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Xu RH, Chen C. Moderating Effect of Coping Strategies on the Association Between the Infodemic-Driven Overuse of Health Care Services and Cyberchondria and Anxiety: Partial Least Squares Structural Equation Modeling Study. J Med Internet Res 2024; 26:e53417. [PMID: 38593427 DOI: 10.2196/53417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/14/2023] [Accepted: 03/22/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has led to a substantial increase in health information, which has, in turn, caused a significant rise in cyberchondria and anxiety among individuals who search for web-based medical information. To cope with this information overload and safeguard their mental well-being, individuals may adopt various strategies. However, the effectiveness of these strategies in mitigating the negative effects of information overload and promoting overall well-being remains uncertain. OBJECTIVE This study aimed to investigate the moderating effect of coping strategies on the relationship between the infodemic-driven misuse of health care and depression and cyberchondria. The findings could add a new dimension to our understanding of the psychological impacts of the infodemic, especially in the context of a global health crisis, and the moderating effect of different coping strategies on the relationship between the overuse of health care and cyberchondria and anxiety. METHODS The data used in this study were obtained from a cross-sectional web-based survey. A professional survey company was contracted to collect the data using its web-based panel. The survey was completed by Chinese individuals aged 18 years or older without cognitive problems. Model parameters of the relationships between infodemic-driven overuse of health care, cyberchondria, and anxiety were analyzed using bootstrapped partial least squares structural equation modeling. Additionally, the moderating effects of coping strategies on the aforementioned relationships were also examined. RESULTS A total of 986 respondents completed the web-based survey. The mean scores of the Generalized Anxiety Disorder-7 and Cyberchondria Severity Scale-12 were 8.4 (SD 3.8) and 39.7 (SD 7.5), respectively. The mean score of problem-focused coping was higher than those of emotion- and avoidant-focused coping. There was a significantly positive relationship between a high level of infodemic and increased overuse of health care (bootstrapped mean 0.21, SD 0.03; 95% CI 0.1581-0.271). The overuse of health care resulted in more severe cyberchondria (bootstrapped mean 0.107, SD 0.032) and higher anxiety levels (bootstrapped mean 0.282, SD 0.032) in all the models. Emotion (bootstrapped mean 0.02, SD 0.008 and 0.037, SD 0.015)- and avoidant (bootstrapped mean 0.026, SD 0.009 and 0.049, SD 0.016)-focused coping strategies significantly moderated the relationship between the overuse of health care and cyberchondria and that between the overuse of health care and anxiety, respectively. Regarding the problem-based model, the moderating effect was significant for the relationship between the overuse of health care and anxiety (bootstrapped mean 0.007, SD 0.011; 95% CI 0.005-0.027). CONCLUSIONS This study provides empirical evidence about the impact of coping strategies on the relationship between infodemic-related overuse of health care services and cyberchondria and anxiety. Future research can build on the findings of this study to further explore these relationships and develop and test interventions aimed at mitigating the negative impact of the infodemic on mental health.
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Affiliation(s)
- Richard Huan Xu
- Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, Hong Kong Polytechnic University, Hung Hom, China (Hong Kong)
| | - Caiyun Chen
- Nanjing Academy of Administration, Nanjing, China
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Gupta R, Xie BE, Zhu M, Segal JB. Randomized Experiments to Reduce Overuse of Health Care: A Scoping Review. Med Care 2024; 62:263-269. [PMID: 38315879 PMCID: PMC10939761 DOI: 10.1097/mlr.0000000000001978] [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] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Health care overuse is pervasive in countries with advanced health care delivery systems. We hypothesize that effective interventions to reduce low-value care that targets patients or clinicians are mediated by psychological and cognitive processes that change behaviors and that interventions targeting these processes are varied. Thus, we performed a scoping review of experimental studies of interventions, including the interventions' objectives and characteristics, to reduce low-value care that targeted psychological and cognitive processes. METHODS We systematically searched databases for experimental studies of interventions to change cognitive orientations and affective states in the setting of health care overuse. Outcomes included observed overuse or a stated intention to use services. We used existing frameworks for behavior change and mechanisms of change to categorize the interventions and the mediating processes. RESULTS Twenty-seven articles met the inclusion criteria. Sixteen studied the provision of information to patients or clinicians, with most providing cost information. Six studies used educational interventions, including the provision of feedback about individual practice. Studies rarely used counseling, behavioral nudges, persuasion, and rewards. Mechanisms for behavior change included gain in knowledge or confidence and motivation by social norms. CONCLUSIONS In this scoping review, we found few experiments testing interventions that directly target the psychological and cognitive processes of patients or clinicians to reduce low-value care. Most studies provided information to patients or clinicians without measuring or considering mediating factors toward behavior change. These findings highlight the need for process-driven experimental designs, including trials of behavioral nudges and persuasive language involving a trusting patient-clinician relationship, to identify effective interventions to reduce low-value care.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Meng Zhu
- Johns Hopkins Carey Business School, Baltimore, MD
- Pamplin College of Business, Virgina Tech, Blacksburg, VA
| | - Jodi B. Segal
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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Otte JA, Llargués Pou M. Enablers and barriers to a quaternary prevention approach: a qualitative study of field experts. BMJ Open 2024; 14:e076836. [PMID: 38508616 PMCID: PMC10952943 DOI: 10.1136/bmjopen-2023-076836] [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: 06/17/2023] [Accepted: 02/27/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE There is a growing concern about the sustainability of healthcare and the impacts of 'overuse' on patients and systems. Quaternary prevention (P4), a concept promoting the protection of patients from medical interventions in which harms outweigh benefits, is well positioned to stimulate reflection and inspire solutions, yet has not been widely adopted. We sought to identify enablers and barriers to a P4 approach, according to field experts and advocates in one health system. DESIGN Qualitative methodology, using semistructured interviews and a grounded theory approach facilitated thematic analysis and development of a conceptual model. SETTING Virtual interviews, conducted in British Columbia, Canada. PARTICIPANTS 12 field experts, recruited based on their interest and work related to P4 and related concepts. RESULTS Four factors were seen as promoting or hindering P4 efforts depending on context: relationship between patient and clinician, education of clinicians and the public, health system design and influencers. We extracted four broad enablers of P4: evidence-based medicine, personal experiences and questioning attitude, public P4 campaigns and experience in resource-poor contexts. There were six barriers: peer pressure between clinicians, awareness and screening campaigns, cognitive biases, cultural factors, complexity of the problem and industry influence. CONCLUSIONS Elicited facilitators and impediments to the application of P4 were similar to those seen in existing literature but framed uniquely; our findings place increased emphasis on the clinician-patient relationship as central to decision-making and position other drivers as influencing this relationship. A transition to a model of care that explicitly integrates conscious protection of patients by reducing overtesting, overdiagnosis and overtreatment will require changes across health systems and society.
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Affiliation(s)
- Jessica Anneliese Otte
- Department of Family Practice and Division of Palliative Care, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Therapeutics Initiative, Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Maria Llargués Pou
- Sta. Mª de Palautordera Primary Healthcare Center (CAP) - Baix Montseny Primary Healthcare Team (EAP), Institut Català de la Salut, Barcelona, Catalonia, Spain
- Emergency Department, University General Hospital of Granollers, Barcelona, Catalonia, Spain
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4
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Segal JB. Reducing Low-Value Health Care. Ann Intern Med 2024; 177:397-398. [PMID: 38315995 DOI: 10.7326/m24-3501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
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Advani SD, Claeys K. Behavioral Strategies in Diagnostic Stewardship. Infect Dis Clin North Am 2023; 37:729-747. [PMID: 37537001 DOI: 10.1016/j.idc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.
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Affiliation(s)
- Sonali D Advani
- Department of Internal Medicine-Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Suite 154, Durham, NC 27710, USA.
| | - Kimberly Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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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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Sznol JA, Becher R, Maung AA, Bhattacharya B, Davis K, Schuster KM. Routine post-operative labs and healthcare system burden in acute appendicitis. Am J Surg 2023; 226:571-577. [PMID: 37291012 DOI: 10.1016/j.amjsurg.2023.06.005] [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: 03/20/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management. METHODS A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected. RESULTS A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient. CONCLUSIONS In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.
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Affiliation(s)
- Joshua A Sznol
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Robert Becher
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Adrian A Maung
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Bishwajit Bhattacharya
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kimberly Davis
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
| | - Kevin M Schuster
- Department of Surgery, P.O. Box 208062, Yale School of Medicine, New Haven, CT 06520, USA.
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Ganguli I, Mulligan KL, Chant ED, Lipsitz S, Simmons L, Sepucha K, Rudin RS. Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2342464. [PMID: 37943557 PMCID: PMC10636635 DOI: 10.1001/jamanetworkopen.2023.42464] [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] [Received: 07/21/2023] [Accepted: 09/28/2023] [Indexed: 11/10/2023] Open
Abstract
Importance Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations. Objective To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits. Design, Setting, and Participants Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023. Interventions In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips. Main outcomes and measures The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted. Results There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials. Conclusions and Relevance In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships. Trial Registration ClinicalTrials.gov Identifier: NCT04902664.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kathleen L. Mulligan
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Emma D. Chant
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Stuart Lipsitz
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Leigh Simmons
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen Sepucha
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert S. Rudin
- Health Care Division, RAND Corporation, Boston, Massachusetts
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Ellenbogen MI, Wiegand AA, Austin JM, Schoenborn NL, Kodavarti N, Segal JB. Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis. J Gen Intern Med 2023; 38:2519-2526. [PMID: 36781578 PMCID: PMC10465435 DOI: 10.1007/s11606-023-08060-3] [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: 10/03/2022] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Healthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA. OBJECTIVE To learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse. PARTICIPANTS Leaders at select healthcare systems in the USA. INTERVENTIONS None APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework. KEY RESULTS We interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse. CONCLUSIONS Our qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.
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Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA.
| | - Aaron A Wiegand
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Matthew Austin
- Department of Anesthesia and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA
| | - Nihal Kodavarti
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Sijbom M, Büchner FL, Saadah NH, Numans ME, de Boer MGJ. Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework. BMJ Open 2023; 13:e065006. [PMID: 37197815 DOI: 10.1136/bmjopen-2022-065006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVES This study aimed to identify determinants of inappropriate antibiotic prescription in primary care in developed countries and to construct a framework with the determinants to help understand which actions can best be targeted to counteract development of antimicrobial resistance (AMR). DESIGN A systematic review of peer-reviewed studies reporting determinants of inappropriate antibiotic prescription published through 9 September 2021 in PubMed, Embase, Web of Science and the Cochrane Library was performed. SETTING All studies focusing on primary care in developed countries where general practitioners (GPs) act as gatekeepers for referral to medical specialists and hospital care were included. RESULTS Seventeen studies fulfilled the inclusion criteria and were used for the analysis which identified 45 determinants of inappropriate antibiotic prescription. Important determinants for inappropriate antibiotic prescription were comorbidity, primary care not considered to be responsible for development of AMR and GP perception of patient desire for antibiotics. A framework was constructed with the determinants and provides a broad overview of several domains. The framework can be used to identify several reasons for inappropriate antibiotic prescription in a specific primary care setting and from there, choose the most suitable intervention(s) and assist in implementing them for combatting AMR. CONCLUSIONS The type of infection, comorbidity and the GPs perception of a patient's desire for antibiotics are consistently identified as factors driving inappropriate antibiotic prescription in primary care. A framework with determinants of inappropriate antibiotic prescription may be useful after validation for effective implementation of interventions for decreasing these inappropriate prescriptions. PROSPERO REGISTRATION NUMBER CRD42023396225.
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Affiliation(s)
- Martijn Sijbom
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederike L Büchner
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Nicholas H Saadah
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mark G J de Boer
- Infectious Diseases, Leidsen University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Advani SD, McKay V. Beyond implementation: Uncovering the parallels between de-implementation and antimicrobial stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e73. [PMID: 37113202 PMCID: PMC10127237 DOI: 10.1017/ash.2023.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 04/29/2023]
Abstract
De-implementation is defined as the process of discontinuing, removing, reducing, or replacing a harmful, ineffective, or low-value clinical practice or intervention. The goal of de-implementation strategies is to minimize patient harm, maximize use of resources, and reduce healthcare costs and inequities. Both antibiotic and diagnostic stewardship programs focus on reducing low-value interventions (tests or antimicrobials). Stewardship interventions commonly involve de-implementation and deprescribing strategies. This commentary explores unique aspects of deimplementing low-value testing and unnecessary antimicrobial use, similarities between de-implementation and stewardship approaches, multilevel factors that impact de-implementation, and opportunities for future research.
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Affiliation(s)
- Sonali D. Advani
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
- Author for correspondence: Sonali D. Advani, MBBS, MPH, FIDSA, Duke University School of Medicine, 315 Trent Drive, Hanes House, Room 154, Durham, NC27710. E-mail:
| | - Virginia McKay
- Brown School, Washington University in St. Louis, St. Louis, Missouri
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Mafi JN, Walling AM, Villaflores C, Vangala S, Sorensen A, Cheng E, Turner A, Trutner Z, Cheng G, Arbanas JC, Waterman B, Shu S, Goldstein N, Sarkisian C. A pragmatic parallel arm randomized-controlled trial of a multi-pronged electronic health record-based clinical decision support tool protocol to reduce low-value antipsychotic prescriptions among older adults with Alzheimer's and related dementias. PLoS One 2022; 17:e0277409. [PMID: 36538552 PMCID: PMC9767350 DOI: 10.1371/journal.pone.0277409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/02/2022] [Indexed: 12/24/2022] Open
Abstract
Among patients with Alzheimer's disease and its related dementias (ADRD) with behavioral disturbances, antipsychotic prescriptions have limited efficacy and increase the risk of death. Yet, physicians continue to routinely prescribe low-value antipsychotic medications for behavioral disturbances among patients with ADRD. We designed a pragmatic randomized-controlled trial to measure the impact of a behavioral economic electronic health record (EHR) clinical decision support (CDS) intervention to reduce physician prescriptions of new antipsychotic medications among patients with ADRD. Utilizing a pragmatic parallel arm randomized-controlled trial design, the study will randomize eligible physicians from a large academic health system to either receive a EHR CDS intervention or not (control) when they prescribe a new antipsychotic medication during visits with patients with ADRD. The intervention will include three components: 1) alerts prescribers that antipsychotic prescriptions increase mortality risk (motivating physicians' intrinsic desire for non-malfeasance); 2) offers non-pharmacological behavioral resources for caregivers; 3) auto-defaults the prescription to contain the lowest dose and number of pill-days (n = 30) without refills if the prescriber does not cancel the order (appealing to default bias). Over 1 year, we will compare the cumulative total of new antipsychotic pill-days prescribed (primary outcome) by physicians in the intervention group versus in the control group. The study protocol meets international SPIRIT guidelines. Behavioral economics, or the study of human behavior as a function of more than rational incentives, considering a whole host of cognitive and social psychological preferences, tendencies, and biases, is increasingly recognized as an important conceptual framework to improve physician behavior. This pragmatic trial is among the first to combine two distinct behavioral economic principles, a desire for non-malfeasance and default bias, to improve physician prescribing patterns for patients with ADRD. We anticipate this trial will substantially advance understanding of how behavioral-economic informed EHR CDS tools can potentially reduce harmful, low-value care among patients with ADRD.
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Affiliation(s)
- John N. Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- RAND Corporation, Santa Monica, California, United States of America
- * E-mail:
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- RAND Corporation, Santa Monica, California, United States of America
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
| | - Chad Villaflores
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Andrea Sorensen
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Eric Cheng
- Division of Medical Informatics, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Ashley Turner
- Division of Medical Informatics, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Zoe Trutner
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Grace Cheng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Julia Cave Arbanas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Benjamin Waterman
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Suzanne Shu
- Division of Marketing, Charles H. Dyson School of Applied Economics and Management at Cornell University, Ithaca, New York, United States of America
| | - Noah Goldstein
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Division of Management and Organizations, Anderson School of Management at UCLA, Los Angeles, California, United States of America
| | - Catherine Sarkisian
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
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Kroon D, van Dulmen SA, Westert GP, Jeurissen PPT, Kool RB. Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study. BMJ Open 2022; 12:e062902. [PMID: 36343997 PMCID: PMC9644331 DOI: 10.1136/bmjopen-2022-062902] [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] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.
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Affiliation(s)
| | | | | | | | - Rudolf B Kool
- IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
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14
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Skowronski G, Kerridge I, Light E, McErlean G, Stewart C, Preisz A, Sheahan L. Raising the Dead? Limits of CPR and Harms of Defensive Practices. Hastings Cent Rep 2022; 52:8-12. [PMID: 36537273 DOI: 10.1002/hast.1442] [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] [Indexed: 01/18/2023]
Abstract
We describe the case of an eighty-four-year-old man with disseminated lung cancer who had been receiving palliative care in the hospital and was found by nursing staff unresponsive, with clinically obvious signs of death, including rigor mortis. Because there was no documentation to the contrary, the nurses commenced cardiopulmonary resuscitation and called a code blue, resulting in resuscitative efforts that continued for around twenty minutes. In discussion with the hospital ethicist, senior nurses justified these actions, mainly citing disciplinary and medicolegal concerns. We argue that moral harms arise from CPR performed on a corpse and that legal concerns about failing to perform it are unfounded. We contend that such efforts are an unintended consequence of managerialist policies mandating do-not-resuscitate orders and advance care plans and of defensive practices that can value the interests of institutions and practitioners over those of patients. Health management teaching should include managerialism and its pitfalls, while clinician training should prioritize ethical reasoning and legal knowledge over defensive practice.
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15
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Gutman CK, Lion KC, Aronson P, Fisher C, Bylund C, McFarlane A, Lou X, Patterson MD, Lababidi A, Fernandez R. Disparities and implicit bias in the management of low-risk febrile infants: a mixed methods study protocol. BMJ Open 2022; 12:e063611. [PMID: 36127098 PMCID: PMC9490627 DOI: 10.1136/bmjopen-2022-063611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The management of low-risk febrile infants presents a model population for exploring how implicit racial bias promotes inequitable emergency care for children who belong to racial, ethnic and language minority groups. Although widely used clinical standards guide the clinical care of febrile infants, there remains substantial variability in management strategies. Deviations from recommended care may be informed by the physician's assessment of the family's values, risk tolerance and access to supportive resources. However, in the fast-paced emergency setting, such assessments may be influenced by implicit racial bias. Despite significant research to inform the clinical care of febrile infants, there is a dearth of knowledge regarding health disparities and clinical guideline implementation. The proposed mixed methods approach will (1) quantify the extent of disparities by race, ethnicity and language proficiency and (2) explore the role of implicit bias in physician-patient communication when caring for this population. METHODS AND ANALYSIS With 42 participating sites from the Pediatric Emergency Medicine Collaborative Research Committee, we will conduct a multicenter, cross-sectional study of low-risk febrile infants treated in the emergency department (ED) and apply multivariable logistic regression to assess the association between (1) race and ethnicity and (2) limited English proficiency with the primary outcome, discharge to home without lumbar puncture or antibiotics. We will concurrently perform an interpretive study using purposive sampling to conduct individual semistructured interviews with (1) minority parents of febrile infants and (2) paediatric ED physicians. We will triangulate or compare perspectives to better elucidate disparities and bias in communication and medical decision-making. ETHICS AND DISSEMINATION This study has been approved by the University of Florida Institutional Review Board. All participating sites in the multicenter analysis will obtain local institutional review board approval. The results of this study will be presented at academic conferences and in peer-reviewed publications.
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Affiliation(s)
- Colleen K Gutman
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - K Casey Lion
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Paul Aronson
- Departments of Emergency Medicine and Pediatrics, Yale University, New Haven, Connecticut, USA
| | - Carla Fisher
- College of Journalism and Communications, University of Florida, Gainesville, Florida, USA
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Carma Bylund
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Antionette McFarlane
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
| | - Xiangyang Lou
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Mary D Patterson
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
- Center for Experiential Learning and Simulation, University of Florida, Gainesville, Florida, USA
| | - Ahmed Lababidi
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Rosemarie Fernandez
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
- Center for Experiential Learning and Simulation, University of Florida, Gainesville, Florida, USA
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16
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Juang WC, Chiou SMJ, Yang HL, Li YC. Exploring emergency physicians’ knowledge, attitudes, and behaviour towards Choosing Wisely in Taiwan. PLoS One 2022; 17:e0271346. [PMID: 35819965 PMCID: PMC9275691 DOI: 10.1371/journal.pone.0271346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/28/2022] [Indexed: 11/27/2022] Open
Abstract
Background In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to reduce unnecessary care. However, it is unclear how much emergency physicians in Taiwan understand about Choosing Wisely. The purpose of this study was to explore the knowledge, attitude, and behaviour of emergency physicians in Taiwan regarding Choosing Wisely and its related factors; the intention was to identify the baseline knowledge on the basis of which to promote Choosing Wisely in Taiwan. Methods This was a cross-sectional study including emergency physicians in Taiwan as research subjects who answered online questionnaires. A 42-item questionnaire was designed according to the Knowledge, Attitude, and Behaviour model (KAB). The questionnaire linkages were delivered to emergency physicians through social media (eg., Line, Facebook) and received assistance from different hospital directors. A total of 162 valid questionnaires were collected. Data analyses include t-test, analysis of variance, chi-square test, Pearson’s correlation, and multivariate linear regression model. Results The study determined that although only 38.9% of emergency physicians had heard of Choosing Wisely, the mean correct rate of knowledge score among emergency physicians was 70.1%. Attitude and the behaviour related to Choosing Wisely were positively associated, which means that the more positive the attitude towards Choosing Wisely is, the more positive the behaviour towards Choosing Wisely is. In multiple linear regression analyses, having served as a supervisor, belonging to divisions of health insurance service, and having heard of Choosing Wisely (P < 0.05) positively affect the knowledge of Choosing Wisely, but age presented a negative association. Conclusion This study found that physicians’ knowledge does not influence their attitudes and behaviours, which may be related to barriers of practicing Choosing Wisely activities. To effectively promote Choosing Wisely campaign, it is recommended to focus on the significant factors associated with emergency physicians’ perceptions regarding knowledge, attitude, and behavior of Choosing Wisely. Based on these factors, appropriate practice guidelines for Choosing Wisely can be formulated and promoted.
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Affiliation(s)
- Wang-Chuan Juang
- Department of Quality Management Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Sonia Ming-Jiu Chiou
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Hui-Ling Yang
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Department of Planning, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung, Taiwan
| | - Ying-Chun Li
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- * E-mail:
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17
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Korenstein D, Scherer LD, Foy A, Pineles L, Lydecker AD, Owczarzak J, Magder L, Brown JP, Pfeiffer CD, Terndrup C, Leykum L, Stevens D, Feldstein DA, Weisenberg SA, Baghdadi JD, Morgan DJ. Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing. Am J Med 2022; 135:e182-e193. [PMID: 35307357 PMCID: PMC9728553 DOI: 10.1016/j.amjmed.2022.02.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization. METHODS We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins. RESULTS Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty. CONCLUSIONS Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.
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Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Laura D Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS); Division of Cardiology, University of Colorado School of Medicine, Aurora; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Colo
| | - Andrew Foy
- Department of Medicine; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pa
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Alison D Lydecker
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jessica P Brown
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Christopher D Pfeiffer
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland; Division of Hospital and Specialty Medicine, VA Portland Health Care System, Ore
| | - Christopher Terndrup
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland
| | - Luci Leykum
- Department of Medicine, Dell Medical School, the University of Texas at Austin; South Texas Veterans Health Care System, San Antonio
| | - Deborah Stevens
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - David A Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Scott A Weisenberg
- Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore; VA Maryland Healthcare System, Baltimore
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore; VA Maryland Healthcare System, Baltimore
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18
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Furlan L, Francesco PD, Costantino G, Montano N. Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care. J Intern Med 2022; 291:397-407. [PMID: 35307902 PMCID: PMC9314697 DOI: 10.1111/joim.13472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In recent years, the Choosing Wisely and Less is More campaigns have gained growing attention in the medical scientific community. Several projects have been launched to facilitate confrontation among patients and physicians, to achieve better and harmless patient-centered care. Such initiatives have paved the way to a new "way of thinking." Embracing such a philosophy goes through a cognitive process that takes into account several issues. Medicine is a highly inaccurate science and physicians should deal with uncertainty. Evidence from the literature should not be accepted as it is but rather be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics. A wise choice requires active effort into minimizing the chance that potential biases may affect our clinical decisions. Potential harms and all consequences (both direct and indirect) of prescribing tests, procedures, or medications should be carefully evaluated, as well as patients' needs and preferences. Through such a cognitive process, a patient management shift is needed, moving from being centered on establishing a diagnosis towards finding the best management strategy for the right patient at the right time. Finally, while "thinking wisely," physicians should also "act wisely," being among the leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.
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Affiliation(s)
- Ludovico Furlan
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Di Francesco
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Costantino
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Anaesthesia-Intensive Care Unit, Emergency Department and Emergency Medicine Unit, IRCCS Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
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Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication. Jt Comm J Qual Patient Saf 2022; 48:233-240. [PMID: 35177360 PMCID: PMC9941976 DOI: 10.1016/j.jcjq.2022.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise. METHODS Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention. RESULTS Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse. CONCLUSION Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.
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20
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Alishahi Tabriz A, Turner K, Clary A, Hong YR, Nguyen OT, Wei G, Carlson RB, Birken SA. De-implementing low-value care in cancer care delivery: a systematic review. Implement Sci 2022; 17:24. [PMID: 35279182 PMCID: PMC8917720 DOI: 10.1186/s13012-022-01197-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 02/14/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings. METHODS We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care. RESULTS Out of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers' behavior, and 1 de-implementation intervention focused on changing the patients' behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias. CONCLUSIONS This review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).
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Affiliation(s)
- Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4115 E. Fowler Avenue, Tampa, FL 33617 USA
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4115 E. Fowler Avenue, Tampa, FL 33617 USA
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Alecia Clary
- The Reagan-Udall Foundation for the FDA, 1900 L Street, NW, Suite 835, Washington, DC, 20036 USA
| | - Young-Rock Hong
- UF Health Cancer Center, Gainesville, FL USA
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, HPNP Building, Room 3111, Gainesville, FL 32610 USA
| | - Oliver T. Nguyen
- Department of Community Health & Family Medicine, University of Florida, P.O. Box 100211, Gainesville, FL 32610 USA
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL USA
| | - Grace Wei
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602 USA
| | - Rebecca B. Carlson
- Health Sciences Library, The University of North Carolina at Chapel Hill, 335 S. Columbia Street, Chapel Hill, NC 27599 USA
| | - Sarah A. Birken
- Department of Implementation Science, Wake Forest School of Medicine, 525@Vine Room 5219, Medical Center Boulevard, Winston-Salem, NC 27157 USA
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Ries NM, Johnston B, Jansen J. A qualitative interview study of Australian physicians on defensive practice and low value care: "it's easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other". BMC Med Ethics 2022; 23:16. [PMID: 35246129 PMCID: PMC8895622 DOI: 10.1186/s12910-022-00755-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/18/2022] [Indexed: 12/27/2022] Open
Abstract
Background Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour. Methods A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change. Results All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences. Conclusions The findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00755-2.
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Affiliation(s)
- Nola M Ries
- Faculty of Law, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.
| | - Briony Johnston
- Faculty of Law, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
| | - Jesse Jansen
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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22
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Gutman CK, Holmes S, Balhara KS. Low-value care in pediatric populations: There is no silver lining. Acad Emerg Med 2022; 29:804-807. [PMID: 35212441 DOI: 10.1111/acem.14470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Colleen K. Gutman
- Department of Emergency Medicine University of Florida College of Medicine Gainesville Florida USA
| | - Sherita Holmes
- Department of Pediatrics Emory University School of Medicine Atlanta Georgia USA
- Division of Emergency Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Kamna S. Balhara
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
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23
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Ganguli I, Thakore N, Rosenthal MB, Korenstein D. Longitudinal Content Analysis of the Characteristics and Expected Impact of Low-Value Services Identified in US Choosing Wisely Recommendations. JAMA Intern Med 2022; 182:127-133. [PMID: 34870673 PMCID: PMC8649907 DOI: 10.1001/jamainternmed.2021.6911] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The US Choosing Wisely campaign has had substantial reach in mobilizing efforts to reduce low-value care, achieved largely by engaging physician specialty societies in stewardship. While some early recommendations were criticized for avoiding revenue-generating services, there is limited evidence of how the composition of recommendations shifted as more societies contributed. OBJECTIVE To analyze the characteristics and expected impact of Choosing Wisely recommendations. DESIGN, SETTING, AND PARTICIPANTS This qualitative study included content and trend analyses of all 626 Choosing Wisely recommendations by US physician societies as of March 1, 2021. Data were analyzed between March and May 2021. MAIN OUTCOMES AND MEASURES Primary outcomes were proportions of identified low-value services by characteristics (society type, service type, indication, do vs avoid, and clinical context) and expected impact (effect on the revenue of society members, cost, number of individuals at risk, direct harm potential, and cascade potential). RESULTS Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging (168 [26.8%]) and laboratory studies (156 [24.9%]) in the context of chronic conditions (169 [27.0%]) and healthy patients with risk factors alone (126 [20.1%]). Most of the identified low-value services were revenue neutral for the recommending society (402 [64.2%]) and the plurality were low cost (<$200; 284 [45.4%]); low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations (1.2 percentage points per year; P = .001). Nearly half (280 [44.7%]) of recommendations identified services with high direct harm potential, and 388 (62.0%) identified those with high potential for cascades (ie, triggering downstream services). CONCLUSIONS AND RELEVANCE The results of this qualitative study suggest that the Choosing Wisely recommendations identified services with a range of expected impacts. Stakeholders could explicitly set priorities for future recommendations, while clinical leaders and payers might target intervention efforts on recommendations with the greatest potential for impact based on spending across populations, direct harms, and cascades.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Deborah Korenstein
- Department of Medicine and Primary Care, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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Parchman ML, Palazzo LG, Mogk JM, Webbon JC, Demosthenes L, Vossenkemper E, Hoke G, Moskovitz J, Dunlap L, Diaz del Carpio R. What strategies are used by clinician champions to reduce low-value care? SAGE Open Med 2022; 10:20503121211069855. [PMID: 35646351 PMCID: PMC9133862 DOI: 10.1177/20503121211069855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Clinician champions are front-line clinicians who advocate for and influence practice change in their local context. The strategies they use when leading efforts to reduce the use of low-value care have not been well described. The purpose of this study is to identify and describe strategies used by six clinician champions who led a low-value care initiative in their clinical setting. Methods: Qualitative data collected during an overuse reduction initiative led by clinician champions were used to identify strategies, guided by the Expert Recommendations for Implementing Change compilation of strategies. Clinician champions were asked to rank the importance of these activities and indicate which one of the six most important activities they would be willing to discuss in an interview. A 30-min semi-structured interview was conducted with each clinician about the activity they selected and thematically analyzed. Results: Twelve Expert Recommendations for Implementing Change strategies were identified. The top six strategies discussed during interviews were: build a coalition, conduct a local needs assessment, develop a formal implementation blueprint, conduct educational meetings, use facilitation, and develop clinical reminders. Common themes that emerged across all interviews were the use of data to engage clinicians in conversations, including the patient’s perspective in designing the interventions, and investing the time upfront to plan and launch the initiative because of the inherent challenges of relinquishing a service. Conclusions: Clinician champions identified multiple strategies as important when de-implementing a low-value service. Many were used to engage in conversations with stakeholders, including leadership, providers, and patients, to increase buy-in and support, challenge beliefs, promote behavior change, and gather insights about next steps in their effort. Future work is needed to better understand how prepare clinicians for this role and to understand the mechanisms through which these strategies might be effective.
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Affiliation(s)
- Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Lorella G Palazzo
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jessica M Mogk
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Janna C Webbon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Lauren Demosthenes
- University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | | | - George Hoke
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Joshua Moskovitz
- Department of Emergency Medicine, Albert Einstein College of Medicine, New York, NY, USA
- Department of Public Health, Hofstra School of Health and Human Services, New York, NY, USA
| | - Leslie Dunlap
- University of New Mexico Hospital, Albuquerque, NM, USA
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25
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Segal JB, Sen AP, Glanzberg-Krainin E, Hutfless S. Factors Associated With Overuse of Health Care Within US Health Systems. JAMA HEALTH FORUM 2022; 3:e214543. [PMID: 35977230 PMCID: PMC8903118 DOI: 10.1001/jamahealthforum.2021.4543] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022] Open
Abstract
Question What features of health care systems in the US are associated with overuse of health care? Findings In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital. Meaning In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care. Importance Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions. Objective To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery. Design, Setting, and Participants In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018. Exposures We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites. Main Outcomes and Measures Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0. Results There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively. Conclusions and Relevance In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.
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Affiliation(s)
- Jodi B. Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Aditi P. Sen
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Eliana Glanzberg-Krainin
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Susan Hutfless
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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26
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Ries NM, Johnston B, Jansen J. Views of healthcare consumer representatives on defensive practice: 'We are your biggest advocate and supporter… not the enemy'. Health Expect 2021; 25:374-383. [PMID: 34859547 PMCID: PMC8849368 DOI: 10.1111/hex.13395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/01/2021] [Accepted: 11/16/2021] [Indexed: 12/25/2022] Open
Abstract
Background The patient–clinician interaction is a site at which defensive practice could occur, when clinicians provide tests, procedures and treatments mainly to reduce perceived legal risks, rather than to advance patient care. Defensive practice is a driver of low‐value care and exposes patients to the risks of unnecessary interventions. To date, patient perspectives on defensive practice and its impacts on them are largely missing from the literature. This exploratory study conducted in Australia aimed to examine the views and experiences of healthcare consumer representatives in this under‐examined area. Methods Semi‐structured interviews were conducted with healthcare consumer representatives involved in healthcare consumer advocacy organisations in Australia. Data were transcribed and analysed thematically. Results Nine healthcare consumer representatives participated. Most had over 20 years of involvement and advocacy in healthcare, including personal experiences as a patient or carer and/or formal service roles on committees or complaint bodies for healthcare organisations. Participants uniformly viewed defensive practice as having a negative impact on the clinician–patient relationship. Themes identified the importance of fostering patient–clinician partnership, effective communication and informed decision‐making. The themes support a shift from the concept of defensive practice to preventive practice in partnership, which focuses on the shared interests of patients and clinicians in achieving safe and high‐value care. Conclusion This Australian study offers healthcare consumers' perspectives on the impacts of defensive practice on patients. The findings highlight the features of clinician–patient partnership that will help to improve communication and decision‐making, and prevent the defensive provision of low‐value care. Patient or Public Contribution Healthcare consumer representatives were involved as participants in this study.
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Affiliation(s)
- Nola M Ries
- Faculty of Law, Law Health Justice Research Centre, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Briony Johnston
- Faculty of Law, Law Health Justice Research Centre, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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27
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The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016. J Gen Intern Med 2021; 36:3711-3718. [PMID: 33852141 PMCID: PMC8045442 DOI: 10.1007/s11606-021-06784-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/31/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed. OBJECTIVE To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries. DESIGN We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services. SETTING/PARTICIPANTS NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees. MAIN MEASURES We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources. KEY RESULTS During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study. CONCLUSIONS US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.
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Chimonas S, Mamoor M, Zimbalist SA, Barrow B, Bach PB, Korenstein D. Mapping conflict of interests: scoping review. BMJ 2021; 375:e066576. [PMID: 34732464 PMCID: PMC8565086 DOI: 10.1136/bmj-2021-066576] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify all known ties between the medical product industry and the healthcare ecosystem. DESIGN Scoping review. METHODS From initial literature searches and expert input, a map was created to show the network of medical product industry ties across parties and activities in the healthcare ecosystem. Through a scoping review, the ties were then verified, cataloged, and characterized, with data abstracted on types of industry ties (financial, non-financial), applicable policies for conflict of interests, and publicly available data sources. MAIN OUTCOME MEASURES Presence and types of medical product industry ties to activities and parties, presence of policies for conflict of interests, and publicly available data. RESULTS A map derived through synthesis of 538 articles from 37 countries shows an extensive network of medical product industry ties to activities and parties in the healthcare ecosystem. Key activities include research, healthcare education, guideline development, formulary selection, and clinical care. Parties include non-profit entities, the healthcare profession, the market supply chain, and government. The medical product industry has direct ties to all parties and some activities through multiple pathways; direct ties extend through interrelationships among parties and activities. The most frequently identified parties were within the healthcare profession, with individual professionals described in 422 (78%) of the included studies. More than half (303, 56%) of the publications documented medical product industry ties to research, with clinical care (156, 29%), health professional education (145, 27%), guideline development (33, 6%), and formulary selection (8, 1%) appearing less often. Policies for conflict of interests exist for some financial and a few non-financial ties; publicly available data sources seldom describe or quantify these ties. CONCLUSIONS An extensive network of medical product industry ties to activities and parties exists in the healthcare ecosystem. Policies for conflict of interests and publicly available data are lacking, suggesting that enhanced oversight and transparency are needed to protect patient care from commercial influence and to ensure public trust.
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Affiliation(s)
- Susan Chimonas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
| | - Maha Mamoor
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
| | - Sophia A Zimbalist
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
| | - Brooke Barrow
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Peter B Bach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
- Delfi Diagnostics, Baltimore, MD, USA
| | - Deborah Korenstein
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, New York, NY 10017, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Ablordeppey EA, Powell B, McKay V, Keating S, James A, Carpenter C, Kollef M, Griffey R. Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion. BMJ Open Qual 2021; 10:bmjoq-2020-001222. [PMID: 34663588 PMCID: PMC8524291 DOI: 10.1136/bmjoq-2020-001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/02/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Avoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation has slow rate of adoption. This demonstrates a gap that is ripe for the development of an intervention. Methods The intervention is a deimplementation programme called DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) that will be created to address one unnecessary imaging modality in the acute care environment. We propose a three-phase approach to changing low-value practices. In phase 1, we will be guided by the Consolidated Framework for Implementation Research framework to explore barriers and facilitators of POCUS for CVC confirmation in a single centre, large tertiary, academic hospital via focus groups. The qualitative methods will inform the development and adaptation of strategies that address identified determinants of change. In phase 2, the multifaceted strategies will be conceptualised using Morgan’s framework for understanding and reducing medical overuse. In phase 3, we will locally implement these strategies and assess them using Proctor’s outcomes (adoption, deadoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on the programme. Secondary outcomes will include POCUS-guided CVC confirmation efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS confirmation after CVC insertion. With limited data available to inform interventions that use concurrent implementation and deimplementation strategies to substitute chest X-ray for POCUS using the DRAUP programme, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that will expand the knowledge of implementation approaches to replacing low value or unnecessary care in acute care environments. Ethics and dissemination Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means. Trial registration number ClinicalTrials.gov Identifier, NCT04324762, registered on 27 March 2020.
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Affiliation(s)
- Enyo A Ablordeppey
- Department of Anesthesiology and Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Byron Powell
- Brown School at Washington University in St Louis, St Louis, Missouri, USA
| | - Virginia McKay
- Brown School at Washington University in St Louis, St Louis, Missouri, USA
| | - Shannon Keating
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Aimee James
- Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Marin Kollef
- Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Richard Griffey
- Department of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Morgan DJ, Pineles L, Korenstein D. Uncertainty in Medicine-Reply. JAMA Intern Med 2021; 181:1418. [PMID: 34279562 DOI: 10.1001/jamainternmed.2021.3711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore.,Veterans Affairs Maryland Healthcare System, Baltimore
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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Ospina NS, Salloum RG, Maraka S, Brito JP. De-implementing low-value care in endocrinology. Endocrine 2021; 73:292-300. [PMID: 33977312 PMCID: PMC8476071 DOI: 10.1007/s12020-021-02732-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/15/2021] [Indexed: 01/18/2023]
Abstract
Low-value care exposes patients to ineffective, costly, and potentially harmful care. In endocrinology, low-value care practices are common in the care of patients with highly prevalent conditions. There is an urgent need to move past the identification of these practices to an active process of de-implementation. However, clinicians, researchers, and other stakeholders might lack familiarity with the frameworks and processes that can help guide successful de-implementation. To address this gap and support the de-implementation of low-value care, we provide a summary of low-value care practices in endocrinology and a primer on the fundamentals of de-implementation science. Our goal is to increase awareness of low-value care within endocrinology and suggest a path forward for addressing low-value care using principles of de-implementation science.
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Affiliation(s)
- Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, 1600 SW Archer Road, Room H2, Gainesville, FL, 32606, USA.
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road, Room 2243, Gainesville, FL, 32610, USA
| | - Spyridoula Maraka
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, #587, Little Rock, AR, 72205, USA
- Central Arkansas Veterans Healthcare System, 4300W 7th St, #4E-132, Little Rock, AR, 72205, USA
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Scott IA, Elshaug AG, Fox M. Low value care is a health hazard that calls for patient empowerment. Med J Aust 2021; 215:101-103.e1. [PMID: 34275155 DOI: 10.5694/mja2.51168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, Brisbane, QLD.,University of Queensland, Brisbane, QLD
| | - Adam G Elshaug
- Centre for Health Policy, University of Melbourne, Melbourne, VIC
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Morgan DJ, Pineles L, Owczarzak J, Magder L, Scherer L, Brown JP, Pfeiffer C, Terndrup C, Leykum L, Feldstein D, Foy A, Stevens D, Koch C, Masnick M, Weisenberg S, Korenstein D. Clinician Conceptualization of the Benefits of Treatments for Individual Patients. JAMA Netw Open 2021; 4:e2119747. [PMID: 34287630 PMCID: PMC8295738 DOI: 10.1001/jamanetworkopen.2021.19747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Knowing the expected effect of treatment on an individual patient is essential for patient care. OBJECTIVE To explore clinicians' conceptualizations of the chance that treatments will decrease the risk of disease outcomes. DESIGN, SETTING, AND PARTICIPANTS This survey study of attending and resident physicians, nurse practitioners, and physician assistants was conducted in outpatient clinical settings in 8 US states from June 2018 to November 2019. The survey was an in-person, paper, 26-item survey in which clinicians were asked to estimate the probability of adverse disease outcomes and expected effects of therapies for diseases common in primary care. MAIN OUTCOMES AND MEASURES Estimated chance that treatments would benefit an individual patient. RESULTS Of 723 clinicians, 585 (81%) responded, and 542 completed all the questions necessary for analysis, with a median (interquartile range [IQR]) age of 32 (29-44) years, 287 (53%) women, and 294 (54%) White participants. Clinicians consistently overestimated the chance that treatments would benefit an individual patient. The median (IQR) estimated chance that warfarin would prevent a stroke in the next year was 50% (5%-80%) compared with scientific evidence, which indicates an absolute risk reduction (ARR) of 0.2% to 1.0% based on a relative risk reduction (RRR) of 39% to 50%. The median (IQR) estimated chance that antihypertensive therapy would prevent a cardiovascular event within 5 years was 30% (10%-70%) vs evidence of an ARR of 0% to 3% based on an RRR of 0% to 28%. The median (IQR) estimated chance that bisphosphonate therapy would prevent a hip fracture in the next 5 years was 40% (10%-60%) vs evidence of ARR of 0.1% to 0.4% based on an RRR of 20% to 40%. The median (IQR) estimated chance that moderate-intensity statin therapy would prevent a cardiovascular event in the next 5 years was 20% (IQR 5%-50%) vs evidence of an ARR of 0.3% to 2% based on an RRR of 19% to 33%. Estimates of the chance that a treatment would prevent an adverse outcome exceeded estimates of the absolute chance of that outcome for 60% to 70% of clinicians. Clinicians whose overestimations were greater were more likely to report using that treatment for patients in their practice (eg, use of warfarin: correlation coefficient, 0.46; 95% CI, 0.40-0.53; P < .001). CONCLUSIONS AND RELEVANCE In this survey study, clinicians significantly overestimated the benefits of treatment to individual patients. Clinicians with greater overestimates were more likely to report using treatments in actual patients.
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Affiliation(s)
- Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- VA Maryland Healthcare System, Baltimore
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Laura Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Aurora
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Denver, Colorado
| | - Jessica P. Brown
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Chris Pfeiffer
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland
| | - Chris Terndrup
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland
| | - Luci Leykum
- Department of Medicine, Dell Medical School, the University of Texas at Austin
- South Texas Veterans Health Care System, San Antonio
| | - David Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Andrew Foy
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Deborah Stevens
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Christina Koch
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Max Masnick
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
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Morgan DJ, Pineles L, Owczarzak J, Magder L, Scherer L, Brown JP, Pfeiffer C, Terndrup C, Leykum L, Feldstein D, Foy A, Stevens D, Koch C, Masnick M, Weisenberg S, Korenstein D. Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing. JAMA Intern Med 2021; 181:747-755. [PMID: 33818595 PMCID: PMC8022260 DOI: 10.1001/jamainternmed.2021.0269] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Accurate diagnosis is essential to proper patient care. OBJECTIVE To explore practitioner understanding of diagnostic reasoning. DESIGN, SETTING, AND PARTICIPANTS In this survey study, 723 practitioners at outpatient clinics in 8 US states were asked to estimate the probability of disease for 4 scenarios common in primary care (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability from June 1, 2018, to November 26, 2019. Of these practitioners, 585 responded to the survey, and 553 answered all of the questions. An expert panel developed the survey and determined correct responses based on literature review. RESULTS A total of 553 (290 resident physicians, 202 attending physicians, and 61 nurse practitioners and physician assistants) of 723 practitioners (76.5%) fully completed the survey (median age, 32 years; interquartile range, 29-44 years; 293 female [53.0%]; 296 [53.5%] White). Pretest probability was overestimated in all scenarios. Probabilities of disease after positive results were overestimated as follows: pneumonia after positive radiology results, 95% (evidence range, 46%-65%; comparison P < .001); breast cancer after positive mammography results, 50% (evidence range, 3%-9%; P < .001); cardiac ischemia after positive stress test result, 70% (evidence range, 2%-11%; P < .001); and urinary tract infection after positive urine culture result, 80% (evidence range, 0%-8.3%; P < .001). Overestimates of probability of disease with negative results were also observed as follows: pneumonia after negative radiography results, 50% (evidence range, 10%-19%; P < .001); breast cancer after negative mammography results, 5% (evidence range, <0.05%; P < .001); cardiac ischemia after negative stress test result, 5% (evidence range, 0.43%-2.5%; P < .001); and urinary tract infection after negative urine culture result, 5% (evidence range, 0%-0.11%; P < .001). Probability adjustments in response to test results varied from accurate to overestimates of risk by type of test (imputed median positive and negative likelihood ratios [LRs] for practitioners for chest radiography for pneumonia: positive LR, 4.8; evidence, 2.6; negative LR, 0.3; evidence, 0.3; mammography for breast cancer: positive LR, 44.3; evidence range, 13.0-33.0; negative LR, 1.0; evidence range, 0.05-0.24; exercise stress test for cardiac ischemia: positive LR, 21.0; evidence range, 2.0-2.7; negative LR, 0.6; evidence range, 0.5-0.6; urine culture for urinary tract infection: positive LR, 9.0; evidence, 9.0; negative LR, 0.1; evidence, 0.1). CONCLUSIONS AND RELEVANCE This survey study suggests that for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse.
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore.,Veterans Affairs (VA) Maryland Healthcare System, Baltimore
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jill Owczarzak
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Laura Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora.,Division of Cardiology, University of Colorado School of Medicine, Aurora.,Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Denver, Colorado
| | - Jessica P Brown
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Chris Pfeiffer
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland
| | - Chris Terndrup
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland
| | - Luci Leykum
- Department of Medicine, Dell Medical School, the University of Texas at Austin, Austin.,Department of Medicine, South Texas Veterans Health Care System, San Antonio
| | - David Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Andrew Foy
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Deborah Stevens
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Christina Koch
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Max Masnick
- Department of Informatics, Genomic Medicine Institute, Geisinger, Danville, Pennsylvania
| | - Scott Weisenberg
- Division of Infectious Diseases, New York University Grossman School of Medicine, New York
| | - Deborah Korenstein
- Division of General Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Müskens JLJM, Kool RB, van Dulmen SA, Westert GP. Overuse of diagnostic testing in healthcare: a systematic review. BMJ Qual Saf 2021; 31:54-63. [PMID: 33972387 PMCID: PMC8685650 DOI: 10.1136/bmjqs-2020-012576] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Overuse of diagnostic testing substantially contributes to healthcare expenses and potentially exposes patients to unnecessary harm. Our objective was to systematically identify and examine studies that assessed the prevalence of diagnostic testing overuse across healthcare settings to estimate the overall prevalence of low-value diagnostic overtesting. METHODS PubMed, Web of Science and Embase were searched from inception until 18 February 2020 to identify articles published in the English language that examined the prevalence of diagnostic testing overuse using database data. Each of the assessments was categorised as using a patient-indication lens, a patient-population lens or a service lens. RESULTS 118 assessments of diagnostic testing overuse, extracted from 35 studies, were included in this study. Most included assessments used a patient-indication lens (n=67, 57%), followed by the service lens (n=27, 23%) and patient-population lens (n=24, 20%). Prevalence estimates of diagnostic testing overuse ranged from 0.09% to 97.5% (median prevalence of assessments using a patient-indication lens: 11.0%, patient-population lens: 2.0% and service lens: 30.7%). The majority of assessments (n=85) reported overuse of diagnostic testing to be below 25%. Overuse of diagnostic imaging tests was most often assessed (n=96). Among the 33 assessments reporting high levels of overuse (≥25%), preoperative testing (n=7) and imaging for uncomplicated low back pain (n=6) were most frequently examined. For assessments of similar diagnostic tests, major variation in the prevalence of overuse was observed. Differences in the definitions of low-value tests used, their operationalisation and assessment methods likely contributed to this observed variation. CONCLUSION Our findings suggest that substantial overuse of diagnostic testing is present with wide variation in overuse. Preoperative testing and imaging for non-specific low back pain are the most frequently identified low-value diagnostic tests. Uniform definitions and assessments are required in order to obtain a more comprehensive understanding of the magnitude of diagnostic testing overuse.
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Affiliation(s)
- Joris L J M Müskens
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rudolf Bertijn Kool
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Gert P Westert
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Michalsen A, Neitzke G, Dutzmann J, Rogge A, Seidlein AH, Jöbges S, Burchardi H, Hartog C, Nauck F, Salomon F, Duttge G, Michels G, Knochel K, Meier S, Gretenkort P, Janssens U. [Overtreatment in intensive care medicine-recognition, designation, and avoidance : Position paper of the Ethics Section of the DIVI and the Ethics section of the DGIIN]. Med Klin Intensivmed Notfmed 2021; 116:281-294. [PMID: 33646332 PMCID: PMC7919250 DOI: 10.1007/s00063-021-00794-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
Ungeachtet der sozialgesetzlichen Vorgaben existieren im deutschen Gesundheitssystem in der Patientenversorgung nebeneinander Unter‑, Fehl- und Überversorgung. Überversorgung bezeichnet diagnostische und therapeutische Maßnahmen, die nicht angemessen sind, da sie die Lebensdauer oder Lebensqualität der Patienten nicht verbessern, mehr Schaden als Nutzen verursachen und/oder von den Patienten nicht gewollt werden. Daraus können hohe Belastungen für die Patienten, deren Familien, die Behandlungsteams und die Gesellschaft resultieren. Dieses Positionspapier erläutert Ursachen von Überversorgung in der Intensivmedizin und gibt differenzierte Empfehlungen zu ihrer Erkennung und Vermeidung. Zur Erkennung und Vermeidung von Überversorgung in der Intensivmedizin erfordert es Maßnahmen auf der Mikro‑, Meso- und Makroebene, insbesondere die folgenden: 1) regelmäßige Evaluierung des Therapieziels im Behandlungsteam unter Berücksichtigung des Patientenwillens und unter Begleitung von Patienten und Angehörigen; 2) Förderung einer patientenzentrierten Unternehmenskultur im Krankenhaus mit Vorrang einer qualitativ hochwertigen Patientenversorgung; 3) Minimierung von Fehlanreizen im Krankenhausfinanzierungssystem gestützt auf die notwendige Reformierung des fallpauschalbasierten Vergütungssystems; 4) Stärkung der interdisziplinären/interprofessionellen Zusammenarbeit in Aus‑, Fort- und Weiterbildung; 5) Initiierung und Begleitung eines gesellschaftlichen Diskurses zur Überversorgung.
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Affiliation(s)
- Andrej Michalsen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Konstanz, Konstanz, Deutschland
| | - Gerald Neitzke
- Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Jochen Dutzmann
- Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Annette Rogge
- Geschäftsbereichs der Medizinethik, Christian-Albrechts-Universität zu Kiel, Kiel, Deutschland
| | - Anna-Henrikje Seidlein
- Institut für Ethik und Geschichte der Medizin, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - Susanne Jöbges
- Institut für Biomedizinische Ethik und Geschichte der Medizin, Universität Zürich, Zürich, Schweiz
| | | | - Christiane Hartog
- Klinik für Anästhesiologie und Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Deutschland.,Patienten- und Angehörigenzentrierte Versorgung (PAV), Klinik Bavaria, Kreischa, Deutschland
| | - Friedemann Nauck
- Klinik für Palliativmedizin, Georg-August-Universität Göttingen, Göttingen, Deutschland
| | | | - Gunnar Duttge
- Abteilung für strafrechtliches Medizin- und Biorecht, Georg-August-Universität Göttingen, Göttingen, Deutschland
| | - Guido Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital Eschweiler, Eschweiler, Deutschland
| | - Kathrin Knochel
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital Kinderpalliativzentrum, Klinikum der Universität München, München, Deutschland.,Ethik der Medizin und Gesundheitstechnologie, Technische Universität München, München, Deutschland
| | - Stefan Meier
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Peter Gretenkort
- Simulations- und Notfallakademie, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital Eschweiler, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland.
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Augustsson H, Ingvarsson S, Nilsen P, von Thiele Schwarz U, Muli I, Dervish J, Hasson H. Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implement Sci Commun 2021; 2:13. [PMID: 33541443 PMCID: PMC7860215 DOI: 10.1186/s43058-021-00110-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION The review has not been registered.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
| | - Irene Muli
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Jessica Dervish
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
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Dusendang JR, Marwaha S, Alexeeff SE, Herrinton LJ. Presentation of Rash in a Community-Based Health System. Perm J 2021; 24:1-4. [PMID: 33482970 DOI: 10.7812/tpp/20.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Coordination of care between primary care providers and dermatologists is important to ensure high quality and cost efficiency. In our integrated care setting, we used a retrospective cohort study to assess which patients self-refer to dermatology and which returned for a follow-up visit in dermatology. METHODS We identified 107,832 patients with a new rash diagnosis who presented to primary care or dermatology between January and March 2017. We compared patients who self-referred to dermatology with those who used primary care, using multi-level generalized estimating equations with adjustment for patient-level covariables and medical center. We also characterized patients who returned for a follow-up visit in dermatology. RESULTS Among patients with a new rash diagnosis, 99% were originally seen in primary care. Patients with a history of a dermatological condition were more likely to present to dermatology. Patients with a history of a dermatological condition or with psoriasis, pigment, hair, bullous, or multiple conditions were more likely to have a follow-up visit with a dermatologist. For each outcome, initial location of care and return for a follow-up visit, we found minimal clustering by medical center or provider. CONCLUSION One percent of patients with a new rash diagnosis self-refer to dermatology in this setting. Patients with a history of a dermatological condition were more likely to self-refer to dermatology and to have a follow-up visit with a dermatologist. Individual dermatologists and primary care providers had little impact on a patient's odds of returning for a follow-up visit.
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Affiliation(s)
| | - Sangeeta Marwaha
- Dermatology, Kaiser Permanente Northern California, Sacramento, CA
| | - Stacey E Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Lesage A, Leclère B, Moret L, Le Glatin C. Decreasing patient-reported burden of treatment: A systematic review of quantitative interventional studies. PLoS One 2021; 16:e0245112. [PMID: 33434200 PMCID: PMC7802949 DOI: 10.1371/journal.pone.0245112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/22/2020] [Indexed: 11/21/2022] Open
Abstract
Objectives To describe and analyse studies aiming at quantitatively assessing the impact of interventions on patient-reported burden of treatment as an outcome (primary or secondary). Methods The aim of the search strategy was to identify all publications describing a medical intervention intended to reduce patient-reported burden of treatment in adult patients with long-term conditions, from January 1, 2008 to July 15, 2019. Four databases (Medline, PsycINFO, the “Trials” section of the Cochrane-Library, and OpenGrey) were searched in English, French, Spanish, Italian and Portuguese. Each identified article was reviewed and the risk of bias was assessed using a tool adapted from the Cochrane Collaboration recommendations. Results Of 641 articles retrieved, 11 were included in this review. There were nine randomized controlled trials, one non-randomized controlled trial, and one before-and-after study. The sample sizes ranged from 55 to 1,546 patients. Eight out of the eleven studies reported significant positive outcomes of the studied interventions. Reducing dosing frequency, improving background therapy, offering home care or providing easier-to-use medical devices were associated with positive outcomes. Conclusions Only a few studies have specifically focused on decreasing the subjective burden of treatment. Small trials conducted in patients with a single specific disorder have reported positive outcomes. However, a large, high-quality study assessing the impact of a change in care process in patients with multiple morbidities did not show such results. Further studies are needed to implement this aspect of patient-centred care.
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Affiliation(s)
- Aurore Lesage
- Department of Medical Evaluation and Epidemiology, Nantes University Hospital, Nantes, France
| | - Brice Leclère
- Department of Medical Evaluation and Epidemiology, Nantes University Hospital, Nantes, France
- MiHAR Lab, University of Nantes, Nantes, France
| | - Leïla Moret
- Department of Medical Evaluation and Epidemiology, Nantes University Hospital, Nantes, France
- UMR INSERM 1246—MethodS in Patients-Centred Outcomes and HEalth ResEarch (SPHERE), University of Nantes, Nantes, France
| | - Clément Le Glatin
- Department of Medical Evaluation and Epidemiology, Nantes University Hospital, Nantes, France
- * E-mail:
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Natt N, Dekhtyar M, Park YS, Shinkai K, Carney PA, Fancher TL, Lawson L, Leep Hunderfund AN. Promoting Value Through Patient-Centered Communication: A Multisite Validity Study of Third-Year Medical Students. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1900-1907. [PMID: 32459676 DOI: 10.1097/acm.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE To examine validity evidence for a standardized patient scenario assessing medical students' ability to promote value using patient-centered communication (in response to a patient requesting an unnecessary test) and to explore the potential effect of various implementation and curricular factors on student scores. METHOD Third-year medical students (N = 516) from 5 U.S. MD-granting medical schools completed the communication scenario between 2014 and 2017 as part of a larger objective structured clinical examination (OSCE). Centralized raters assessed performance using an 11-item checklist. The authors collected multiple sources of validity evidence. RESULTS The mean checklist score was 0.85 (standard deviation 0.09). Interrater reliability for checklist scores was excellent (0.87, 95% confidence interval = 0.78-0.93). Generalizability and Phi-coefficients were, respectively, 0.65 and 0.57. Scores decreased as the number of OSCE stations increased (r = -0.15, P = .001) and increased when they were used for summative purposes (r = 0.26, P < .001). Scores were not associated with curricular time devoted to high-value care (r = 0.02, P = .67) and decreased when more clerkships were completed before the assessment (r = -0.12, P = .006). CONCLUSIONS This multisite study provides validity evidence supporting the use of scenario scores to assess the ability of medical students to promote value in clinical encounters using patient-centered communication. Findings illuminate the potential effect of OSCE structure and purpose on student performance and suggest clerkship learning experiences may not reinforce what students are taught in the formal curriculum regarding high-value care. Devoting more time to the topic appears insufficient to counteract this erosion.
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Affiliation(s)
- Neena Natt
- N. Natt is associate professor of medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael Dekhtyar
- M. Dekhtyar is former research associate, Medical Education Outcomes, American Medical Association, Chicago, Illinois
| | - Yoon Soo Park
- Y.S. Park is associate professor of medical education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Kanade Shinkai
- K. Shinkai is professor of dermatology, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0003-0384-1158
| | - Patricia A Carney
- P.A. Carney is professor of family medicine, Oregon Health & Science University, Portland, Oregon; ORCID:https://orcid.org/0000-0002-2937-655X
| | - Tonya L Fancher
- T.L. Fancher is professor of medicine, Division of General Medicine, University of California Davis, Sacramento, California; ORCID: https://orcid.org/0000-0001-5486-6123
| | - Luan Lawson
- L. Lawson is associate professor of emergency medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Andrea N Leep Hunderfund
- A.N. Leep Hunderfund is assistant professor of neurology, Mayo Clinic, and associate director, Mayo Clinic Program in Professionalism and Values, Rochester, Minnesota; ORCID: https://orcid.org/0000-0002-7784-504X
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Abstract
Overcoming overuse in musculoskeletal health care requires an understanding of its drivers. In this, the third article in a series on "Overcoming Overuse" of musculoskeletal health care, we consider the drivers of overuse under 4 domains: (1) the culture of health care consumption, (2) patient factors and experiences, (3) clinician factors and experiences, and (4) practice environment. These domains are interrelated, interact, and influence the clinician-patient interaction. We map drivers to potential solutions to overcome overuse. J Orthop Sports Phys Ther 2020;50(12):657-660. doi:10.2519/jospt.2020.0111.
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Oakes AH, Sen AP, Segal JB. The impact of global budget payment reform on systemic overuse in Maryland. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100475. [PMID: 33027725 DOI: 10.1016/j.hjdsi.2020.100475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/13/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Medical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending. OBJECTIVE To assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services. METHODS We conducted a retrospective analysis of deidentified claims for 18-64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011-2013) and after implementation (2014-2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index. RESULTS Global budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of -0.002 points (95%CI, -0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses. CONCLUSIONS We did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care.
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Affiliation(s)
- Allison H Oakes
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA; Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, USA.
| | - Aditi P Sen
- Johns Hopkins University Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Johns Hopkins University Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
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Pezeshki MZ, Janati A, Arab-Zozani M. Medical Overuse in the Iranian Healthcare System: A Systematic Scoping Review and Practical Recommendations for Decreasing Medical Overuse During Unexpected COVID-19 Pandemic Opportunity. Risk Manag Healthc Policy 2020; 13:1103-1110. [PMID: 32848487 PMCID: PMC7429239 DOI: 10.2147/rmhp.s262908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/15/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose To perform an inclusive search for original studies that report medical overuse in the Iranian healthcare system and discovering the area of overuse. Patients and Methods A systematic search of the literature is conducted in bibliographic databases including PubMed, Embase, Scopus, Web of Sciences, Cochrane and Scientific Information Database using a comprehensive search strategy without time limit until the end of 2018, updated by 1 July 2020, accomplished by reference tracking, author contacting and expert consultation to identify studies on the overuse of medical care. Results We reviewed 4124 published articles based on predetermined inclusion criteria. The author’s consensus included a total of 41 articles. Of these, 32 were in English and 9 in Farsi, published between 1975–2019. The result categorized into two distinct clinical areas: treatment (18 articles) and diagnostic (23 articles) services. Almost all of the studies only described the magnitude of unnecessary overuse. Unnecessary overuse of antibiotics, MRI, and CT-scan were the most reported topics. The ranges of their overuse proportion were as follows: antibiotic (31 to 97%); MRI (33 to 88%), and CT-scan (19 to 50%). Conclusion Our review showed, even so, the magnitude of unnecessary overuse of medical services is high but there are only a few interventional studies in clinical and administrative level for finding effective methods for decreasing these unnecessary services. Researchers should be encouraged to conducting interventional studies. We suggest the ministry of health to use the golden opportunity of COVID-19 epidemic for designing Iran national policy and action plan for controlling and preventing unnecessary healthcare services and including a section for “Interventional Research” in the action plan.
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Affiliation(s)
- Mohammad Zakaria Pezeshki
- Social Determinants of Health Research Center, Department of Community and Family Medicine, Tabriz Medical School, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Janati
- Iranian Center of Excellence in Health Management, Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
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Chi KW, Coon ER, Destino L, Schroeder AR. Parental Perspectives on Continuous Pulse Oximetry Use in Bronchiolitis Hospitalizations. Pediatrics 2020; 146:peds.2020-0130. [PMID: 32675334 PMCID: PMC8758278 DOI: 10.1542/peds.2020-0130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Because of the impact of continuous pulse oximetry (CPOX) on the overdiagnosis of hypoxemia in bronchiolitis, the American Academy of Pediatrics and the Choosing Wisely campaign have issued recommendations for intermittent monitoring. Parental preferences for monitoring may impact adoption of these recommendations, but these perspectives are poorly understood. METHODS Using this cross-sectional survey, we explored parental perspectives on CPOX monitoring before discharge and 1 week after bronchiolitis hospitalizations. During the 1-week call, half of the participants were randomly assigned to receive a verbal statement on the potential harms of CPOX to determine if conveying the concept of overdiagnosis can change parental preferences on monitoring frequency. An aggregate variable measuring favorable perceptions of CPOX was created to determine CPOX affinity predictors. RESULTS In-hospital interviews were completed on 357 patients, of which 306 (86%) completed the 1-week follow-up. Although 25% of parents agreed or strongly agreed that hospital monitors made them feel anxious, 98% agreed that the monitors were helpful. Compared to other vital signs, respiratory rate (87%) and oxygen saturation (84%) were commonly rated as "extremely important." Providing an educational statement on CPOX comparatively decreased parental desire for continuous monitoring (40% vs 20%; P < .001). Although there were no significant predictors of CPOX affinity, the effect size of the educational intervention was higher in college-educated parents. CONCLUSIONS Parents find security in CPOX. A brief statement on the potential harms of CPOX use had an impact on stated monitoring preferences. Parental perspectives are important to consider because they may influence the adoption of intermittent monitoring.
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Affiliation(s)
- Kevin W. Chi
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Eric R. Coon
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Lauren Destino
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Alan R. Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Abstract
BACKGROUND Medical care overuse is a significant source of patient harm and wasteful spending. Understanding the drivers of overuse is essential to the design of effective interventions. OBJECTIVE We tested the association between structural factors of the health care delivery system and regional differences systemic overuse. RESEARCH DESIGN We conducted a retrospective analysis of deidentified claims for 18- to 64-year-old adults from the IBM MarketScan Commercial Claims and Encounters Database. We calculated a semiannual Johns Hopkins Overuse Index for each of the 375 Metropolitan Statistical Areas in the United States, from January 2011 to June 2015. We fit an ordinary least squares regression to model the Johns Hopkins Overuse Index as a function of regional characteristics of the health care system, adjusted for confounders and time. RESULTS The supply of regional health care resources was associated with systemic overuse in commercially insured beneficiaries. Regional characteristics associated with systemic overuse included number of physicians per 1000 residents (P=0.001) and higher Medicare malpractice geographic price cost index (P<0.001). Regions with a higher density of primary care physicians (P=0.008) and a higher proportion of hospital-based providers (P=0.016) had less systemic overuse. Differences in hospital and insurer market power were inversely associated with systemic overuse. CONCLUSIONS Systemic overuse is associated with observable, structural characteristics of the regional health care system. These findings suggest that interventions that aim to improve care efficiency via reductions in overuse should focus on the structural drivers of this phenomenon, rather than on the eradication of individual overused procedures.
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Taking Action to Address Medical Overuse: Common Challenges and Facilitators. Am J Med 2020; 133:567-572. [PMID: 32032544 DOI: 10.1016/j.amjmed.2020.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/23/2019] [Accepted: 01/02/2020] [Indexed: 11/24/2022]
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Prusaczyk B, Swindle T, Curran G. Defining and conceptualizing outcomes for de-implementation: key distinctions from implementation outcomes. Implement Sci Commun 2020; 1:43. [PMID: 32885200 PMCID: PMC7427870 DOI: 10.1186/s43058-020-00035-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Increasingly, scholars argue that de-implementation is a distinct concept from implementation; factors contributing to stopping a current practice might be distinct from those that encourage adoption of a new one. One such distinction is related to de-implementation outcomes. We offer preliminary analysis and guidance on de-implementation outcomes, including how they may differ from or overlap with implementation outcomes, how they may be conceptualized and measured, and how they could be measured in different settings such as clinical care vs. community programs. CONCEPTUALIZATION OF OUTCOMES We conceptualize each of the outcomes from Proctor and colleagues' taxonomy of implementation outcomes for de-implementation research. First, we suggest key considerations for researchers assessing de-implementation outcomes, such as considering how the cultural or historical significance to the practice may impact de-implementation success and, as others have stated, the importance of the patient in driving healthcare overuse. Second, we conceptualize de-implementation outcomes, paying attention to a number of factors such as the importance of measuring outcomes not only of the targeted practice but of the de-implementation process as well. Also, the degree to which a practice should be de-implemented must be distinguished, as well as if there are thresholds that certain outcomes must reach before action is taken. We include a number of examples across all outcomes, both from clinical and community settings, to demonstrate the importance of these considerations. We also discuss how the concepts of health disparities, cultural or community relevance, and altruism impact the assessment of de-implementation outcomes. CONCLUSION We conceptualized existing implementation outcomes within the context of de-implementation, noted where there are similarities and differences to implementation research, and recommended a clear distinction between the target for de-implementation and the strategies used to promote de-implementation. This critical analysis can serve as a building block for others working to understand de-implementation processes and de-implement practices in real-world settings.
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Affiliation(s)
- Beth Prusaczyk
- Washington University School of Medicine in St. Louis, 660 S. Euclid Avenue, St. Louis, MO 63110 USA
| | - Taren Swindle
- University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 77205 USA
| | - Geoffrey Curran
- University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 77205 USA
- Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA
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van Bruchem-Visser RL, van Dijk G, Mattace Raso F, de Beaufort I. Requests for futile treatments: what mechanisms play a role? Results of a qualitative study among Dutch physicians. BMJ Open 2020; 10:e035675. [PMID: 32350017 PMCID: PMC7213846 DOI: 10.1136/bmjopen-2019-035675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Overtreatment is increasingly seen as a challenge in clinical practice and can lead to unnecessary interventions, poor healthcare outcomes and increasing costs. However, little is known as to what exactly causes overtreatment. In 2015, the Royal Dutch Medical Association (RDMA) attempted to address this problem and distinguished several mechanisms that were thought to drive overtreatment. In 14 qualitative interviews among Dutch physicians, we investigated which mechanisms played a role in decision-making and whether all mechanisms were considered equally important. DESIGN We asked physicians to present a case from personal experience, in which the patient or family requested continuing treatment against the advice of the physician. PARTICIPANTS Fourteen physicians from five different medical areas agreed to participate. SETTING Interviews were held face-to-face at the workplace of the physician. RESULTS Three closely related mechanisms were mentioned most frequently as drivers of overtreatment, as perceived by the physician: 'death is not a common topic of conversation', ''never give up' is the default attitude in our society' and 'patients' culture and outlook on life influences their perception of death'. The mechanism 'medical view taking priority' was mentioned to be an inhibitor of overtreatment. CONCLUSIONS Of the 15 mechanisms described by the report of the Steering Committee of the RDMA, not all mechanisms were mentioned as driving overtreatment. Three mechanisms were mentioned most as being a driver of overtreatment ('death is not a common topic of conversation'; ''never give up' is the default attitude in our society'' and 'patients' culture and outlook on life influences their perception of death'), some played no role at all, and others were considered to be inhibitors of overtreatment, especially the mechanism 'medical view taking priority'.
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Affiliation(s)
| | - Gert van Dijk
- Medical Ethics and Philosophy of Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Francesco Mattace Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Inez de Beaufort
- Medical Ethics and Philosophy of Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
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Del Giorno R, Ottini A, Greco A, Stefanelli K, Kola F, Clivio L, Ceschi A, Gabutti L. Peer-pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals. Int J Clin Pract 2020; 74:e13448. [PMID: 31750587 PMCID: PMC7065013 DOI: 10.1111/ijcp.13448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/05/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter-hospital monitoring/benchmarking, via peer-pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter-hospital variation. METHODS Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter-hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra-hospital prescription rate. The variance was used to assess inter-hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed. RESULTS A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter-hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by -0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction. CONCLUSIONS Thanks to a multimodal approach based on monitoring-benchmarking, a significant reduction in inter-hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation-based suspicion of overuse, into an occasion to actively review prescription habits.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Andrea Ottini
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Angela Greco
- Quality and Patient Safety ServiceLa Carità HospitalLocarnoSwitzerland
| | - Kevyn Stefanelli
- Department of Social Sciences and EconomicsSapienza University of RomeRomeItaly
| | - Florenc Kola
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
| | - Luca Clivio
- Department of InformaticsEnte Ospedaliero CantonaleBellinzonaSwitzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and ToxicologyInstitute of Pharmacological Sciences of Southern SwitzerlandEnte Ospedaliero CantonaleLuganoSwitzerland
- Department of Clinical Pharmacology and ToxicologyUniversity Hospital ZurichZurichSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
| | - Luca Gabutti
- Department of Internal Medicine and NephrologyRegional Hospital of Bellinzona and ValliBellinzonaSwitzerland
- Institute of BiomedicineUniversity of Southern SwitzerlandLuganoSwitzerland
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Martín-Delgado J, Carrillo I, Mira JJ. [Outcome of complaints by patients due to the refusal of Primary Care Physicians to agree to a treatment request]. J Healthc Qual Res 2020; 35:113-116. [PMID: 32273106 DOI: 10.1016/j.jhqr.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyse the frequency of complaints due to the refusal of Primary Care Physicians to indicate a diagnostic test, treatment, or referral requested by a patient. METHODS Observational, retrospective study was conducted by analysing the complaints filed in a Primary Care Area during the years 2016, 2017, and 2018. RESULTS A total of 378 complaints were included. Of these, 30 (8%) were justified in the refusal by the doctors to a request of the patient (28 addressed to general practitioners and 2 to paediatricians). The most frequent related to the request was for a treatment (18 [60%]) followed by the request for diagnostic tests (9 [30%]). While the total number of claims increased by 151%, the relative weight of the claims for not responding to a patient's request was reduced (2016, 8/70, 11.4%; 2017, 11/132, 8.3%; and 2018, 11/176, 6.3%). No professional liability claims were filed. CONCLUSIONS Complaints for rejecting patient requests increased slightly, but tends to decrease their relative weight when considering the volume of complaints.
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Affiliation(s)
- J Martín-Delgado
- Grupo de Investigación Atenea, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO)-Sant Joan d'Alacant, Alicante, España.
| | - I Carrillo
- Grupo de Investigación Atenea, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO)-Sant Joan d'Alacant, Alicante, España; Departamento de Psicología de la Salud, Universidad Miguel Hernández, Elche, Alicante, España
| | - J J Mira
- Grupo de Investigación Atenea, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO)-Sant Joan d'Alacant, Alicante, España; Departamento de Psicología de la Salud, Universidad Miguel Hernández, Elche, Alicante, España; Departamento de Salud Alicante-Sant Joan d'Alacant, Alicante, España
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