The Tyranny of Guidelines

Evidence-based radiology 5 years on-a single-centre review of image referral appropriateness

BACKGROUND

The iRefer guidelines provide evidence-based recommendations on imaging and are designed to facilitate appropriate referrals and limit unnecessary radiation exposure. In 2017, a review at this institution assessed the appropriateness of imaging referrals. This study provides an update 5 years later on the referral appropriateness and aims to assess what impact the previous review has had on referral appropriateness.

METHODS

A retrospective study of 945 referrals across GPs, ED, and inpatients was audited against the iRefer guidelines with costs and cumulative dose estimates calculated for inappropriate referrals considering salaries of those involved, the average time spent performing and reporting radiographs, and the median effective dose values.

RESULTS

Results show a decrease in the volume of requests overall with the relative proportion of inappropriate requests rising significantly. Inappropriate requests for abdominal X-rays from GPs decreased from 72 to 37.5%, whereas inappropriate ED referrals increased from 38 to 46% and inappropriate inpatient requests remained static at 30%. The proportion of inappropriate GP requests for spinal radiographs significantly increased for cervical, thoracic, and lumbar spine radiographs, respectively (18 to 66%; 47 to 72%; 53 to 80%; p-value < 0.001). Inappropriate radiographs represent an increased financial and dose-based burden.

CONCLUSION

The volume of radiograph requests reduced after over a 5-year interval; however, the relative proportion of inappropriate requests rose significantly. The iRefer guidelines provide a useful resource to ensure that imaging is used appropriately, effectively, and safely; however, more work is needed to ensure that requests are adhering to these guidelines.

Voices from the Front Lines: An Analysis of Physicians' Reflective Narratives about Flaws with the 'System'

Physicians often express frustration with the 'system' in which they work. Over time, this frustration may put them at risk of burnout and disengagement, which may impact patient care. In this study, we aimed to understand the nature of the system flaws that physicians identified in their published narratives and to explore their self-representation as agents of change. We reviewed all reflective narratives published in four medical journals (NEJM, JAMA, CMAJ, Annals IM) between January 2015 and December 2017 (n = 282). By consensus, we identified those that addressed system flaws (n = 87). Using content and narrative analysis, we analyzed the types of flaws and the physicians' orientation to the flawed system. We identified seven recurring system flaws-five related to medical culture: failures of communication, erosive impact of the hidden curriculum, inadequate health advocacy, frenzied pace of work, and experience of stigma. Less frequently, physicians' narratives also exposed limited and disparate healthcare resources and restrictive institutional practices as impeding patient-centered care. Physicians expressed agency to create change foremost when writing about flaws related to medical culture. While physicians are challenged by system flaws, they strive to practice in ways that do not succumb to them. We saw tension between the elements outside the physician's control and those within it. This tension becomes a source of distress when the compromises that emerge from system flaws move physicians away from the values that define their professional identity.

Interprofessional training: Geriatrics and palliative care principles for primary care teams in an ACO

There is a well-described need to increase the competence of the primary care workforce in the principles of geriatrics and palliative care, and as value-based payment models proliferate, there is increased incentive for the acquisition of these skills. Through a Geriatric Workforce Enhancement Program grant, we developed an adaptable curriculum around commonly encountered topics in palliative care and geriatrics that can be delivered to multidisciplinary clinicians in primary care settings. All participants in this training were part of an Accountable Care Organization (ACO) and were motivated to improve to care for complex older adults. A needs assessment was performed on each practice or group of learners and the curriculum was adapted accordingly. With the use of patient education and screening tools with strong validity evidence, the participants were trained in the principals of geriatrics and palliative care with a focus on advance care planning and assessing for frailty and functional decline. Comparison of pre- and post-test scores demonstrated increased confidence and knowledge in goals of care and basic geriatric assessment. Participants described feeling more able to address needs, have conversations around goals of care, and more able to recognize patients who would benefit from collaboration with geriatrics and palliative care.

A Proposal for an Out-of-Range Glycemic Population Health Safety Measure for Older Adults With Diabetes

OBJECTIVE

To evaluate patient-level glycemic control and facility variation of a proposed out-of-range (OOR) measure (overtreatment [OT] [HbA1c <7% (53 mmol/mol)] or undertreatment [UT] [>9% (75 mmol/mol)]) compared with the standard measure (SM) (HbA1c <8% [64 mmol/mol]) in high-risk older adults.

RESEARCH DESIGN AND METHODS

Veterans Health Administration patients ≥65 years of age in 2012 who were taking antihyperglycemic agents in 2013 were identified. Patient-level rates and facility-level rates/rankings were calculated by age and comorbid illness burden.

RESULTS

We identified 303,097 patients who were taking antiglycemic agents other than metformin only. The study population comprised 193,689 patients with at least one significant medical, neurological, or mental health condition; 98.2% were taking a sulfonylurea and/or insulin; 55.2% were aged 65-75 years; and 44.8% were aged >75 years. The 47.4% of patients 65-75 years met the OOR measure (33.4% OT, 14% UT), and 65.7% met the SM. For patients aged >75 years, rates were 48.1% for OOR (39.2% OT; 8.9% UT) and 73.2% for SM. Facility-level rates for OOR for patients aged 65-75 years ranged from 33.7 to 60.4% (median 47.4%), with a strong inverse correlation (ρ = -0.41) between SM and OOR performance rankings. Among the best-performing 20% facilities on the SM, 14 of 28 ranked in the worst-performing 20% on the OOR measure; 12 of 27 of the worst-performing 20% facilities on the SM ranked in the best-performing 20% on the OOR measure.

CONCLUSIONS

Facility rankings that are based on an SM (potential benefits) and OOR measure (potential risks) differ substantially. An OOR for high-risk populations can focus quality improvement on individual patient evaluation to reduce the risk for short-term harms.

Dosage Adjustments Related to Young or Old Age and Organ Impairment

Differences in physiology related to young or old age and/or organ system impairment alter the absorption, distribution, metabolism, and excretion of many medications and consequently their effectiveness and toxicity. This module discusses common alterations in medication use and dosage that are required in the pediatric age group, in the elderly, and in patients with renal or hepatic disease.