Limited Hospital Variation in the Use and Yield of CT for Pulmonary Embolism in Patients Undergoing Total Hip or Total Knee Replacement Surgery

The Choosing Wisely Initiative and MRIs: Over- and Under-Diagnosis in Japan and Myanmar

Recently, the “Choosing Wisely” initiative has gained traction and high-value care has garnered attention. However, the actual situation of high-value care is different between developed and developing countries. To elucidate this, we highlight the differences between the high-value care provided by healthcare systems in Japan and Myanmar, as representations of developed and developing countries, respectively. Despite the total numbers of magnetic resonance imaging (MRI) equipment in Japan being 400 times higher than in Myanmar, and gross domestic product per capita being 32 times higher in Japan, the individual costs (out of pocket expenditures) per MRI scan are the same (USD 60). However, the total cost per MRI scan is different, implying that differing healthcare costs indicate the existence of over- and under-diagnosis problems among different countries. This study suggests that detailed patient histories and physical examinations are important for selecting relevant diagnostic imaging and reducing unnecessary imaging.

Large hospital variation in the utilization of Post-procedural CT to detect pulmonary embolism/Deep Vein Thrombosis in Patients Undergoing Total Knee or Hip Replacement Surgery: Japanese Nationwide Diagnosis Procedure Combination Database Study

OBJECTIVE

The purpose of the study was to investigate variation in the use of in-hospital CT for venous thromboembolism (VTE) detection after total knee or hip replacement (TKR/THR) among surgical patients, using a nationwide Japanese in-hospital administrative database.

METHODS

This retrospective study using a national administrative database (4/2012-3/2013) extracted patients who underwent TKR/THR surgeries at hospitals meeting the annual case-volume threshold of ≥ 30. Hospitals were categorized into three equally sized groups by frequency of postoperative CT use (low, middle, and high CT use group) to compare baseline patient-level and hospital-level characteristics. To further investigate between-hospital variation in CT usage, we fitted a hierarchical logistic regression model including hospital-specific random intercepts and fixed patient- and hospital-level effects. The intra class correlation coefficient was used to measure the amount of variability in CT use attributable to between-hospital variation.

RESULTS

A total of 39,127 patients discharged from 447 hospitals met the inclusion criteria. The median hospital stay was 25 days (interquartile range, 20 - 32) and 7,599 (19.4%) patients underwent CT for VTE. CT utilization varied greatly among the hospitals; the crude frequency ranged from 0 to 100 % (median, 7.3 %; interquartile range, 1.8 - 18.3 %). After adjustment for known hospital- and patient-level factors related to CT use, 47 % of the variation in CT use remained attributable to the behavior of individual hospitals.

CONCLUSION

We observed large inter hospital variability in the utilization of post-procedure CT for VTE detection in this Japanese TKR/THR cohort, suggesting that CT utilization is not optimized across the nation.

ADVANCES IN KNOWLEDGE

We observed significant variability in the utilization of post-procedure CT for VTE detection among inpatients who underwent TKR/THR surgeries in a large sample of Japanese hospitals. The large variation suggests that CT utilization is not optimized across the nation, and that there may be potential overutilization of the technology in the highest CT use hospitals.

Radiologist involvement is associated with reduced use of MRI in the acute period of low back pain in a non-elderly population

PURPOSE

To test the hypothesis that "acute-period" lumbar MRI in non-elderly patients with low back pain is less frequently performed at clinics/hospitals with greater involvement of full-time radiologists in the imaging workflow.

METHODS

In a national-level claims database, we identified 14,819 non-elderly patients (mean age: 38.7±8.0 years) who visited clinics/hospitals for low back pain in 2013-2015. We classified the clinics/hospitals into four groups based on the level of full-time radiologist involvement and MRI ownership, and compared the frequency of acute-period lumbar MRI using hierarchical logistic regression analysis.

RESULTS

Patients visiting facilities without a full-time radiologist (n=2105) were significantly (p<0.001) more likely to undergo acute-period MRI than those visiting facilities with ≥1 radiologist partially managing imaging workflow (level-1, n=491) or ≥1 radiologist intensively involved in imaging workflow (level-2, n=1190) (15.7% vs. 6.9% and 7.3%; adjusted odds ratio of no-radiologist versus level-2: 2.93, p=0.018). No difference was observed between level-1 and level-2 involvement.

CONCLUSIONS

Facilities with no full-time radiologist were more likely to perform acute-period MRI to assess for low back pain, while no difference was seen between facilities with varying levels of radiologist involvement in the imaging workflow. Radiologist involvement may contribute to optimal utilisation of medical imaging.

KEY POINTS

• Lumbar MRI was more frequently performed at facilities without full-time radiologists. • Full-time radiologists may play an important role in appropriate utilisation of imaging. • Frequency of MRI was similar between moderate and intensive radiologist involvement.