead to any change in the management of the patient. The Choosing Wisely (CW) campaign aims to reduce the use of such services. In the Norwegian version of CW, specific magnetic resonance imaging (MRI) of the head, lower back, and knee are amongst others identified as potential low-value examinations. However, referral practice and access to imaging may drive low-value utilisation. By using registry data from 2019 and descriptive analysis, this study aimed to examine the role of referral practice and access to imaging on the use of specific CW-examinations in one representative area in Norway. RESULTS A total of 237,554 examinations were performed by four public and two private imaging facilities located within the area. Forty-two percent (19,210/45,289) of all MRI examinations were related to CW. Private imaging centres performed most of the CW-imaging. A total of 3700 referrers were identified, and 2.3% were identified as "high-referrers," accounting for 33% of all CW-examinations. Referrers' experience did not influence imaging utilisation. A subset of referrers ("super-referrers," 0.5%) accounted for 10% of CW-examinations. Distance to service had no impact on the use of CW-examinations. CONCLUSIONS This study provides valuable insight into the use of imaging and referral practice in one representative area in Norway. A great variation in referral practice was observed. Therefore, targeting referrers with high referral rates may be a promising strategy for reducing the use of low-value imaging.
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Affiliation(s)
- Eivind Richter Andersen
- Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802, Gjøvik, Norway.
| | - Ingrid Øfsti Brandsæter
- grid.5947.f0000 0001 1516 2393Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802 Gjøvik, Norway
| | - Bjørn Morten Hofmann
- grid.5947.f0000 0001 1516 2393Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802 Gjøvik, Norway ,grid.5510.10000 0004 1936 8921Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Elin Kjelle
- grid.5947.f0000 0001 1516 2393Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802 Gjøvik, Norway
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15
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Phelan A, Broughan J, McCombe G, Collins C, Fawsitt R, O’Callaghan M, Quinlan D, Stanley F, Cullen W. Impact of enhancing GP access to diagnostic imaging: A scoping review. PLoS One 2023; 18:e0281461. [PMID: 36897853 PMCID: PMC10004541 DOI: 10.1371/journal.pone.0281461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/24/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Direct access to diagnostic imaging in General Practice provides an avenue to reduce referrals to hospital-based specialities and emergency departments, and to ensure timely diagnosis. Enhanced GP access to radiology imaging could potentially reduce hospital referrals, hospital admissions, enhance patient care, and improve disease outcomes. This scoping review aims to demonstrate the value of direct access to diagnostic imaging in General Practice and how it has impacted on healthcare delivery and patient care. METHODS A search was conducted of 'PubMed', 'Cochrane Library', 'Embase' and 'Google Scholar' for papers published between 2012-2022 using Arksey and O'Malley's scoping review framework. The search process was guided by the PRISMA extension for Scoping Reviews checklist (PRISMA-ScR). RESULTS Twenty-three papers were included. The studies spanned numerous geographical locations (most commonly UK, Denmark, and Netherlands), encompassing several study designs (most commonly cohort studies, randomised controlled trials and observational studies), and a range of populations and sample sizes. Key outcomes reported included the level of access to imaging serves, the feasibility and cost effectiveness of direct access interventions, GP and patient satisfaction with direct access initiatives, and intervention related scan waiting times and referral process. CONCLUSION Direct access to imaging for GPs can have many benefits for healthcare service delivery, patient care, and the wider healthcare ecosystem. GP focused direct access initiatives should therefore be considered as a desirable and viable health policy directive. Further research is needed to more closely examine the impacts that access to imaging studies have on health system operations, especially those in General Practice. Research examining the impacts of access to multiple imaging modalities is also warranted.
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Affiliation(s)
- Amy Phelan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - John Broughan
- Clinical Research Centre, School of Medicine, University College Dublin, Dublin, Ireland
- * E-mail:
| | - Geoff McCombe
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Claire Collins
- Research, Policy and Information, Irish College of General Practitioners, Dublin, Ireland
| | - Ronan Fawsitt
- General Practice, Castle Gardens Medical Centre, Kilkenny, Ireland
- Primary Care Advisor, Ireland East Hospital Group, Dublin, Ireland
| | - Mike O’Callaghan
- Irish College of General Practitioners, ICGP, Dublin, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | | | - Fintan Stanley
- Irish College of General Practitioners, ICGP, Dublin, Ireland
| | - Walter Cullen
- School of Medicine, University College Dublin, Dublin, Ireland
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Kandemir V, Akar MS, Yiğit Ş, Durgut F, Atiç R, Özkul E. Can American Orthopaedic Foot and Ankle Society (AOFAS) score prevent unnecessary MRI in isolated ankle ligament injuries? J Orthop Surg (Hong Kong) 2022; 30:10225536221131374. [PMID: 36192368 DOI: 10.1177/10225536221131374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND OBJECTIVE Ankle injuries are the most common musculoskeletal injuries. Its incidence is also high among sports injuries. Direct X-ray, ultrasound and MRI can be requested after the history and physical examination in the patient who presents with ankle ligament injury. Some classifications are used for requesting direct X-ray after ankle injury. Since clear limits are not specified in the literature for MRI, the rate of unnecessary MRI examinations is high. We argue that the decision can be made according to the AOFAS score to be checked before MR is requested, and thus unnecessary MR requests can be reduced. MATERIAL AND METHOD Ankle MRI images of patients who underwent ankle MRI due to ankle trauma between January 2018 and December 2020 were scanned. 328 patients who met the criteria were included in the study. Patients with AOFAS scores in their outpatient clinic records were identified. AOFAS scores of patients with at least one ligament injury and those with normal MR images were statistically compared. Sensitivity and specificity were determined for the AOFAS score using ROC analysis. RESULTS Patients with ligament damage as a result of MRI examination were 21.3% (n=70), and patients without any ligament damage were 78.7% (n=258). There was a statistically significant difference in terms of AOFAS between the group with ligament damage and the group without ligament damage (p< 0.05). In the ROC analysis, the AOFAS threshold value for MR request was determined as 80.5 (84.3% sensitivity and 72.3% specificity). Based on the determined threshold value, 73 patients who had unnecessary MRI would have been eliminated, thus reducing the number of MRIs by 42.6%. CONCLUSION The AOFAS scores of patients with ligament damage were statistically significantly lower than those of patients without ligament pathology. Unnecessary MRI can be significantly prevented by using the AOFAS score in ankle traumas without bone fractures.
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Affiliation(s)
- Veysel Kandemir
- Department of Orthopaedic Surgery, Tatvan State Hospital, Bitlis, Turkey
| | - Mehmet Sait Akar
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Şeyhmus Yiğit
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Fatih Durgut
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Ramazan Atiç
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Emin Özkul
- Department of Orthopaedic Surgery, 37507Dicle University, Faculty of Medicine, Diyarbakır, Turkey
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Murphy MC, Debenham J, Bulsara C, Chivers P, Rio EK, Docking S, Travers M, Gibson W. Assessment and monitoring of Achilles tendinopathy in clinical practice: a qualitative descriptive exploration of the barriers clinicians face. BMJ Open Sport Exerc Med 2022; 8:e001355. [PMID: 35813131 PMCID: PMC9214351 DOI: 10.1136/bmjsem-2022-001355] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/11/2022] Open
Abstract
Our primary objective was to explore the barriers preventing clinicians from implementing what they think is ideal practice as it relates to using tools to aid diagnosis and monitor progress in mid-portion Achilles tendinopathy. Our secondary objectives were to describe the assessments employed by clinicians in their own practice to aid with (a) diagnosis and (b) monitoring progress in Achilles tendinopathy and explore the outcome measure domains clinicians believe to be the most and least important when managing patients with Achilles tendinopathy. We employed a qualitative descriptive study design. Thirteen participants (eight female, five male) from across Australia, consisting of two junior physiotherapists, five senior physiotherapists working in private practice, four senior physiotherapists working within elite sports organisations and two sport and exercise medicine doctors, were included and one-on-one interviews were performed. Audio was transcribed then entered into NVivo for coding and analysis. Four main themes were perceived as barriers to implementing ideal practice of assessment and monitoring in people with Achilles tendinopathy: financial constraints, time constraints, access to equipment and patient symptom severity. Assessments related to function, pain on loading, pain over a specified time frame and palpation are commonly used to assist diagnosis. Assessments related to disability, pain on loading, pain over a specified time frame and physical function capacity are used to monitor progress over time. Furthermore, pain on loading and pain over a specified time frame were considered the most important outcome measure domains for assisting diagnosis whereas pain on loading, patient rating of the condition and physical function capacity were the most important outcome measure domains for monitoring progress. A number of barriers exist that prevent clinicians from implementing what they view as ideal assessment and monitoring for Achilles tendinopathy. These barriers should be considered when developing new assessments and in clinical practice recommendations.
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Affiliation(s)
- Myles Calder Murphy
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - James Debenham
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Caroline Bulsara
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Paola Chivers
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Ebonie Kendra Rio
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Sean Docking
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
- School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia
| | - Mervyn Travers
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - William Gibson
- National School of Nursing, Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
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18
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Andersen ER, Hofmann BM, Kjelle E. Reducing low-value radiological services in Norway -a qualitative multi-professional study on measures and facilitators for change. BMC Health Serv Res 2022; 22:678. [PMID: 35596215 PMCID: PMC9122550 DOI: 10.1186/s12913-022-08077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/11/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Overuse, underuse, and significant variation in the utilisation of radiological services are well documented in the literature. Several radiological examinations are identified as low-value examinations as they do not lead to a change in diagnosis or course of treatment. Even so, such examinations are frequently performed. Many measures for reducing low-value imaging have been carried out with variable outcomes. While there is little evidence as to why some measures work and others do not, adjusting to the context seems important for success. The objective of this study was to investigate which measures stakeholders consider appropriate for reducing the use of low-value imaging and what it takes to make them work. METHODS Semi-structured interviews were conducted among radiographers, radiologists, radiological department managers, hospital clinicians, general practitioners, and health government/authorities' representatives. The interview guide covered two broad areas: Experience with low-value services, and possible future measures deemed appropriate for reducing low-value services. Data were analysed in line with a qualitative framework analysis. RESULTS The analysis included information from 27 participants. All participants acknowledged that low-value imaging was a problem, but few had very specific suggestions on reducing this in practice. Suggested measures were to stop referrals from being sent, provide support in assessing referrals, or change the healthcare system. Identified facilitators were categorised as management and resources, evidence, and experienced value. In general, appropriate measures should be practical, well-founded, and valuable. CONCLUSIONS This study provides insight into various stakeholders' perceptions of suitable interventions to reduce low-value imaging. While many measures for reducing low-value imaging are available, contextual sensitivity is crucial to make them work.
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Affiliation(s)
- Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway.
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway.,Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway
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Rossettini G, Colombi A, Carlino E, Manoni M, Mirandola M, Polli A, Camerone EM, Testa M. Unraveling Negative Expectations and Nocebo-Related Effects in Musculoskeletal Pain. Front Psychol 2022; 13:789377. [PMID: 35369173 PMCID: PMC8966654 DOI: 10.3389/fpsyg.2022.789377] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/24/2022] [Indexed: 12/16/2022] Open
Abstract
This Perspective adapts the ViolEx Model, a framework validated in several clinical conditions, to better understand the role of expectations in the recovery and/or maintenance of musculoskeletal (MSK) pain. Here, particular attention is given to the condition in which dysfunctional expectations are maintained despite no longer being supported by confirmatory evidence (i.e., belief-lifting the arm leads to permanent tendon damage; evidence-after the patient lifts the arm no tendon damage occurs). While the ViolEx Model suggests that cognitive immunization strategies are responsible for the maintenance of dysfunctional expectations, we suggest that such phenomenon can also be understood from a Bayesian Brain perspective, according to which the level of precision of the priors (i.e., expectations) is the determinant factor accounting for the extent of priors' updating (i.e., we merge the two frameworks, suggesting that highly precise prior can lead to cognitive immunization responses). Importantly, this Perspective translates the theory behind these two frameworks into clinical suggestions. Precisely, it is argued that different strategies should be implemented when treating MSK pain patients, depending on the nature of their expectations (i.e., positive or negative and the level of their precision).
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Affiliation(s)
- Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy.,School of Physiotherapy, University of Verona, Verona, Italy
| | - Andrea Colombi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Elisa Carlino
- Department of Neuroscience, University of Turin Medical School, Turin, Italy
| | - Mattia Manoni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | | | - Andrea Polli
- Pain in Motion (PAIN) Department, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Research Foundation, Flanders (FWO) Postdoctoral Fellow, Brussels, Belgium
| | - Eleonora Maria Camerone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy.,Department of Psychology, University of Milan-Bicocca, Milano, Italy
| | - Marco Testa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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Witherow J, Jenkins H, Elliott J, Ip G, Maher C, Magnussen J, Hancock M. Characteristics and Effectiveness of Interventions That Target the Reporting, Communication, or Clinical Interpretation of Lumbar Imaging Findings: A Systematic Review. AJNR Am J Neuroradiol 2022; 43:493-500. [PMID: 35210277 PMCID: PMC8910802 DOI: 10.3174/ajnr.a7432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients and clinicians may misinterpret the clinical importance of imaging findings in patients with low back pain, leading to potential harm related to overdiagnosis. PURPOSE Our aims were to qualitatively summarize the characteristics of tested interventions that target the reporting, communication, or clinical interpretation of lumbar imaging findings and determine whether interventions are effective in improving low back pain-related health outcomes, health care use, or health care costs. DATA SOURCES PubMed, MEDLINE, CINAHL, EMBASE, PsycINFO, and the Cochrane Library were searched from inception to October 20, 2021. STUDY SELECTION The search retrieved 4394 articles, nine articles (seven studies) met the inclusion criteria to summarize intervention characteristics. Five of these studies had an adequate design for evaluating intervention effectiveness. DATA ANALYSES Intervention characteristics were summarized using the Template for Intervention Description and Replication checklist. Effectiveness data were extracted from short, intermediate, and long-term follow-up points. Studies were assessed for risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology was used to determine the certainty of the evidence. DATA SYNTHESIS Four studies investigated the insertion of prevalence information into imaging reports. Single studies investigated withholding diagnostic information, education, and reassurance. Moderate-quality evidence (from 1 study) suggests that inserting prevalence information into imaging reports probably does not change the overall health care use in the long-term but may reduce opioid prescribing. LIMITATIONS The available evidence is limited, and a meta-analysis was not possible. CONCLUSIONS Further work is required to develop and test interventions that target the reporting, communication, and clinical interpretation of lumbar imaging findings that may reduce overdiagnosis and improve the management of low back pain.
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Affiliation(s)
- J.L. Witherow
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - H.J. Jenkins
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - J.M. Elliott
- Faculty of Medicine and Health (J.M.E.),The Kolling Institute of Medical Research (J.M.E.), Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - G.H. Ip
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - C.G. Maher
- Sydney School of Public Health (C.G.M.), Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia,Institute for Musculoskeletal Health (C.G.M.), Sydney, New South Wales, Australia
| | - J.S. Magnussen
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - M.J. Hancock
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
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21
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Dickson C, de Zoete RMJ, Stanton TR. From Where We've Come to Where We Need to Go: Physiotherapy Management of Chronic Whiplash-Associated Disorder. FRONTIERS IN PAIN RESEARCH 2022; 2:795369. [PMID: 35295440 PMCID: PMC8915571 DOI: 10.3389/fpain.2021.795369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Cameron Dickson
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA, Australia
- *Correspondence: Cameron Dickson
| | - Rutger M. J. de Zoete
- School of Allied Health Science and Practice, The University of Adelaide, Adelaide, SA, Australia
| | - Tasha R. Stanton
- Innovation, Implementation and Clinical Translation in Health, University of South Australia, Adelaide, SA, Australia
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Schmidt CO, Sierocinski E, Baumeister S, Hegenscheid K, Völzke H, Chenot JF. Effects of whole-body MRI on outpatient health service costs: a general-population prospective cohort study in Mecklenburg-Vorpommern, Germany. BMJ Open 2022; 12:e056572. [PMID: 34996801 PMCID: PMC8744128 DOI: 10.1136/bmjopen-2021-056572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Whole-body MRI (wb-MRI) is increasingly used in research and screening but little is known about the effects of incidental findings (IFs) on health service utilisation and costs. Such effects are particularly critical in an observational study. Our principal research question was therefore how participation in a wb-MRI examination with its resemblance to a population-based health screening is associated with outpatient service costs. DESIGN Prospective cohort study. SETTING General population Mecklenburg-Vorpommern, Germany. PARTICIPANTS Analyses included 5019 participants of the Study of Health in Pomerania with statutory health insurance data. 2969 took part in a wb-MRI examination in addition to a clinical examination programme that was administered to all participants. MRI non-participants served as a quasi-experimental control group with propensity score weighting to account for baseline differences. PRIMARY AND SECONDARY OUTCOME MEASURES Outpatient costs (total healthcare usage, primary care, specialist care, laboratory tests, imaging) during 24 months after the examination were retrieved from claims data. Two-part models were used to compute treatment effects. RESULTS In total, 1366 potentially relevant IFs were disclosed to 948 MRI participants (32% of all participants); most concerned masses and lesions (769 participants, 81%). Costs for outpatient care during the 2-year observation period amounted to an average of €2547 (95% CI 2424 to 2671) for MRI non-participants and to €2839 (95% CI 2741 to 2936) for MRI participants, indicating an increase of €295 (95% CI 134 to 456) per participant which corresponds to 11.6% (95% CI 5.2% to 17.9%). The cost increase was sustained rather than being a short-term spike. Imaging and specialist care related costs were the main contributors to the increase in costs. CONCLUSIONS Communicated findings from population-based wb-MRI substantially impacted health service utilisation and costs. This introduced bias into the natural course of healthcare utilisation and should be taken care for in any longitudinal analyses.
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Affiliation(s)
- Carsten Oliver Schmidt
- Institute for Community Medicine - Department SHIP/KEF, University Medicine Greifswald, Greifswald, MV, Germany
| | - Elizabeth Sierocinski
- Institute for Community Medicine - Department of Family Medicine, University Medicine Greifswald, Greifswald, MV, Germany
| | - Sebastian Baumeister
- Institute of Health Services Research in Dentistry, University of Muenster, Muenster, Niedersachsen, Germany
| | - Katrin Hegenscheid
- Unfallkrankenhaus Berlin, Berlin, Berlin, Germany
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, MV, Germany
| | - Henry Völzke
- Institute for Community Medicine - Department SHIP/KEF, University Medicine Greifswald, Greifswald, MV, Germany
- DZD - German Center for Diabetes Research - Partner Site Greifswald, Greifswald, MV, Germany
- DZHK - German Centre for Cardiovascular Research - Partner Site Greifswald, Greifswald, MV, Germany
| | - J-F Chenot
- Institute for Community Medicine - Department of Family Medicine, University Medicine Greifswald, Greifswald, MV, Germany
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