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Dolansky MA, Horvat Davey C, Moore SM. Research and Practice in Quality Improvement and Implementation Science: The Synergy for Change Model. J Nurs Care Qual 2024; 39:199-205. [PMID: 38232232 DOI: 10.1097/ncq.0000000000000760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Nurses play an essential role in the achievement of quality depicted by the Quintuple Aim to improve clinical outcomes, patient experience, equity, provider well-being, and reduction of costs. When quality gaps occur, practice change is required and is facilitated by quality improvement (QI) and implementation science (IS) methods. QI and IS research are required to advance our understanding of the mechanisms that explain how evidence is implemented and improvements are made. PROBLEM Despite past efforts of the evidence-based practice and QI movements, challenges persist in sustaining practice improvements and translating research findings to direct patient care. APPROACH The purpose of this article is to describe the Synergy for Change Model that proposes that both QI and IS research and practice be used to accelerate improvements in health care quality. CONCLUSIONS Recognizing the synergy of QI and IS practice and research will accelerate nursing's contributions to high-quality and safe care.
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Affiliation(s)
- Mary A Dolansky
- Author Affiliations: Hirsh Institute (Dr Dolansky); and Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio (Drs Dolansky, Horvat Davey, and Moore)
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Gutowski KS, Applebaum SA, Thomae BL, Knight KC, Chwa ES, Gosain AK. The Quality and Readability of Online Patient Information on Positional Head Shape Conditions. Cleft Palate Craniofac J 2024; 61:1186-1194. [PMID: 36850070 DOI: 10.1177/10556656231159972] [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: 03/01/2023] Open
Abstract
OBJECTIVE Families increasingly use online resources to acquire medical information about their child's condition with little understanding of the legitimacy of the source of information or of the information itself. We evaluate the quality and readability of online information related to positional head shape conditions and identify unmet needs for healthcare providers to improve online patient education. DESIGN The search terms "flat head baby," "brachycephaly," and "plagiocephaly" were queried on the Google search engine and the first 20 websites for each were reviewed. Included websites were evaluated for quality using the DISCERN Instrument and readability using the Flesch-Kincaid Reading Grade Level (FKGL) and Flesch Reading Ease Score (FRES). Websites were categorized by upload source and results were compared using one-way ANOVA. RESULTS 38 websites met inclusion criteria. There was no significant correlation between DISCERN score and Google search rank between the three search terms. Professional organizations provided websites with the highest mean DISCERN score (56.3) and commercial websites with the lowest score (36.6, P = .003), indicating "good" and "poor" quality content, respectively. Readability assessments showed an overall average FKGL of 9.9 and FRES of 54.4, suggesting "fairly difficult". Hospitals provided the most website results and tended to publish lower quality information, yet are the most readable. CONCLUSIONS High quality websites written at an appropriate reading level for the general public are lacking. A review of online resources for positional head shape conditions can be used to derive recommendations to improve the content of online patient education for pediatric healthcare.
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Affiliation(s)
- Kristof S Gutowski
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Sarah A Applebaum
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Benjamin L Thomae
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Karlee C Knight
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Emily S Chwa
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Arun K Gosain
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
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Chiu AS, Hoxha I, Jensen CB, Saucke MC, Pitt SC. Medical Maximizing Preferences and Beliefs About Cancer Among US Adults. JAMA Netw Open 2024; 7:e2417098. [PMID: 38874925 PMCID: PMC11179133 DOI: 10.1001/jamanetworkopen.2024.17098] [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: 01/23/2024] [Accepted: 04/16/2024] [Indexed: 06/15/2024] Open
Abstract
Importance Medical overutilization contributes to significant health care expenditures and exposes patients to questionably beneficial surgery and unnecessary risk. Objectives To understand public attitudes toward medical utilization and the association of these attitudes with beliefs about cancer. Design, Setting, and Participants In this cross-sectional survey study conducted from August 26 to October 28, 2020, US-based, English-speaking adults were recruited from the general public using Prolific Academic, a research participant platform. Quota-filling was used to obtain a sample demographically representative of the US population. Adults with a personal history of cancer other than nonmelanoma skin cancer were excluded. Statistical analysis was completed in July 2022. Main Outcome and Measures Medical utilization preferences were characterized with the validated, single-item Maximizer-Minimizer Elicitation Question. Participants preferring to take action in medically ambiguous situations (hereafter referred to as "maximizers") were compared with those who leaned toward waiting and seeing (hereafter referred to as "nonmaximizers"). Beliefs and emotions about cancer incidence, survivability, and preventability were assessed using validated measures. Logistic regression modeled factors associated with preferring to maximize medical utilization. Results Of 1131 participants (mean [SD] age, 45 [16] years; 568 women [50.2%]), 287 (25.4%) were classified as maximizers, and 844 (74.6%) were classified as nonmaximizers. Logistic regression revealed that self-reporting very good or excellent health status (compared with good, fair, or poor; odds ratio [OR], 2.01 [95% CI, 1.52-2.65]), Black race (compared with White race; OR, 1.88 [95% CI, 1.22-2.89]), high levels of cancer worry (compared with low levels; OR, 1.62 [95% CI, 1.09-2.42]), and overestimating cancer incidence (compared with accurate estimation or underestimating; OR, 1.58 [95% CI, 1.09-2.28]) were significantly associated with maximizing preferences. Those who believed that they personally had a higher-than-average risk of developing cancer were more likely to be maximizers (23.6% [59 of 250] vs 17.4% [131 of 751]; P = .03); this factor was not significant in regression analyses. Conclusions and Relevance In this survey study of US adults, those with medical maximizing tendencies more often overestimated the incidence of cancer and had higher levels of cancer-related worry. Targeted and personalized education about cancer and its risk factors may help reduce overutilization of oncologic care.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ines Hoxha
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Catherine B Jensen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Surgery, University of Michigan, Ann Arbor
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Susan C Pitt
- Department of Surgery, University of Michigan, Ann Arbor
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Kenseth A, Kantorova D, Seo MK, Aas E, Cairns J, Kerr D, Askautrud H, Jacobsen JE. Is Risk-Stratifying Patients with Colorectal Cancer Using a Deep Learning-Based Prognostic Biomarker Cost-Effective? PHARMACOECONOMICS 2024; 42:679-691. [PMID: 38584239 DOI: 10.1007/s40273-024-01371-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/03/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVES Accurate risk stratification of patients with stage II and III colorectal cancer (CRC) prior to treatment selection enables limited health resources to be efficiently allocated to patients who are likely to benefit from adjuvant chemotherapy. We aimed to investigate the cost-effectiveness of a recently developed deep learning-based prognostic method, Histotyping, from the perspective of the Norwegian healthcare system. METHODS Two partitioned survival models were developed to assess the cost-effectiveness of Histotyping for two treatment cohorts: patients with CRC stage II and III. For each of the two cohorts, Histotyping was used for risk stratification to assign adjuvant chemotherapy and was compared with the standard of care (SOC) (adjuvant chemotherapy to all patients). Health outcomes measured in the model were quality-adjusted life years (QALYs) and life years (LYs) gained. Deterministic and probabilistic sensitivity analyses were performed to determine the impact of uncertainty. Scenario analyses were performed to assess the impact of the parameters with the greatest uncertainty. RESULTS Risk-stratifying patients with CRC stage II and III using Histotyping was dominant (less costly and more effective) compared to SOC. In patients with CRC stage II, the net monetary benefit of Histotyping was 270,934 Norwegian kroners (NOK) (year of valuation is 2021), and the net health benefit of Histotyping was 0.99. In stage III, the net monetary benefit of Histotyping was 195,419 NOK, and the net health benefit of Histotyping was 0.71. CONCLUSIONS Risk-stratifying patients with CRC using Histotyping prior to the administration of adjuvant chemotherapy is likely to be a cost-effective strategy in Norway.
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Affiliation(s)
- Anna Kenseth
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
| | - Dominika Kantorova
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
| | - Mikyung Kelly Seo
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
- Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom.
| | - Eline Aas
- Department of Health Management and Health Economics, Institute of Health and Society,, University of Oslo, Oslo, Norway
| | - John Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - David Kerr
- Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Hanne Askautrud
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
| | - Jørn Evert Jacobsen
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Research and Innovation, Vestfold Hospital Trust, Tønsberg, Norway
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Lim YH, Saberi SA, Kamal K, Jalian HR, Avram M. Retrospective Analysis of US Litigations Involving Dermatologists From 2011 to 2022. Dermatol Surg 2024; 50:518-522. [PMID: 38416806 DOI: 10.1097/dss.0000000000004142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
BACKGROUND Physician malpractice lawsuits are climbing, and the reasons underlying litigation against dermatologists are unclear. OBJECTIVE To determine the reasons patients pursue litigation against dermatologists or dermatology practices. MATERIALS AND METHODS A retrospective analysis of all state and federal cases between 2011 and 2022 was performed after a query using "Dermatology" and "dermatologist" as search terms on 2 national legal data repositories. RESULTS The authors identified a total of 48 (37 state and 11 federal) lawsuits in which a practicing dermatologist or dermatology group practice was the defendant. The most common reason for litigation was unexpected harm (26 cases, 54.2%), followed by diagnostic error (e.g. incorrect or delayed diagnoses) (16 cases, 33.3%). Six cases resulted from the dermatologist failing to communicate important information, such as medication side effects or obtaining informed consent. Male dermatologists were sued at a rate 3.1 times higher than female dermatologists. CONCLUSION Although lawsuits from patients against dermatologists largely involve injury from elective procedures, clinicians should practice caution regarding missed diagnoses and ensure critical information is shared with patients to safeguard against easily avoidable litigation.
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Affiliation(s)
- Young H Lim
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | - Mathew Avram
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
- Dermatology Laser and Cosmetic Center, Massachusetts General Hospital, Boston, Massachusetts
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Raudasoja A, Tikkinen KAO, Bellini B, Ben-Sheleg E, Ellen ME, Francesconi P, Hussien M, Kaji Y, Karlafti E, Koizumi S, Ouahrani E, Paier-Abuzahra M, Savopoulos C, Spary-Kainz U, Komulainen J, Sipilä R. Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey. BMC PRIMARY CARE 2024; 25:159. [PMID: 38724909 PMCID: PMC11084097 DOI: 10.1186/s12875-024-02382-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/11/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. METHODS Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. RESULTS Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. CONCLUSIONS More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.
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Affiliation(s)
- Aleksi Raudasoja
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Eliana Ben-Sheleg
- Department of Epidemiology, Biostatistics and Community Health Sciences, University of the Negev, Be'er Sheva, Israel
- Israel Implementation Science and Policy Engagement Centre (IS-PEC), Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Moriah E Ellen
- Department of Health Policy and Management, and Israel Implementation Science and Policy Engagement Centre (IS-PEC), Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Muaad Hussien
- Department of Medicine, Mälarsjukhuset Hospital, Eskilstuna, Sweden
| | - Yuki Kaji
- Department of General Medicine, Division of Behavioral Sciences, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Eleni Karlafti
- Emergency Department, and 1st Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Shunzo Koizumi
- Shichijo Clinic, Saga Medical School, Kyoto, Saga, Japan
| | - Emir Ouahrani
- Department of geriatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Muna Paier-Abuzahra
- Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
| | - Christos Savopoulos
- 1st Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ulrike Spary-Kainz
- Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
| | | | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
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Wang W, Blackburn K, Lantz R. Counting the Cost of Pins and Needles: A Case Study of Paresthesias and the Cost of Healthcare in the United States. Cureus 2024; 16:e59302. [PMID: 38813296 PMCID: PMC11136470 DOI: 10.7759/cureus.59302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2024] [Indexed: 05/31/2024] Open
Abstract
Healthcare costs in the United States (US) exceed those of comparable nations without yielding better outcomes. Factors contributing to this include lack of cost transparency, limited outpatient resources due to primary care provider shortages, and high patient volumes, where patients are not educated on differentials and the stepwise process of workup. Addressing these issues could curb unnecessary hospitalizations and expenses. A 31-year-old woman with hypertension, alcohol use, anemia, and obesity experienced paresthesias in September 2022. At her first visit, the exam was consistent with decreased bilateral plantar sensation; however, there was no weakness or gait abnormality. This was not consistent with a focal neurologic distribution. Despite multiple ER visits, her condition persisted. Initial evaluations included potassium replacement ($80 for labs, $13 for tablet), nonacute head CT ($1500), and benign CT L-spine ($2500). Subsequent hospitalization led to brain MRI/MRA head/neck ($6700) and serum workup ($240), revealing deficiencies in vitamin D, folate, and B12. Treatment involved prednisone taper ($30) and supplemental vitamins ($35), with lifestyle recommendations ($0). After evaluating CompuNet lab costs and equivalent market imaging prices, potential savings exceeding $15,000 were identified through more focused and cost-conscious initial testing including vitamin studies and outpatient management, reducing hospitalizations and imaging expenses. Rising healthcare costs in the US are driven by various factors, yet fail to correlate with improved outcomes. Our case argues that enhancing access to primary care, promoting cost transparency, and educating patients on healthcare decisions are crucial for mitigating excessive spending.
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Affiliation(s)
- Weilong Wang
- Internal Medicine, Wright State University, Dayton, USA
| | - Kayla Blackburn
- College of Medicine, Boonshoft School of Medicine, Wright State University, Dayton, USA
| | - Rebekah Lantz
- Internal Medicine, Miami Valley Hospital, Dayton, USA
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Ellen M, Correia L, Levinson W. Choosing wisely 10 years later: reflection and looking ahead. BMJ Evid Based Med 2024; 29:10-13. [PMID: 37479242 DOI: 10.1136/bmjebm-2023-112266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Luis Correia
- Department of Internal Medicine, Center for Evidence-Based Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Hery D, Schwarte B, Patel K, Elliott JO, Vasko S. Plastic Surgery Tourism: Complications, Costs, and Unnecessary Spending? Aesthet Surg J Open Forum 2023; 6:ojad113. [PMID: 38213470 PMCID: PMC10783483 DOI: 10.1093/asjof/ojad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Background The liability of plastic surgery tourism in patient health and postoperative resource allocation is significant. Procedures completed within the context of medical tourism often lack rigorous quality assurance and provide limited preoperative evaluation or postoperative care. Not only does this jeopardize the patient's well-being, but it also increases the financial burden and redirects invaluable resources domestically through often unnecessary diagnostic tests and hospitalizations. Objectives This manuscript will examine the complications and associated costs following plastic surgery tourism and highlight unnecessary expenses for patients with outpatient complications. Methods A retrospective review was conducted of all patients 18 years or older who underwent destination surgery and were seen within 1 year postoperatively in consultation with plastic surgery at our health system between January 11, 2015 and January 7, 2022. Patient admissions were reviewed and deemed necessary or unnecessary after review by 2 physicians. Results The inclusion criteria were met by 41 patients, of whom hospitalization was deemed necessary in 28 patients vs unnecessary in 13 patients. The most common procedures included abdominoplasty, liposuction, breast augmentation, and "Brazilian butt lift." The most common complications were seroma and infection. Patients deemed to have a necessary admission often required at least 1 operation, were more likely to need intravenous antibiotics, were less likely to have the diagnosis of "pain," necessitated a longer hospitalization, and incurred a higher cost. The total financial burden was $523,272 for all 41 patients. Conclusions Plastic surgery tourism poses substantial health risks, the morbidities are expensive, and it strains hospital resources. Level of Evidence 5
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Affiliation(s)
- Danielle Hery
- Corresponding Author: Dr Danielle Hery, OhioHealth Riverside Methodist Hospital, 3535 Olentangy River Rd, Columbus, OH 43214, USA. E-mail:
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Semenova K, Lee W, Shah S, Shah S, Chandan VS. Cost benefit analysis and pathology review of ileostomy and colostomy specimens processed over a 20-year period. Hum Pathol 2023; 141:1-5. [PMID: 37579979 DOI: 10.1016/j.humpath.2023.08.002] [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: 06/16/2023] [Revised: 08/05/2023] [Accepted: 08/10/2023] [Indexed: 08/16/2023]
Abstract
Rising healthcare costs have been linked to overtreatment and overuse of available resources. Identifying and eliminating low-value services is vital for reducing such costs. At many institutions, including ours, all ileostomy and colostomy specimens are sent for pathological evaluation. It is estimated that approximately 120,000 ileostomy/colostomy procedures are done every year, and at least 1 million patients have stomas at any given time in North America. Hence, we decided to analyze the pathological findings and cost-benefit of undertaking the pathological evaluation of these colostomy and ileostomy specimens. The pathology database of our department was searched for all ileostomy and colostomy specimens received between 2000 and 2020, resulting in a total of 2762 cases (1944 ileostomy and 818 colostomy). We performed a cost-benefit analysis and pathologic review of these cases. The results of our study show that 99.38% of these specimens did not show any significant pathological abnormality, and non-neoplastic pathologic findings accounted for 99.63% of cases. Less than 1% of our cases showed any clinically significant pathological findings. All 10 cases that showed a neoplastic or malignant diagnosis showed some abnormal finding that was appreciated at the time of gross examination. We conclude that microscopic evaluation of ileostomy and colostomy specimens incurs significant costs and provides no clear value or relevant information for patient care. The results of our study provide support for ileostomy and colostomy specimens to be triaged by gross-only pathological examination in the first instance for the vast majority of cases.
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Affiliation(s)
- Kapitolina Semenova
- Department of Pathology and Laboratory Medicine, University of California Irvine, CA, 92868 USA
| | - Whayoung Lee
- Department of Pathology and Laboratory Medicine, University of California Irvine, CA, 92868 USA
| | - Sameer Shah
- California University of Science and Medicine, Colton, CA, 92324 USA
| | - Sejal Shah
- Department of Pathology and Laboratory Medicine, University of California Irvine, CA, 92868 USA
| | - Vishal S Chandan
- Department of Pathology and Laboratory Medicine, University of California Irvine, CA, 92868 USA.
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Sacks GD, Shin P, Braithwaite RS, Soares KC, Kingham TP, D'Angelica MI, Drebin JA, Jarnagin WR, Wei AC. The Influence of Patient Preference on Surgeons' Treatment Recommendations in the Management of Intraductal Papillary Mucinous Neoplasms. Ann Surg 2023; 278:e1068-e1072. [PMID: 36804447 DOI: 10.1097/sla.0000000000005829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasms (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. BACKGROUND Surgeons vary widely in management of IPMN. METHODS We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. RESULTS One hundred and fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20%-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs. 5%) more likely to recommend resection than those who were below the median (95% CI: 11.34%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs. 15.0, P =0.06; V2: 7.0 vs. 15.0, P =0.05). CONCLUSIONS The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.
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Affiliation(s)
- Greg D Sacks
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
- VA New York Harbor Healthcare System, New York, NY
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Shin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Jeffrey A Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Alice C Wei
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
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Alaeddin N, Jongejan RMS, Stingl JC, de Rijke YB, Peeters RP, Breteler MMB, de Vries FM. Over- and Undertreatment With Levothyroxine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:711-718. [PMID: 37656481 DOI: 10.3238/arztebl.m2023.0192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Levothyroxine is a very commonly prescribed drug, and treatment with it is often insufficient or excessive. Nonetheless, there have been only a few reports on the determinants of inadequate levothyroxine treatment. METHODS Data from 2938 participants in the population-based Rhineland Study were analyzed. Putative determinants of inadequate levothyroxine treatment (overtreatment, thyrotropin level <0.56 mU/L; undertreatment, thyrotropin level >4.27 mU/L) were studied with logistic regression. The determinants of the levothyroxine dose were assessed with linear regression. RESULTS Overall, 23% of the participants (n = 662) stated that they were taking levothyroxine. Among these participants, 18% were overtreated and 4% were undertreated. Individuals over 70 years of age and above were four times as likely to be overtreated (OR = 4.05, 95% CI [1.20; 13.72]). Each rise in the levothyroxine dose by 25 μg was associated with an increased risk of overtreatment (OR = 1.02, 95% CI [1.02; 1.03]) and of undertreatment (OR = 1.02, 95% CI [1.00; 1.03]). Well-controlled participants (normal thyrotropin levels 0.56-4.27 mU/L) received a lower levothyroxine dose (1.04 ± 0.5 μg/kg/d) than overtreated (1.40 ±0.5 μg/kg/d) or undertreated (1.37 ±0.5 μg/kg/d) participants. No association was found between sociodemographic factors or comorbidities and the levothyroxine dose. Iodine supplementation was associated with a lower daily dose (β = -0.19, 95% CI [-0.28; -0.10]), while three years or more of levothyroxine exposure was associated with a higher daily dose (β = 0.24, 95% CI [0.07; 0.41]). CONCLUSION Levothyroxine intake was high in our sample, and suboptimal despite monitoring. Our findings underscore the need for careful dosing and for due consideration of deintensification of treatment where appropriate.
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Affiliation(s)
- Nersi Alaeddin
- Population Health Sciences, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany; Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Institute of Clinical Pharmacology, Faculty of Medicine, RWTH Aachen, Germany; Academic Centre for Thyroid Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), Faculty of Medicine, University of Bonn, Bonn, Germany
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Derakhshan Z, Larijani B, Shamsi-Gooshki E, Salari P. Presenting a Comprehensive Definition of Unnecessary Healthcare Services and Their Drivers: A Systematic Review and Meta-synthesis. Med J Islam Repub Iran 2023; 37:106. [PMID: 38021385 PMCID: PMC10657265 DOI: 10.47176/mjiri.37.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Indexed: 12/01/2023] Open
Abstract
Background Providing unnecessary healthcare services is a major common problem in every health system. The scope and cause of healthcare services must be identified in order to be managed and controlled. Finding the most complete definition of the problem and its causes are the goals of this meta-synthesis. Methods A comprehensive search strategy was performed using a wide range of keywords and databases. Based on the defined inclusion and exclusion criteria, 22 articles were selected for content analysis and meta-synthesis. The Graneheim and Lundman method was used for content analysis. The MAXQDA software Version 18.2.0 was used for the first round of content analysis. Content analysis and meta-synthesis were used to comprehensively define the term "unnecessary healthcare services" and find the etiologic factors driving healthcare providers to unnecessary healthcare services. Results The term "unnecessary healthcare services" is defined as "overproviding healthcare services that could be harmful, low-value, insufficient, and inappropriate." The etiologic pattern of unnecessary healthcare services shows intrinsic and extrinsic factors as a driving force for unnecessary healthcare services. Conclusion A multilayer strategy for efficient management and prevention of unnecessary healthcare services is appropriate due to the multifaceted character of these services. This approach consists of the modification of the intrinsic factors and extrinsic drivers.
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Affiliation(s)
- Zeinab Derakhshan
- Medical Ethics and History of Medicine Research Center, and Department of
Medical Ethics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism
Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Shamsi-Gooshki
- Medical Ethics and History of Medicine Research Center, and Department of
Medical Ethics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Pooneh Salari
- Medical Ethics and History of Medicine Research Center, Tehran University of
Medical Sciences, Tehran, Iran
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Suesserman M, Gorny S, Lasaga D, Helms J, Olson D, Bowen E, Bhattacharya S. Procedure code overutilization detection from healthcare claims using unsupervised deep learning methods. BMC Med Inform Decis Mak 2023; 23:196. [PMID: 37770866 PMCID: PMC10536726 DOI: 10.1186/s12911-023-02268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 08/17/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Fraud, Waste, and Abuse (FWA) in medical claims have a negative impact on the quality and cost of healthcare. A major component of FWA in claims is procedure code overutilization, where one or more prescribed procedures may not be relevant to a given diagnosis and patient profile, resulting in unnecessary and unwarranted treatments and medical payments. This study aims to identify such unwarranted procedures from millions of healthcare claims. In the absence of labeled examples of unwarranted procedures, the study focused on the application of unsupervised machine learning techniques. METHODS Experiments were conducted with deep autoencoders to find claims containing anomalous procedure codes indicative of FWA, and were compared against a baseline density-based clustering model. Diagnoses, procedures, and demographic data associated with healthcare claims were used as features for the models. A dataset of one hundred thousand claims sampled from a larger claims database is used to initially train and tune the models, followed by experimentations on a dataset with thirty-three million claims. Experimental results show that the autoencoder model, when trained with a novel feature-weighted loss function, outperforms the density-based clustering approach in finding potential outlier procedure codes. RESULTS Given the unsupervised nature of our experiments, model performance was evaluated using a synthetic outlier test dataset, and a manually annotated outlier test dataset. Precision, recall and F1-scores on the synthetic outlier test dataset for the autoencoder model trained on one hundred thousand claims were 0.87, 1.0 and 0.93, respectively, while the results for these metrics on the manually annotated outlier test dataset were 0.36, 0.86 and 0.51, respectively. The model performance on the manually annotated outlier test dataset improved further when trained on the larger thirty-three million claims dataset with precision, recall and F1-scores of 0.48, 0.90 and 0.63, respectively. CONCLUSIONS This study demonstrates the feasibility of leveraging unsupervised, deep-learning methods to identify potential procedure overutilization from healthcare claims.
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Affiliation(s)
| | - Samantha Gorny
- Program Integrity, Deloitte & Touche LLP, New York, NY, USA
| | - Daniel Lasaga
- Program Integrity, Deloitte & Touche LLP, New York, NY, USA
| | - John Helms
- AI Center of Excellence, Deloitte & Touche LLP, New York, NY, USA
| | - Dan Olson
- Program Integrity, Deloitte & Touche LLP, New York, NY, USA
| | - Edward Bowen
- AI Center of Excellence, Deloitte & Touche LLP, New York, NY, USA
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Lang E, Nożewski J. Why we all need Choosing Wisely? Intern Emerg Med 2023; 18:1613-1616. [PMID: 37477819 DOI: 10.1007/s11739-023-03356-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Eddy Lang
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jakub Nożewski
- Department of Emergency Medicine, John Biziel's Clinical Hospital No 2, Street: Ujejskiego 75, 85-168, Bydgoszcz, Poland.
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Muluk SL, Lin GA, Anderson TS. Association of Device Industry Payments, Physician Supply, and Regional Utilization of Orthopedic and Cardiac Procedures. J Gen Intern Med 2023; 38:2501-2510. [PMID: 36952081 PMCID: PMC10465424 DOI: 10.1007/s11606-023-08101-x] [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: 10/02/2022] [Accepted: 02/09/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Geographic variation in high-cost medical procedure utilization in the USA is not fully explained by patient factors but may be influenced by the supply of procedural physicians and marketing payments. OBJECTIVE To examine the association between physician supply, medical device-related marketing payments to physicians, and utilization of knee arthroplasty (KA) and percutaneous coronary interventions (PCI) within hospital referral regions (HRRs). DESIGN Cross-sectional analysis of data from the 2018 CMS Open Payments database and procedural utilization data from the CMS Provider Utilization and Payment database. PARTICIPANTS Medicare-participating procedural cardiologists and orthopedic surgeons. MAIN MEASURES Regional rates of PCIs and KAs per 100,000 Medicare fee-for-service (FFS) beneficiaries were estimated after adjustment for beneficiary demographics. KEY RESULTS Across 306 HRRs, there were 109,301 payments (value $17,554,728) to cardiologists for cardiac stents and 68,132 payments (value $40,492,126) to orthopedic surgeons for prosthetic knees. Among HRRs, one additional interventional cardiologist was associated with an increase of 12.9 (CI, 9.3-16.5) PCIs per 100,000 beneficiaries, and one additional orthopedic surgeon was associated with an increase of 20.6 (CI, 16.9-24.4) KAs per 100,000 beneficiaries. A $10,000 increase in gift payments from stent manufacturers was associated with an increase of 26.0 (CI, 5.1-46.9) PCIs per 100,000 beneficiaries, while total and service payments were not associated with greater regional PCI utilization. A $10,000 increase in total payments from knee prosthetic manufacturers was associated with an increase of 2.9 (CI, 1.4-4.5) KAs per 100,000 beneficiaries, while a similar increase in gift and service payments was associated with an increase of 14.5 (CI, 5.0-24.1) and 3.4 (CI, 1.6-5.2) KAs, respectively. CONCLUSIONS Among Medicare FFS beneficiaries, regional supply of physicians and receipt of industry payments were associated with greater use of PCIs and KAs. Relationships between payments and procedural utilization were more consistent for KAs, a largely elective procedure, compared to PCIs, which may be elective or emergent.
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Affiliation(s)
- Sruthi L Muluk
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Grace A Lin
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline, MA, USA.
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Long V, Chen Z, Du R, Chan YH, Yew YW, Oon HH, Thng S, Lim NQBI, Tan C, Chandran NS, Valderas JM, Phan P, Choi E. Understanding Discordant Perceptions of Disease Severity Between Physicians and Patients With Eczema and Psoriasis Using Structural Equation Modeling. JAMA Dermatol 2023; 159:811-819. [PMID: 37436741 PMCID: PMC10339220 DOI: 10.1001/jamadermatol.2023.2008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/12/2023] [Indexed: 07/13/2023]
Abstract
Importance Patients and physicians often have differing opinions on the patient's disease severity. This phenomenon, termed discordant severity grading (DSG), hinders the patient-physician relationship and is a source of frustration. Objective To test and validate a model explaining the cognitive, behavioral, and disease factors associated with DSG. Design, Setting, and Participants A qualitative study was first performed to derive a theoretical model. In this subsequent prospective cross-sectional quantitative study, the qualitatively derived theoretical model was validated using structural equation modeling (SEM). Recruitment was conducted between October 2021 and September 2022. This was a multicenter study in 3 Singapore outpatient tertiary dermatological centers. Dermatology patients and their attending physicians were recruited by convenience sampling. Patients were aged 18 to 99 years with psoriasis or eczema of at least 3 months' duration and recruited only once. The data were analyzed between October 2022 to May 2023. Main Outcomes and Measures The outcome was the difference between global disease severity (0-10 numerical rating scale with a higher score indicating greater severity) as independently scored by the patient and the dermatologist. Positive discordance was defined as patient-graded severity more than 2 points higher (graded more severely) than physicians, and negative discordance if more than 2 points lower than physicians. Confirmatory factor analysis followed by SEM was used to assess the associations between preidentified patient, physician, and disease factors with the difference in severity grading. Results Of the 1053 patients (mean [SD] age, 43.5 [17.5] years), a total of 579 (55.0%) patients were male, 802 (76.2%) had eczema, and 251 (23.8%) had psoriasis. Of 44 physicians recruited, 20 (45.5%) were male, 24 (54.5%) were aged between 31 and 40 years, 20 were senior residents or fellows, and 14 were consultants or attending physicians. The median (IQR) number of patients recruited per physician was 5 (2-18) patients. Of 1053 patient-physician pairs, 487 pairs (46.3%) demonstrated discordance (positive, 447 [42.4%]; negative, 40 [3.8%]). Agreement between patient and physician rating was poor (intraclass correlation, 0.27). The SEM analyses showed that positive discordance was associated with higher symptom expression (standardized coefficient B = 0.12; P = .02) and greater quality-of-life impairment (B = 0.31; P < .001), but not patient or physician demographics. A higher quality-of-life impairment was in turn associated with lower resilience and stability (B = -0.23; P < .001), increased negative social comparisons (B = 0.45; P < .001), lower self-efficacy (B = -0.11; P = .02), increased disease cyclicity (B = 0.47; P < .001), and greater expectation of chronicity (B = 0.18; P < .001). The model was well-fitted (Tucker-Lewis: 0.94; Root Mean Square Error of Approximation: 0.034). Conclusions and Relevance This cross-sectional study identified various modifiable contributory factors to DSG, increased understanding of the phenomenon, and set a framework for targeted interventions to bridge this discordance.
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Affiliation(s)
- Valencia Long
- Division of Dermatology, Department of Medicine, National University Healthcare System, Singapore
| | - Zhaojin Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ruochen Du
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yik Weng Yew
- Dermatology, National Skin Centre, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Steven Thng
- Dermatology, National Skin Centre, Singapore
| | | | - Chris Tan
- Division of Dermatology, Department of Medicine, National University Healthcare System, Singapore
| | - Nisha Suyien Chandran
- Division of Dermatology, Department of Medicine, National University Healthcare System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jose M. Valderas
- Centre for Research in Health System Performance, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Family Medicine, National University Healthcare System, Singapore
| | - Phillip Phan
- Carey Business School, Johns Hopkins University, Baltimore, Maryland
| | - Ellie Choi
- Division of Dermatology, Department of Medicine, National University Healthcare System, Singapore
- Centre for Research in Health System Performance, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Jang JS, Jung HW. Examining the factors associated with inpatients' perception of overtreatment in Korea: a cross-sectional study. BMC Health Serv Res 2023; 23:633. [PMID: 37316854 DOI: 10.1186/s12913-023-09563-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/16/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Patients' perception of receiving overtreatment can cause distrust in medical services. Unlike outpatients, inpatients are highly likely to receive many medical services without fully understanding their medical situation. This information asymmetry could prompt inpatients to perceive treatment as excessive. This study tested the hypothesis that there are systematic patterns in inpatients' perceptions of overtreatment. METHODS We examined determinant factors of inpatients' perception of overtreatment in a cross-sectional design that used data from the 2017 Korean Health Panel (KHP), a nationally representative survey. For sensitivity analysis, the concept of overtreatment was analyzed by dividing it into a broad meaning (any overtreatment) and a narrow meaning (strict overtreatment). We performed chi-square for descriptive statistics, and multivariate logistic regression with sampling weights employing Andersen's behavioral model. RESULTS There were 1,742 inpatients from the KHP data set that were included in the analysis. Among them, 347 (19.9%) reported any overtreatment and 77 (4.42%) reported strict overtreatment. Furthermore, we found that the inpatient's perception of overtreatment was associated with gender, marital status, income level, chronic disease, subjective health status, health recovery, and general tertiary hospital. CONCLUSION Medical institutions should understand factors that contribute to inpatients' perception of overtreatment to mitigate patients' complaints due to information asymmetry. Moreover, based on the result of this study, government agencies, such as the Health Insurance Review and Assessment Service, should create policy-based controls and evaluate overtreatment behavior of the medical providers and intervene in the miscommunication between patients and providers.
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Affiliation(s)
- Jin Su Jang
- Human Behavior & Genetic Institute, Associate Research Center, Korea University, Seoul, Republic of Korea
| | - Hyun Woo Jung
- Department of Health Administration, Graduate School BK21 - Graduate Program of Developing Global Experts in Health Policy and Management, Yonsei University, Wonju, Korea.
- Division of Health Administration, College of Software and Digital Healthcare Convergence, Yonsei University, Yeonsedae-gil 1, Heungeop-myeon, Wonju-si, 26493, Gangwon-do, Republic of Korea.
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Viriyathorn S, Witthayapipopsakul W, Kulthanmanusorn A, Rittimanomai S, Khuntha S, Patcharanarumol W, Tangcharoensathien V. Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review. Health Serv Insights 2023; 16:11786329231178766. [PMID: 37325777 PMCID: PMC10262611 DOI: 10.1177/11786329231178766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/11/2023] [Indexed: 06/17/2023] Open
Abstract
Background Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients. Methods A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied. Results In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist. Conclusion Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.
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Affiliation(s)
- Shaheda Viriyathorn
- International Health Policy Program (IHPP), Ministry of Public Health, Nonthaburi, Thailand
| | | | - Anond Kulthanmanusorn
- International Health Policy Program (IHPP), Ministry of Public Health, Nonthaburi, Thailand
| | - Salisa Rittimanomai
- International Health Policy Program (IHPP), Ministry of Public Health, Nonthaburi, Thailand
| | - Sarayuth Khuntha
- Mahidol University Health Technology Assessment Program (MUHTA), Bangkok, Thailand
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Abstract
BACKGROUND Recent literature suggests that initial observation of pediatric trigger thumb without early surgical interventions can lead to spontaneous resolution. We sought to analyze current trends in the management of pediatric trigger thumb and compare real-world data with what the literature supports. METHODS We conducted a retrospective study of data collected using the PearlDiver database between 2015 and 2018. Patients who were aged younger than 10 years with a diagnosis of trigger thumb were identified using International Classification of Diseases codes. Current Procedural Terminology codes were used to identify patients who had an operation for trigger thumb. Patient demographics, comorbidities, utilization of hand therapy, and treatment cost were also collected. RESULT Of the 997 patients included in the study, 69% were diagnosed with trigger thumb between the age of 2 and 5 years. In all, 492 patients (49%) had surgery for trigger thumb: 65% of patients had surgery within 1 year of diagnosis, and 76% patients had surgery before the age of 5 years. This treatment pattern was similar across multiple regions of the United States, and there were no significant predictors for surgery. The average cost of treating patients without surgery was $593/patient, whereas that for patients with surgery was $1363/patient. CONCLUSIONS Nationwide data show that pediatric trigger thumb may be managed surgically at higher frequencies and in patients at younger ages than supported by the existing literature. Possible overtreatment is not only detrimental to patients but also burdens the health care system with unnecessary cost.
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Safa N, Yanchar N, Puligandla P, Sewitch M, Baird R, Beaunoyer M, Campbell N, Chadha R, Griffiths C, Jones S, Kaur M, Le-Nguyen A, Nasr A, Piché N, Piper H, Prasil P, Romao RLP, VanHouwelingen L, Wales P, Guadagno E, Emil S. Treatment and Outcomes of Congenital Ovarian Cysts A Study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS). Ann Surg 2023; 277:e1130-e1137. [PMID: 35166261 PMCID: PMC10082055 DOI: 10.1097/sla.0000000000005409] [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: 11/25/2022]
Abstract
OBJECTIVE We conducted a multicenter study to assess treatments and outcomes in a national cohort of infants with congenital ovarian cysts. SUMMARY BACKGROUND DATA Wide variability exists in the treatment of congenital ovarian cysts. The effects of various treatment strategies on outcomes, specifically ovarian preservation, are not known. METHODS Female infants diagnosed with congenital intra-abdominal cysts between 2013 and 2017 at 10 Canadian pediatric surgical centers were retrospectively evaluated. Sonographic characteristics, median time to cyst resolution, incidence of ovarian preservation, and predictors of surgery were evaluated. Subgroup analyses were performed in patients with complex cysts and cysts ≥40 mm in diameter. RESULTS The study population included 189 neonates. Median gestational age at diagnosis and median maximal prenatal cyst diameter were 33 weeks and 40 mm, respectively. Cysts resolved spontaneously in 117 patients (62%), 14 (7%) prenatally, and the remainder at a median age of 124 days. Intervention occurred in 61 patients (32%), including prenatal aspiration (2, 3%), ovary sparing resection (14, 23%), or oophorectomy (45, 74%). Surgery occurred at a median age of 7.4weeks. Independent predictors of surgery included postnatal cyst diameter ≥40 mm [odds ratio (OR) 6.19, 95% confidence interval (CI) 1.66-35.9] and sonographic complex cyst character (OR 63.6, 95% CI 10.9-1232). There was no significant difference in the odds of ovarian preservation (OR 3.06, 95% CI 0.86 -13.2) between patients who underwent early surgery (n = 22) and those initially observed for at least 3 months (n = 131). CONCLUSIONS Most congenital ovarian cysts are asymptomatic and spontaneously resolve. Early surgical intervention does not increase ovarian preservation.
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Affiliation(s)
- Nadia Safa
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Natalie Yanchar
- Division of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Pramod Puligandla
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Maida Sewitch
- Division of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Robert Baird
- Division of Pediatric Surgery Children's Hospital of British Columbia, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mona Beaunoyer
- Divisions of Pediatric Surgery and Pediatric Urology, IWK Health Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Niamh Campbell
- Division of Pediatric Surgery, Center Hospitalier Universitaire Sainte-Justine Universite de Montreal, Montreal, Quebec, Canada
| | - Rati Chadha
- Division of Maternal Fetal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Griffiths
- Division of Pediatric Surgery, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Jones
- Division of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Manvinder Kaur
- Division of Pediatric Surgery, Children's Hospital London Health Sciences Center, Western University, London, Ontario, Canada
| | - Annie Le-Nguyen
- Divisions of Pediatric Surgery and Pediatric Urology, IWK Health Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ahmed Nasr
- Division of Pediatric Surgery, Children's Hospital London Health Sciences Center, Western University, London, Ontario, Canada
| | - Nelson Piché
- Divisions of Pediatric Surgery and Pediatric Urology, IWK Health Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hannah Piper
- Division of Pediatric Surgery Children's Hospital of British Columbia, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pascale Prasil
- Division of Pediatric Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Rodrigo L P Romao
- Division of Pediatric Surgery, Center Hospitalier Universitaire Sainte-Justine Universite de Montreal, Montreal, Quebec, Canada
| | - Lisa VanHouwelingen
- Division of Pediatric Surgery, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Paul Wales
- Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Sherif Emil
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Chadha V, Cauchi P, Kincaid W, Waterston A, Schipani S, Salvi S, Cram O, Ritchie D. Consensus statement for metastatic surveillance of uveal melanoma in Scotland. Eye (Lond) 2023; 37:894-899. [PMID: 35945341 PMCID: PMC10050391 DOI: 10.1038/s41433-022-02198-w] [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: 02/27/2022] [Revised: 06/29/2022] [Accepted: 07/28/2022] [Indexed: 11/09/2022] Open
Abstract
Ophthalmic treatments are successful in managing uveal melanomas achieving good local control. However, a large number still metastasise, primarily to the liver, resulting in mortality. There is no consensus across the world on the mode, frequency, duration or utility of regular liver surveillance for metastasis and there are no published protocols. The Scottish Ocular Oncology Service (SOOS) constituted a Scottish Consensus Statement Group (SCSG) which included ocular oncologists, medical oncologists, radiologists and a uveal melanoma patient as a lay member. This group carried out an extensive review of literature followed by discussions to arrive at a consensus regarding surveillance planning for posterior uveal melanoma patients in Scotland. The Consensus Statement would provide a framework to guide each patient's surveillance plan and provide all patients with clarity and transparency on the issue. The SCSG was unable to find adequate evidence on which to base the strategy. The consensus statement recommends a risk-stratified approach to surveillance for these patients dividing them into low to medium-risk and high-risk groups defining the mode and duration of surveillance for each. It supplements the UK-wide Uveal Melanoma National Guidelines and allows a more uniform consensus-based approach to surveillance in Scotland. It has been adopted nationally by all health care providers in Scotland as a guideline and is available to patients on a publicly accessible website.
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Affiliation(s)
- Vikas Chadha
- Scottish Ocular Oncology Service, Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, UK.
| | - Paul Cauchi
- Scottish Ocular Oncology Service, Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, UK
| | - Wilma Kincaid
- Department of Radiology, Gartnavel General Hospital, Glasgow, UK
| | | | | | - Sachin Salvi
- Sheffield Ocular Oncology Service, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Oliver Cram
- Department of Radiology, Gartnavel General Hospital, Glasgow, UK
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Cernega A, Meleșcanu Imre M, Ripszky Totan A, Arsene AL, Dimitriu B, Radoi D, Ilie MI, Pițuru SM. Collateral Victims of Defensive Medical Practice. Healthcare (Basel) 2023; 11:healthcare11071007. [PMID: 37046933 PMCID: PMC10094659 DOI: 10.3390/healthcare11071007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
This paper analyzes the phenomenon of defensive medical practice, starting from the doctor–patient relationship, and the behavioral and professional factors that can influence the proper functioning of this relationship and the healthcare system. We analyze medical malpractice, given the increase in the number of accusations, as an essential factor in triggering the defensive behavior of doctors, together with other complementary factors that emphasize the need for protection and safety of doctors. The possible consequences for the doctor–patient relationship that defensive practice can generate are presented and identified by analyzing the determining role of the type of health system (fault and no-fault). At the same time, we investigate the context in which overspecialization of medical personnel can generate a form of defensive practice as a result of the limiting effect on the performance of a certain category of operations and procedures. The increase in the number of malpractice accusations impacts the medical community—“the stress syndrome induced by medical malpractice”—turning doctors into collateral victims who, under the pressure of diminishing their reputational safety, practice defensively to protect themselves from future accusations. This type of defensive behavior puts pressure on the entire healthcare system by continuously increasing costs and unresolved cases, which impact patients by limiting access to medical services in the public and private sectors.
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Affiliation(s)
- Ana Cernega
- Department of Organization, Professional Legislation and Management of the Dental Office, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, 17-23 Plevnei Street, 020021 Bucharest, Romania
| | - Marina Meleșcanu Imre
- Department of Prosthodontics, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, 17-23 Calea Plevnei, 010221 Bucharest, Romania
| | - Alexandra Ripszky Totan
- Department of Biochemistry, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, 17-23 Plevnei Street, 020021 Bucharest, Romania
| | - Andreea Letiția Arsene
- Department of General and Pharmaceutical Microbiology, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020956 Bucharest, Romania
| | - Bogdan Dimitriu
- Department of Endodontics, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, 17-23 Plevnei Street, 020021 Bucharest, Romania
| | - Delia Radoi
- Department of Organization, Professional Legislation and Management of the Dental Office, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, 17-23 Plevnei Street, 020021 Bucharest, Romania
| | - Marina-Ionela Ilie
- Department of General and Pharmaceutical Microbiology, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020956 Bucharest, Romania
| | - Silviu-Mirel Pițuru
- Department of Organization, Professional Legislation and Management of the Dental Office, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, 17-23 Plevnei Street, 020021 Bucharest, Romania
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Two Decades of Overuse and Underuse of Interventions for Primary and Secondary Prevention of Cardiovascular Diseases: A Systematic Review. Curr Probl Cardiol 2023; 48:101529. [PMID: 36493917 DOI: 10.1016/j.cpcardiol.2022.101529] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Quality use of anti-hypertensive and cholesterol-lowering medications is crucial for successful cardiovascular disease management. This systematic review aimed to estimate levels of over and underuse of services for primary and secondary prevention of cardiovascular diseases from 2000 to 2020: overprescribing/underprescribing, overtesting/undertesting and overutilization/ underutilization of procedures compared to clinical practice guideline recommendations. Thirteen studies from USA, Europe, Asia and Australia were included. Wide practice variation was identified. Six studies reported overuse (eg, perioperative cardiac consultations, anti-hypertensive overprescribing for normotensive or pre-hypertensive people); and ten studies reported underuse (eg, under-prescribing of statins when indicated and under-screening for familial hypercholesterolemia). Lifestyle recommendations for cardiovascular disease prevention were largely underused. In summary, lack of adherence to published guidelines was prevalent over the past 2 decades for both primary and secondary prevention across settings. Further investigation of potentially justifiable deviations from guidelines are warranted to verify the estimates and identify points for intervention.
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Garrity BM, Perrin JM, Rodean J, Houtrow AJ, Shelton C, Stille C, McLellan S, Coleman C, Mann M, Kuhlthau K, Desmarais A, Berry JG. Annual Days With a Health Care Encounter for Children and Youth Enrolled in Medicaid: A Multistate Analysis. Acad Pediatr 2023; 23:441-447. [PMID: 35863733 DOI: 10.1016/j.acap.2022.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To assess the number of days that children experienced a health care encounter and associations between chronic condition types and health care encounters. METHODS Retrospective analysis of data from 5,082,231 children ages 0 to 18 years enrolled in Medicaid during 2017 in 12 US states contained in the IBM Watson Marketscan Medicaid Database. We counted and categorized enrollees' encounter days, defined as unique days a child had a health care visit, by type of health service. We used International Classification of Disease-10 diagnosis code categories from Agency for Healthcare Research and Quality's Chronic Condition Indicator System to identify chronic mental and physical health conditions. RESULTS Median (interquartile range [IQR]) annual encounter days was 6 (2-13). Children in the 91st to 98th and ≥99th percentiles for encounter days experienced a median of 49 (IQR 38-70) and 229 (IQR 181, 309) days, respectively; these children accounted for 52.6% of days for the cohort. As encounter days increased from the 25th to >90th percentile, the percentage of children with co-existing mental and physical health conditions increased from <0.1% to 47.4% (P < .001). Outpatient visits accounted for a total of 68.3% and 62.2% of days for children the 91st to 98th and ≥99th percentiles. CONCLUSION Ten percent of children enrolled in Medicaid averaged health care encounters at least 1 day per week; 1% experienced health care encounters on most weekdays. Further investigation is needed to understand how families perceive frequent health care encounters, including how to facilitate their children's care in the most feasible way.
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Affiliation(s)
- Brigid M Garrity
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass.
| | - James M Perrin
- Division of General Academic Pediatrics, MassGeneral Hospital for Children (JM Perrin), Boston, Mass; Department of Pediatrics, Harvard Medical School (JM Perrin and JG Berry), Boston, Mass
| | | | - Amy J Houtrow
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh (AJ Houtrow), Pittsburgh, Pa
| | - Charlene Shelton
- School of Medicine, University of Colorado Anschutz Medical Campus (C Shelton and C Stille), Aurora, Colo
| | - Christopher Stille
- School of Medicine, University of Colorado Anschutz Medical Campus (C Shelton and C Stille), Aurora, Colo; General Academic Pediatrics, Children's Hospital Colorado (C Stille), Denver, Colo
| | - Sarah McLellan
- Health Resources and Services Administration, Maternal and Child Health Bureau (S McLellan), Rockville, Md
| | - Cara Coleman
- Family Voices National (C Coleman), Washington, DC
| | - Marie Mann
- Health Resources and Services Administration (M Mann), Rockville, Md
| | - Karen Kuhlthau
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School (K Kuhlthau), Boston, Mass
| | - Anna Desmarais
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass; Department of Pediatrics, Harvard Medical School (JM Perrin and JG Berry), Boston, Mass
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26
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Applying Game Theory Models to Inpatient Medicine: Opportunities to Improve Care. J Community Hosp Intern Med Perspect 2023; 13:20-24. [PMID: 36817294 PMCID: PMC9924631 DOI: 10.55729/2000-9666.1135] [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: 08/15/2022] [Revised: 10/01/2022] [Accepted: 10/11/2022] [Indexed: 01/11/2023] Open
Abstract
Inpatient hospital costs have been increasing exponentially in the United States. Part of this increase is attributed to over and undertreatment, leading to higher costs and potential patient harm. Research improving clinician-patient interactions can help minimize and optimize the costs. Game theory has the ability improve clinician-patient interaction by modeling outcomes. Using variations of game theory, the bad doctor bad patient stigma can reframed to incentives. We believe the use of different models (prisoner dilemma, centipede game, assurance game, and chicken game) can outline the challenges faced during common inpatient scenarios, including end of life conversations and aggressive procedures. Applying game theory to multiple inpatient scenarios may also assist with analysis during morbidity and mortality conferences and quality improvement projects.
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27
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Kim MJ, Kim JR, Jo JH, Kim JS, Park JW. Temporomandibular disorders-related videos on YouTube are unreliable sources of medical information: A cross-sectional analysis of quality and content. Digit Health 2023; 9:20552076231154377. [PMID: 36762021 PMCID: PMC9903026 DOI: 10.1177/20552076231154377] [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: 08/24/2022] [Accepted: 01/16/2023] [Indexed: 02/08/2023] Open
Abstract
Objective The amount of online medical information available is rapidly growing and YouTube is considered as the most popular source of healthcare information nowadays. However, no study has been conducted to comprehensively evaluate YouTube videos related to temporomandibular disorders (TMD). So this study aimed to evaluate the content and quality of YouTube videos as a source of medical information on TMD. Method A total of 237 YouTube videos that were systematically searched using five keywords (temporomandibular disorders, tmd, temporomandibular joint, tmj, and jaw joint) were included. Included videos were categorized by purpose and source for analysis. The quality (DISCERN, Health on the Net (HON), Ensuring Quality Information for Patients (EQIP), and Global Quality Scale (GQS)) and scientific accuracy of video contents were evaluated. Results Total content, DISCERN, HON, EQIP, and GQS scores were 7.5%, 38.9%, 35.2%, 53.0%, and 48.6% of the maximum possible score, respectively. Only 69 videos (29.1%) were considered as "useful" for patients. News media, physician, and medical source videos showed higher evaluation scores than others. Quality evaluation scores were not significantly correlated or negatively correlated with public preference indices. In the ROC curve analysis, content and DISCERN score showed above excellent discrimination ability for high-quality videos based on GQS (P < 0.001) and total score (P < 0.001). Conclusions YouTube videos related to TMD contained low quality and scientifically inaccurate information that could negatively influence patients with TMD.
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Affiliation(s)
- Moon Jong Kim
- Department of Oral Medicine, Seoul National University Gwanak Dental Hospital, Seoul, Korea (ROK)
| | - Ji Rak Kim
- Department of Oral Medicine, School of Dentistry, Kyungpook National University, Daegu, Korea (ROK)
| | - Jung Hwan Jo
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Korea (ROK),Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Korea (ROK)
| | - Ju Sik Kim
- Department of Dentistry, Seoul National University Hospital, Seoul, Korea (ROK)
| | - Ji Woon Park
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Korea (ROK),Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Korea (ROK),Dental Research Institute, Seoul National University, Seoul, Korea (ROK),Ji Woon Park, Department of Oral Medicine and Oral Diagnosis, School of Dentistry and Dental Research Institute, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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28
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Hosseini Sarkhosh SM, Akhavan P. Evaluating preparedness in using blockchains for electronic health record systems. ELECTRONIC LIBRARY 2023. [DOI: 10.1108/el-05-2022-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Purpose
An emerging technology in the primary stages of its life cycle is the blockchain. This research paper aims to evaluate the preparedness of hospitals in using blockchain technology in their electronic health record (EHR) systems.
Design/methodology/approach
In the initial stage, 15 criteria relating to preparedness in using blockchain in EHR systems were identified from the literature and divided into five criteria, namely, technological, legal, financial, environmental and organizational. Then, 17 experts from various specialized fields were invited to form expert panels. After validating the criteria identified by the expert panels, the weights of the criteria were determined through the fuzzy best-worst multicriteria decision-making method. Following that, the preparedness of ten selected hospitals in Tehran to use blockchain in their EHR systems was assessed via the weighted aggregated sum product assessment method. Finally, using sensitivity analysis and examining different scenarios, the robustness of the results of the proposed approach was validated.
Findings
According to expert judgments, the legal criterion (32%) was deemed the most important factor in the preparedness to use blockchain in EHR systems followed by technological (28%), financial (17%), organizational (13%) and environmental (9%) criteria. A sensitivity analysis showed that the proposed approach offers good strength and robustness in evaluating the selected hospitals.
Originality/value
This study can be useful in developing knowledge in the field of technology management for evaluating blockchain implementation in the health-care industry using a novel, coherent and robust approach. In addition, the proposed approach provides comprehensive insight for decision-makers on assessing preparedness in deploying blockchain technology in EHR systems.
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De Ravin E, Sell EA, Newman JG, Rajasekaran K. Medical malpractice in robotic surgery: a Westlaw database analysis. J Robot Surg 2023; 17:191-196. [PMID: 35554817 PMCID: PMC9097886 DOI: 10.1007/s11701-022-01417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/19/2022] [Indexed: 11/27/2022]
Abstract
Malpractice claims involving robot-assisted surgical procedures have increased more than 250% in the past 7 years compared to the seven years prior. We examined robotic surgery malpractice claims to identify trends in claimed liabilities, describe legal outcomes, and determine strategies to minimize future litigation. The Westlaw legal database was queried retrospectively for U.S. state and federal trials regarding robot-assisted surgical procedures from 2006 to 2013 and 2014 to 2021. Data abstracted from verdict reports included year, state, court type, defendant specialty, procedure performed, claimed injuries and liabilities, verdict, and damage amount awarded. Sixty-one cases across 25 states were identified, 16 cases between 2006 and 2013, and 45 from 2014 to 2021. Among those 45 cases, defendant verdicts predominated (n = 35, 77.8%), with only four plaintiff verdicts (8.9%) and six settlements (13.3%). Overall, 169 liabilities were claimed, most commonly negligent surgery (82.2%), misdiagnosis/failure to diagnose (46.7%), delayed treatment (35.6%), and lack of informed consent (31.1%). Thirteen cases resulted in indemnity payments (mean = $1,251,274), with damages ranging from $10,087 (infection and retained foreign body) to $5,008,922 (patient death). Hysterectomy (n = 19, 42.2%) was the most commonly litigated surgery, followed by prostatectomy (n = 5) and hernia repair (n = 4). The most litigated specialties were obstetrics/gynecology (48.9%), general surgery (28.9%), and urology (15.6%). Malpractice litigation in robot-assisted surgery is infrequent. As robotic procedures become more commonplace, surgeons must keep common liabilities in mind, as there are valuable and actionable lessons to be learned from these cases. Malpractice reform, continuing medical education activities, and improved informed consent protocols may help minimize future litigation.
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Affiliation(s)
- Emma De Ravin
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, 800 Walnut Street, 18th Floor, Philadelphia, PA, 19107, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth A Sell
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jason G Newman
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, 800 Walnut Street, 18th Floor, Philadelphia, PA, 19107, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, 800 Walnut Street, 18th Floor, Philadelphia, PA, 19107, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Hoseini Kasnavieh M, Kookli K, Veisi M, Amerzadeh M, Hosseinifar H, Tahmasebi A. Investigating the Rate and Affecting Factors of Unnecessary Cervical Collar Use in Trauma Patients. Bull Emerg Trauma 2023; 11:178-183. [PMID: 38143523 PMCID: PMC10743316 DOI: 10.30476/beat.2023.98793.1441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/05/2023] [Accepted: 08/29/2023] [Indexed: 12/26/2023] Open
Abstract
Objective This study aimed to investigate the necessity of cervical collars in patients with neck problems. Methods This cross-sectional study was conducted on 114 patients who were admitted to the Haft Tir and Rasoul Akram Hospitals (Tehran, Iran) from August to September 2022. The Nexus protocol was used to select the patients with cervical collars. According to the protocol, a cervical collar was required for individuals who had at least one symptom. If none of these symptoms existed, the cervical collar was deemed unnecessary. The data were analyzed using the Chi-square test and Fisher's exact test. Results Of the 114 trauma patients, the cervical collar was used unnecessarily by 49 (43%) patients. Tenderness was the most common complication in 62 patients (54.4%). The prevalence of unnecessary cervical collar use was 37.5% in female trauma patients and 43.88% in male trauma patients, which was not statistically significant (p=0.63). The prevalence of unnecessary cervical collar use in trauma patients with multiple trauma was 39.42% and 80% in patients without multiple trauma, which was statistically significant (p=0.018). Patients with a medical history had a higher rate of unnecessary use of the cervical collar (47.96%) than those without a history (12.5%), and this difference was statistically significant (p=0.008). Conclusion The guidelines for using cervical collars need to be updated by the EMS. Due to the large number of trauma patients in Iran, cervical collars for necessary conditions can help to reduce the healthcare expenses and injuries caused by unnecessary cervical collars.
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Affiliation(s)
| | - Keihan Kookli
- International Campus, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Veisi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amerzadeh
- Department of Health Services Management, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Hossein Hosseinifar
- Evidence-Based Medicine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Tahmasebi
- Hospital Management Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
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Practice Patterns in the Management of Pressure Restrictive Perimembranous Ventricular Septal Defects: A Multinational Survey. Pediatr Cardiol 2022; 44:845-854. [PMID: 36538052 DOI: 10.1007/s00246-022-03073-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
Indications for the closure of pressure restrictive perimembranous ventricular septal defects (pmVSD) are not well established in the pediatric population. We sought to assess practice variability among pediatric cardiologists in the United States (US), Canada, Australia, and New Zealand. A survey ascertaining practice patterns, including case vignettes with incremental progression of disease severity, was designed and administered through representative professional cardiac organizations and email listservs in the designated countries. Among the 299 respondents, 209 (70.0%) were from the US, 65 (21.7%) were from Canada and 25 (8.3%) were from Australia and New Zealand. Indications for pressure restrictive pmVSD closure included the presence of left ventricular (LV) dilation for 81.6% (244/299) (defined as z-score ≥ 2 for 59.0% (144/244) and ≥ 3 for 40.2% (98/244)) and significant pulmonary-systemic flow ratio (QP:QS) for 71.2% (213/299) [defined as ≥ 1.5:1 for 36.2% (77/213) and ≥ 2 for 62% (132/213)]. US pediatric cardiologists elected to close restrictive pmVSD at lower LV z-score and QP:QS ratio cut-offs (p-value 0.0002 and 0.013, respectively). In a case vignette, 63.6% (173/272) chose to intervene if there was right coronary cusp prolapse with stable mild aortic regurgitation. Of the remaining cardiologists, 93% (92/99) intervened if the aortic regurgitation was progressive (from trivial to mild). Commonly identified indications with variable thresholds for closure of pressure restrictive pmVSDs included the presence or progression of LV dilation, significant volume loading, and aortic valve prolapse with regurgitation. US pediatric cardiologists may have a lower threshold for pmVSD closure.
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32
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Doshmangir L, Jabbari H, Arab-Zozani M, Naghavi-Behzad M, Abedi Z, Mostafavi H. Factors affecting hospital services overutilization and reductive strategies in Iran: a qualitative study to explore experts' views. Hosp Pract (1995) 2022; 50:416-424. [PMID: 36222088 DOI: 10.1080/21548331.2022.2134679] [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: 02/24/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES This study aimed to investigate the viewpoints of the main stakeholders of the Iranian healthcare system about the overutilization of hospital services and strategies to eliminate or reduce it in Iran. METHODS This is a qualitative study and thematic data analysis using face-to-face semi-structured interviews and Focus Group Discussions (FGDs). We conducted eight interviewers and two FGDs with hospital stakeholders including faculty members, insurance organizations' authorities, experienced hospital administrative staff, hospital managers, and health-care providers. RESULTS The factors leading to the overutilization of hospital services were categorized into four main themes including site of service, quality, supplier push, and demand pull. Strategies for eliminating or reducing the overutilization of hospital services are also identified based on the influential factors. CONCLUSION Addressing overutilization of hospital services in the health system and adherence to policies for reducing or eliminating overutilization is a way to make preventive strategies to overcome overutilization. Developing a national plan to integrate utilization management into health system programs is a strategy to combat overutilization in various levels of the health system including hospital setting.
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Affiliation(s)
- Leila Doshmangir
- Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Social Determinants of Health Research Centre, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Jabbari
- Department of Community Medicine, School of Medicine, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Zeinab Abedi
- Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hakimeh Mostafavi
- Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Lochner J, Birstler J, Smith MA, Rathouz P, Arndt B, Micek M, Trowbridge E, Trowbridge E, Kamnetz S, Pandhi N. Does a Change in Physician Compensation Lead to Changes in Care Delivery in Family Medicine Clinics? WMJ : OFFICIAL PUBLICATION OF THE STATE MEDICAL SOCIETY OF WISCONSIN 2022; 121:280-284. [PMID: 36637838 PMCID: PMC10103617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Many highly capitated systems still pay physicians based on relative value units (RVU), which may lead to excessive office visits. We reviewed electronic health records from the family medicine clinic panel members of 97 physicians and 42 residents to determine if a change from RVUs to panel-based compensation influenced care delivery as defined by the number of office visits and telephone contacts per panel member per month. METHODS A retrospective analysis of the electronic health records of patients seen in 4 residency training clinics, 10 community clinics, and 4 regional clinics was conducted. We assessed face-to-face care delivery and telephone call volume for the clinics individually and for the clinics pooled by clinic type from 1 year before to at least 1 year after the change. RESULTS Change in physician compensation was not found to have an effect on office visits or telephone calls per panel member per month when pooled by clinic categories. Some significant effects were seen in individual clinics without any clear patterns by clinic size or type. CONCLUSIONS Change in physician compensation was not a key driver of care delivery in family medicine clinics. Understanding changes in care delivery may require looking at a broad array of system, physician, and patient factors.
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Affiliation(s)
- Jennifer Lochner
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
| | - Jen Birstler
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Maureen A Smith
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
| | - Paul Rathouz
- Department of Population Health, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Brian Arndt
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
| | - Mark Micek
- Department of Medicine, Division of General Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
| | - Elizabeth Trowbridge
- Department of Medicine, Division of General Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
| | - Elizabeth Trowbridge
- Department of Medicine, Division of General Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
| | - Sandra Kamnetz
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
| | - Nancy Pandhi
- Department of Family and Community Medicine, University of New Mexico Health Sciences Center, City, New Mexico
- Primary Care Academics Transforming Healthcare Collaborative, UW Health, Madison, Wisconsin
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Singer A, Kosowan L, Abrams EM, Katz A, Lix L, Leong K, Paige A. Implementing an audit and feedback cycle to improve adherence to the Choosing Wisely Canada recommendations: clustered randomized trail. BMC PRIMARY CARE 2022; 23:302. [PMID: 36435746 PMCID: PMC9701433 DOI: 10.1186/s12875-022-01912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Audit and Feedback (A&F), a strategy aimed at promoting modified practice through performance feedback, is a method to change provider behaviour and reduce unnecessary medical services. This study aims to assess the use of A&F to reduce antibiotic prescribing for viral infections and antipsychotic prescribing to patients with dementia. METHODS Clustered randomized trial of 239 primary care providers in Manitoba, Canada, participating in the Manitoba Primary Care Research Network. Forty-six practices were randomly assigned to one of three groups: control group, intervention 1 (recommendations summary), intervention 2 (recommendations summary and personalized feedback). We assessed prescribing rates prior to the intervention (2014/15), during and immediately after the intervention (2016/17) and following the intervention (2018/19). Physician characteristics were assessed. RESULTS Between 2014/15-2016/17, 91.6% of providers in intervention group 1 and 95.9% of providers in intervention group 2 reduced their antibiotic and antipsychotic prescribing rate by ≥ 1 compared to the control group (77.6%) (p-value 0.0073). This reduction was maintained into 2018/19 at 91.4%. On multivariate regression alternatively funded providers had 2.4 × higher odds of reducing their antibiotic prescribing rate compared to fee-for-service providers. In quantile regression of providers with a reduction in antibiotic prescribing, alternatively funded (e.g. salaried or locum) providers compared to fee-for-service providers were significant at the 80th quantile. CONCLUSIONS Both A&F and recommendation summaries sent to providers by a trusted source reduced unnecessary prescriptions. Our findings support further scale up of efforts to engage with primary care practices to improve care with A&F. TRIAL REGISTRATION ClinicalTrials.gov NCT05385445, retrospectively registered, 23/05/2022.
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Affiliation(s)
- Alexander Singer
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Leanne Kosowan
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Alan Katz
- Departments of Community Health Science & Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Centre for Health Policy, Winnipeg, MB, Canada
| | - Lisa Lix
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Katrina Leong
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Allison Paige
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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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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Affiliation(s)
- Rani Marx
- Initiative for Slow Medicine, Berkeley, CA, USA
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Kim H, Mahmood A, Hammarlund NE, Chang CF. Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives. Front Public Health 2022; 10:882715. [PMID: 36299751 PMCID: PMC9589294 DOI: 10.3389/fpubh.2022.882715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/12/2022] [Indexed: 01/21/2023] Open
Abstract
Beginning in the early 2010s, an array of Value-Based Purchasing (VBP) programs has been developed in the United States (U.S.) to contain costs and improve health care quality. Despite documented successes in these efforts in some instances, there have been growing concerns about the programs' unintended consequences for health care disparities due to their built-in biases against health care organizations that serve a disproportionate share of disadvantaged patient populations. We explore the effects of three Medicare hospital VBP programs on health and health care disparities in the U.S. by reviewing their designs, implementation history, and evidence on health care disparities. The available empirical evidence thus far suggests varied impacts of hospital VBP programs on health care disparities. Most of the reviewed studies in this paper demonstrate that hospital VBP programs have the tendency to exacerbate health care disparities, while a few others found evidence of little or no worsening impacts on disparities. We discuss several policy options and recommendations which include various reform approaches and specific programs ranging from those addressing upstream structural barriers to health care access, to health care delivery strategies that target service utilization and health outcomes of vulnerable populations under the VBP programs. Future studies are needed to produce more explicit, conclusive, and consistent evidence on the impacts of hospital VBP programs on disparities.
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Affiliation(s)
- Hyunmin Kim
- School of Health Professions, The University of Southern Mississippi, Hattiesburg, MS, United States
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, United States
| | - Asos Mahmood
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, United States
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Medicine-General Internal Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Noah E. Hammarlund
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, United States
| | - Cyril F. Chang
- Department of Economics, Fogelman College of Business and Economics, The University of Memphis, Memphis, TN, United States
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Raudasoja AJ, Falkenbach P, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Komulainen J, Sipilä R, Tikkinen KAO. Randomized controlled trials in de-implementation research: a systematic scoping review. Implement Sci 2022; 17:65. [PMID: 36183140 PMCID: PMC9526943 DOI: 10.1186/s13012-022-01238-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare costs are rising, and a substantial proportion of medical care is of little value. De-implementation of low-value practices is important for improving overall health outcomes and reducing costs. We aimed to identify and synthesize randomized controlled trials (RCTs) on de-implementation interventions and to provide guidance to improve future research. METHODS MEDLINE and Scopus up to May 24, 2021, for individual and cluster RCTs comparing de-implementation interventions to usual care, another intervention, or placebo. We applied independent duplicate assessment of eligibility, study characteristics, outcomes, intervention categories, implementation theories, and risk of bias. RESULTS Of the 227 eligible trials, 145 (64%) were cluster randomized trials (median 24 clusters; median follow-up time 305 days), and 82 (36%) were individually randomized trials (median follow-up time 274 days). Of the trials, 118 (52%) were published after 2010, 149 (66%) were conducted in a primary care setting, 163 (72%) aimed to reduce the use of drug treatment, 194 (85%) measured the total volume of care, and 64 (28%) low-value care use as outcomes. Of the trials, 48 (21%) described a theoretical basis for the intervention, and 40 (18%) had the study tailored by context-specific factors. Of the de-implementation interventions, 193 (85%) were targeted at physicians, 115 (51%) tested educational sessions, and 152 (67%) multicomponent interventions. Missing data led to high risk of bias in 137 (60%) trials, followed by baseline imbalances in 99 (44%), and deficiencies in allocation concealment in 56 (25%). CONCLUSIONS De-implementation trials were mainly conducted in primary care and typically aimed to reduce low-value drug treatments. Limitations of current de-implementation research may have led to unreliable effect estimates and decreased clinical applicability of studied de-implementation strategies. We identified potential research gaps, including de-implementation in secondary and tertiary care settings, and interventions targeted at other than physicians. Future trials could be improved by favoring simpler intervention designs, better control of potential confounders, larger number of clusters in cluster trials, considering context-specific factors when planning the intervention (tailoring), and using a theoretical basis in intervention design. REGISTRATION OSF Open Science Framework hk4b2.
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Affiliation(s)
- Aleksi J Raudasoja
- Faculty of Medicine, University of Helsinki, Helsinki, Finland. .,Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, Oulu, Finland.,University of Oulu, Oulu, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea & Westminster NHS Foundation Trust, London, UK.,Department of Epidemiology & Biostatistics, Imperial College London, London, UK
| | - Herney A Garcia-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Tampere University Hospital and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Hatanpää Health Center, City of Tampere, Finland.,Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Eero Raittio
- Oral Health Care, Tampere, Finland.,Institute of Dentistry, University of Eastern Finland, Kuopio, Finland.,Nordic Healthcare Group Ltd., Helsinki, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Levitin H, Jones B, Lockhart M, Christopher L, Sharkey M, Willette P, Kalnow A. Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders. West J Emerg Med 2022; 23:724-733. [PMID: 36205683 PMCID: PMC9541997 DOI: 10.5811/westjem.2022.7.55727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 07/19/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users.
Methods: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services.
Results: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown.
Conclusion: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.
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Affiliation(s)
- Howard Levitin
- OhioHealth Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
| | - Bruce Jones
- OhioHealth Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
| | - Marie Lockhart
- OhioHealth Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
| | - Lloyd Christopher
- OhioHealth Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
| | - Meenal Sharkey
- OhioHealth Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
| | - Paul Willette
- OhioHealth Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
| | - Andrew Kalnow
- OhioHealth Doctors Hospital, Department of Emergency Medicine, Columbus, Ohio
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Rynkiewich K, Uttla K, Hojat L. Instant Gratification and Overtreating to Be Safe: Perceptions of U.S. Intensive Care Unit Pharmacists and Residents on Antimicrobial Stewardship. Antibiotics (Basel) 2022; 11:antibiotics11091224. [PMID: 36140003 PMCID: PMC9495149 DOI: 10.3390/antibiotics11091224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/17/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022] Open
Abstract
Antimicrobial stewardship programs have been associated with numerous impacts on medical practice including reductions in costs, antimicrobial resistance, and adverse events. While antimicrobial stewardship is now considered an essential element of medical practice, the understandings of the value of antimicrobial stewardship among medical practitioners vary. Additionally, non-physician practitioners are regularly left out of antimicrobial stewardship interventions targeting antimicrobial decision-making. Here, we contribute the perspective from resident physicians and specialists in pharmacy regarding their involvement in antimicrobial prescribing. Notably, our semi-structured interviews with 10 residents and pharmacy specialists described their limited autonomy in the clinical setting. However, the participants regularly worked alongside primary antimicrobial decision-makers and described feeling pressure to overtreat to be safe. The clear rationales and motivations associated with antimicrobial prescribing have a noticeable impact on physicians in training and non-physician practitioners, and as such, we argue that antimicrobial stewardship interventions targeting primary antimicrobial decision-makers are missing an opportunity to address the breadth of antimicrobial prescribing culture. By looking at the perspectives and rationales of physicians in training and non-physician practitioners, we can see evidence that the act of antimicrobial prescribing is impacted by individuals on all levels of the hierarchies present in medical practice.
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Affiliation(s)
- Katharina Rynkiewich
- Department of Anthropology, Florida Atlantic University, Boca Raton, FL 33431, USA
- Correspondence:
| | - Kruthika Uttla
- Department of Anthropology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Leila Hojat
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH 44106, USA
- Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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CHRISTENSEN V, PARKER K, Kimi LH, SAXTON L, COTTRELL E. 'Never once was I thinking the c-word': Parent perspectives on the facilitators and barriers to getting a childhood cancer diagnosis. J Clin Nurs 2022:10.1111/jocn.16511. [PMID: 36059140 PMCID: PMC9984568 DOI: 10.1111/jocn.16511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To describe the facilitators and barriers of getting from 'something's not right' to a childhood cancer diagnosis from the perspective of parents living in the United States of America. BACKGROUND It is common for families to experience long trajectories from when they first notice symptoms to receiving a childhood cancer diagnosis. Understanding this trajectory within the social and cultural contexts of the United States healthcare system is the first step in developing strategies for reducing this timeframe and mitigating some of the psychosocial impact for parents in receiving a childhood cancer diagnosis. This study examines the interpretations and meanings parents attributed to their child's symptoms, their decisions regarding seeking medical care, interactions with healthcare providers and the time course of events. DESIGN An inductive qualitative inquiry. METHODS In-depth, semi-structured interviews with 55 participants representing 39 unique cases of childhood cancer were conducted. Data were analysed using an inductive thematic approach. COREQ guidelines were followed. RESULTS Participants described multiple barriers and facilitators in their path to receiving a childhood cancer diagnosis. Facilitators included noticing something 'wasn't right' and physician in agreement that symptoms were unusual; acute symptoms requiring action; advocating for a diagnosis; and obtaining a second opinion. Barriers included parents having to interpret symptoms in the context of daily life; physician dismissiveness even when symptoms persisted; and not feeling they could question their physician's assessment. CONCLUSION Families experience multiple facilitators and barriers in their trajectory to receiving a childhood cancer diagnosis. RELEVANCE TO CLINICAL PRACTICE Understanding the path to diagnosis from the parent perspective may increase opportunities for shared decision-making. Clinician educational modules that include family perspectives may improve patient/parent-provider relationships. PARTICIPANT CONTRIBUTION Participants described their family's cancer journey through narrative storytelling. Participants had the opportunity to review and make edits to their transcript.
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Affiliation(s)
- Vivian CHRISTENSEN
- Oregon Clinical and Translational Research Institute (OCTRI), Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098
| | - Kellee PARKER
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road. Mail Code: CDRCP
| | - Lai Hin Kimi
- Oregon Health and Science University, School of Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098
| | - Lauren SAXTON
- Oregon Clinical and Translational Research Institute (OCTRI), Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098
| | - Erika COTTRELL
- Oregon Clinical and Translational Research Institute (OCTRI), Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098,OCHIN, Inc. 1881 SW Naito Pkwy, Portland, OR 97201
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Elhabil MK, Yousif MA, Ahmed KO, Abunada MI, Almghari KI, Eldalo AS. Impact of Clinical Pharmacist-Led Interventions on Drug-Related Problems Among Pediatric Cardiology Patients: First Palestinian Experience. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2022; 11:127-137. [PMID: 36051822 PMCID: PMC9426679 DOI: 10.2147/iprp.s374256] [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: 05/11/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background Discovery and resolution of drug-related problems (DRPs) are taken as the cornerstone in the entire pharmaceutical care process to improve patient outcomes. Very limited reports on the analysis of DRPs in pediatric cardiology have been released worldwide. Objective The aim of this study was to disclose the impact of clinical pharmacist’s interventions on DRPs among pediatric cardiology patients in Palestine. Methods Between January and September 2021, a prospective interventional study involving clinical pharmacist’s care was implemented in the cardiology ward of Al-Rantisy Specialized Pediatric Hospital in Gaza, Palestine. Pharmaceutical Care Network Europe model 9.1 was used to identify DRPs, causes of the problem, clinical pharmacist’s interventions, cardiologist’s acceptance, and outcomes. Results A total of 309 DRPs were identified in 87 patients, representing a mean of 3.55 problems per patient. The most common DRPs were “Treatment effectiveness” (50.8%) and “Treatment safety” (30.4%), while the main causes of these DRPs were “Errors in dose timing instructions” (9.4%) and “Inappropriate combination of drugs” (13.7%), respectively. Analysis revealed that 96.7% of the interventions suggested by the clinical pharmacist were accepted by cardiologists and that 92.1% of problems were fully resolved with improved patient outcomes. Conclusion Interventions offered by the clinical pharmacist successfully addressed DRPs and positively impacted treatment outcomes in pediatric cardiology patients. With the high acceptance of pediatric cardiologists to the clinical pharmacist’s experience in Palestine, there is a growing need to integrate clinical pharmacists into cardiology teamwork care to optimize drug therapy and patient safety.
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Affiliation(s)
- Mohammed Kamel Elhabil
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Mirghani Abdelrahman Yousif
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Kannan O Ahmed
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | | | - Khaled Ismail Almghari
- Department of Pharmacy, Faculty of Medicine and Health Sciences, University of Palestine, Gaza, Palestine
| | - Ahmed Salah Eldalo
- Department of Pharmacy, Faculty of Medicine and Health Sciences, University of Palestine, Gaza, Palestine
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Verkerk EW, van Dulmen SA, Westert GP, Hooft L, Heus P, Kool RB. Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands? BMJ Open Qual 2022. [PMCID: PMC9454034 DOI: 10.1136/bmjoq-2021-001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects. Methods We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated. Results Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy. Conclusions Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.
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Affiliation(s)
- Eva W Verkerk
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Gert P Westert
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rudolf B Kool
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review. Glob Heart 2022; 17:55. [PMID: 36051325 PMCID: PMC9374022 DOI: 10.5334/gh.1142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/30/2022] [Indexed: 11/20/2022] Open
Abstract
Thromboembolic events are a common risk in adults with atrial fibrillation, those with previous cerebrovascular accidents and undergoing emergency or elective surgeries. The widespread availability of antithrombotic agents and differing guidelines contribute to practice variations and increased risk of complications and deaths. The objective of this review was to investigate the extent of overuse and underuse of antithrombotics for primary or secondary prevention as measured by deviation from prescribing guideline recommendations. We conducted a systematic review of Medline and EMBASE for quantitative articles published between 2000 and 2021 and used a modified version of the Hoy’s risk of bias assessment tool. Here we report evidence from the past decade about wide practice variations in hospitals and primary care, and discuss clinician and patient-driven determinants of non-adherence to guidelines. Finally, we summarise implications for practice, identify enhanced ways of measuring overuse and underuse, and propose potential solutions to the measurement challenges.
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Bernstein AS, Stevens KL, Koh HK. Patient-Centered Climate Action and Health Equity. JAMA 2022; 328:419-420. [PMID: 35834232 DOI: 10.1001/jama.2022.12404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Aaron S Bernstein
- Center for Climate, Health, and the Global Environment, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | | | - Howard K Koh
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Choosing Wisely in Adult Hospital Medicine: Co-creation of New Recommendations for Improved Healthcare Value by Clinicians and Patient Advocates. J Gen Intern Med 2022; 37:2454-2461. [PMID: 35668237 PMCID: PMC9360369 DOI: 10.1007/s11606-021-07269-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/02/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND The American Board of Internal Medicine Foundation's Choosing Wisely campaign has resulted in a vast number of recommendations to reduce low-value care. Implementation of these recommendations, in conjunction with patient input, remains challenging. OBJECTIVE To create updated Society of Hospital Medicine Adult Hospitalist Choosing Wisely recommendations that incorporate patient input from inception. DESIGN AND PARTICIPANTS This was a multi-phase study conducted by the Society of Hospital Medicine's High Value Care Committee from July 2017 to January 2020 involving clinicians and patient advocates. APPROACH Phase 1 involved gathering low-value care recommendations from patients and clinicians across the USA. Recommendations were reviewed by the committee in phase 2. Phase 3 involved a modified Delphi scoring in which 7 committee members and 7 patient advocates voted on recommendations based on strength of evidence, potential for patient harm, and relevance to either hospital medicine or patients. A patient-friendly script was developed to allow advocates to better understand the clinical recommendations. KEY RESULTS A total of 1265 recommendations were submitted by clinicians and patients. After accounting for similar suggestions, 283 recommendations were categorized. Recommendations with more than 10 mentions were advanced to phase 3, leaving 22 recommendations for the committee and patient advocates to vote upon. Utilizing a 1-5 Likert scale, the top combined recommendations were reducing use of opioids (4.57), improving sleep (4.52), minimizing overuse of oxygen (4.52), reducing CK-MB use (4.50), appropriate venous thromboembolism prophylaxis (4.43), and decreasing daily chest x-rays (4.43). CONCLUSIONS Specific voting categories, along with the use of patient-friendly language, allowed for the successful co-creation of recommendations.
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Verkerk EW, Van Dulmen SA, Born K, Gupta R, Westert GP, Kool RB. Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands. Int J Health Policy Manag 2022; 11:1514-1521. [PMID: 34273925 PMCID: PMC9808325 DOI: 10.34172/ijhpm.2021.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 04/30/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. METHODS We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. RESULTS The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy. CONCLUSION Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.
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Affiliation(s)
- Eva W. Verkerk
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simone A. Van Dulmen
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karen Born
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Reshma Gupta
- University of California Health, Sacramento, CA, USA
| | - Gert P. Westert
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rudolf B. Kool
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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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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Doll J, Kreikemeier M, Maddigan C, Marshall N, Young M. Analyzing Unnecessary Imaging for Low Back Pain in Nebraska from a Statewide Health Information Exchange. J Med Syst 2022; 46:51. [PMID: 35678939 DOI: 10.1007/s10916-022-01838-8] [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: 05/26/2020] [Accepted: 05/27/2022] [Indexed: 11/25/2022]
Abstract
Excessive amounts of resources in healthcare are wasted due to duplicated or unnecessary health screenings, especially in the diagnosis of low back pain (LBP). Research shows that two-thirds of people will present with LBP at some point throughout their lifetime, but 20-50% of high-tech imaging procedures fail to provide information that improves the patient's condition, representing unnecessary services. The purpose of this study was to evaluate the existence of unnecessary imaging for low back pain throughout healthcare systems in Nebraska based on what was documented in the electronic health record. This study was a retrospective electronic health record analysis of a limited data set focused on procedures related to imaging for LBP extracted from Nebraska Health Information Exchange (HIE) managed by CyncHealth. The sample included 937 patient records with a diagnosis of LBP who received imaging in the state of Nebraska and whose health record was recorded in the Nebraska HIE. To determine necessity, records were categorized in three areas including necessary imaging, likely wasteful imaging, or wasteful imaging based on the criteria from the "First, Do No Harm" study conducted by the Washington Health Alliance. Results revealed a total of 51% of low back pain imaging considered wasteful, 35% likely wasteful, and 14% necessary. Based on these results, further research is warranted to determine specific demographics related to necessary, likely wasteful, and wasteful imaging and the purpose for performing these expensive imaging procedures.
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Affiliation(s)
- Joy Doll
- CyncHealth, Dba Nebraska Health Information Initiative, PO Box 27842, Omaha, NE, 68127, USA.
| | - Madison Kreikemeier
- Former Students at Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Cassie Maddigan
- Former Students at Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Nathaniel Marshall
- Former Students at Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA
| | - Maggie Young
- Former Students at Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA
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Vicente-Guijarro J, Valencia-Martín JL, Fernández-Herreruela C, Sousa P, Mira Solves JJ, Aranaz-Andrés JM. Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018. J Patient Saf 2022; 18:276-286. [PMID: 35503970 PMCID: PMC9162075 DOI: 10.1097/pts.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system. METHODS A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index. RESULTS There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was €56,338,247 (an average of €17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024). CONCLUSIONS Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.
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Affiliation(s)
- Jorge Vicente-Guijarro
- From the Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, IRYCIS
- Departamento de Medicina y Especialidades Médicas, Facultad de Medicina, Universidad de Alcalá, Acalá de Henares
- Instituto Ramón y Cajal de Investigación Sanitaria, IRYCIS, Madrid
| | - José Lorenzo Valencia-Martín
- Instituto Ramón y Cajal de Investigación Sanitaria, IRYCIS, Madrid
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Virgen del Rocío, Sevilla
| | - Carlos Fernández-Herreruela
- Dirección Asistencial Noroeste, Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud
- Perito Médico de Seguros, Asesor en Gestión de Riesgos Sanitarios, Madrid, Spain
| | - Paulo Sousa
- NOVA National School of Public Health, Universidade NOVA de Lisboa
- Comprehensive Health Research Centre (CHRC), Lisbon, Portugal
| | - José Joaquín Mira Solves
- Health Psychology Department, Miguel Hernández University, Elche
- Alicante-Sant Joan Health District, Consellería Sanitat, Alicante
- REDISSEC, Health Services Network Oriented to Chronic Diseases
| | - Jesús María Aranaz-Andrés
- From the Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Ramón y Cajal, IRYCIS
- Instituto Ramón y Cajal de Investigación Sanitaria, IRYCIS, Madrid
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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