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Ashraf H, Rambarat CA, Setteducato ML, Winchester DE. Implementation effort: Reducing the ordering of inappropriate echocardiograms through a point-of-care decision support tool. Am Heart J Plus 2022; 18:100185. [PMID: 38559418 PMCID: PMC10978316 DOI: 10.1016/j.ahjo.2022.100185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/01/2022] [Accepted: 07/15/2022] [Indexed: 04/04/2024]
Abstract
Study objective Reduce inappropriate transthoracic echocardiograms (TTEs) using a series of Plan-Do-Study-Act (PDSA) quality improvement cycles. Design Three PDSA cycles were designed with the first integrating a previously published decision support tool (DST) into the electronic TTE order, the second tailoring the DST to reflect the most common inappropriately ordered TTEs at our institution, and the third integrating direct clinician education. Setting Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, USA. Participants Consecutive patients were studied using the database of all TTEs performed at our institution without regard for specific patient characteristics. Interventions Three PDSA Cycles as described above. Main outcome measure Reduction in inappropriate TTEs at our institution. Results After implementing our DST during the first cycle, no difference in inappropriate TTEs was observed (relative risk [RR] 0.71, p = 0.12, 95 % confidence interval [CI] 0.46-1.09). After the second cycle, we observed a reduction in the proportion of inappropriate TTEs (RR = 0.69, p = 0.014, 95 % CI 0.5-0.94), however two of the four inappropriate TTEs targeted by the DST increased. Feedback gathered from clinicians in the third cycle showed significant knowledge gaps regarding appropriate use criteria for TTE. Conclusions At our facility, implementation of a DST failed to substantially reduce inappropriate TTEs, even when adapted to facility-specific ordering patterns. Gaps in clinician knowledge about TTEs may have contributed to the inefficacy of our DST.
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Affiliation(s)
- Hassan Ashraf
- Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
| | - Cecil A. Rambarat
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
| | - Michael L. Setteducato
- Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
| | - David E. Winchester
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, United States of America
- Cardiology Section, Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, United States of America
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Demeke E, Mekonnen A. Appropriateness of Head CT Scans at Tikur Anbessa Specialized Hospital, Ethiopia. Ethiop J Health Sci 2022; 32:359-368. [PMID: 35693559 PMCID: PMC9175230 DOI: 10.4314/ejhs.v32i2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022] Open
Abstract
Background Overutilization of advanced diagnostic imaging modalities strains health care systems, especially in resource limited setups. The aim of this study is to identify magnitude of inappropriate Head Computed Tomography scans at Tikur Anbessa Specialized Hospital. Methods Retrospective cross-sectional study was conducted at Tikur Anbessa Specialized Hospital, Radiology department, among patients getting Head Computed Tomography examinations in the period of August 2018- November 2018. Appropriateness of each scan was assessed using the American College of Radiology Appropriateness Criteria. Result Of the 443 Head Computed Tomography scans assessed, 61.6% were done for male patients and the mean age of patients scanned is 35. Children younger than 14yrs of age constituted 17.2%. No contrast was used in 63.9% of the scans and 64.3% were initial imaging with no prior study for similar indication. Out of the scans evaluated, 11.7% were inappropriate. Headache (38.5%), Seizure (23.1%) and Head trauma (23.1%) were the commonest indications for inappropriate scan. Scans done for cerebrovascular disease were 240 times more likely to be appropriate. Large number of inappropriate scans were requested from central triage (33.3%) and adult emergency (26.2%). Pediatric department requested inapproprieate scans in 11.9% of the cases. Residents requested majority of inappropriate scans (82.3%). Inappropriateness was associated with use of contrast agent and having only incidental outcomes. Conclusion A large number of inappropriate Head Computed Tomography scans are being done. Mechanisms such as preauthorization by radiologists, increasing awareness by medical students, physicians, radiology residents and radiologists and preparing customized imaging appropriateness guidelines should be implemented.
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Affiliation(s)
- Etsehiwot Demeke
- Department of Radiology, College of Health sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebe Mekonnen
- Department of Radiology, College of Health sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Kim K, Bae JS, Kim JS, Jung SL, Jung CK. Diagnostic Performance of Thyroid Core Needle Biopsy Using the Revised Reporting System: Comparison with Fine Needle Aspiration Cytology. Endocrinol Metab (Seoul) 2022; 37:159-169. [PMID: 35255608 PMCID: PMC8901962 DOI: 10.3803/enm.2021.1299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/06/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND We aim to validate the diagnostic performance of thyroid core needle biopsy (CNB) for diagnosing malignancy in clinical settings to align with the changes made in recently updated thyroid CNB guidelines. METHODS We retrospectively analyzed 1,381 thyroid CNB and 2,223 fine needle aspiration (FNA) samples. The FNA and CNB slides were interpreted according to the Bethesda System for Reporting Thyroid Cytopathology and updated practice guidelines for thyroid CNB, respectively. RESULTS Compared to FNA, CNB showed lower rates of inconclusive results categories I (2.8% vs. 11.2%) and III (1.2% vs. 6.2%), and higher rates of categories II (60.9% vs. 50.4%) and IV (17.5% vs. 2.0%). The upper and lower bounds of the risk of malignancy (ROM) for category IV of CNB were 43.2% and 26.6%, respectively. The CNB subcategory IVb with nuclear atypia had a higher ROM than the subcategory without nuclear atypia (40%-62% vs. 23%-36%). In histologically confirmed cases, there was no significant difference in the diagnostic performance between CNB and FNA for malignancy. However, neoplastic diseases were more frequently detected by CNB than by FNA (88.8% vs. 77.6%, P=0.046). In category IV, there was no difference in unnecessary surgery rate between CNB and FNA (4.7% vs. 6.9%, P=0.6361). CONCLUSION Thyroid CNB decreased the rate of inconclusive results and showed a higher category IV diagnostic rate than FNA. The revised guidelines for thyroid CNB proved to be an excellent reporting system for assessing thyroid nodules.
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Affiliation(s)
- Kwangsoon Kim
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Ja Seong Bae
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Jeong Soo Kim
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - So Lyung Jung
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Chan Kwon Jung
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul,
Korea
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul,
Korea
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Erkmen CP, Randhawa S, Patterson F, Kim R, Weir M, Ma GX. Quantifying Benefits and Harms of Lung Cancer Screening in an Underserved Population: Results From a Prospective Study. Semin Thorac Cardiovasc Surg 2021; 34:691-700. [PMID: 34091014 DOI: 10.1053/j.semtcvs.2021.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/17/2022]
Abstract
Lung cancer screening with annual low-dose computed tomography reduces lung cancer death by 20-26%. However, potential harms of screening include false-positive results, procedures from false positives, procedural complications and failure to adhere to follow-up recommendations. In diverse, underserved populations, it is unknown if benefits of early lung cancer detection outweigh harms. We conducted a prospective observational study of lung cancer screening participants in an urban, safety-net institution from September 2014 to June 2020. We measured benefits of screening in terms of cancer diagnosis, stage, and treatment. We measured harms of screening by calculating false-positive rate, procedures as a result of false positive screens, procedural complications, and failure to follow-up with recommended care. Of patients with 3-year follow up, we measured these same outcomes in addition to compliance with annual screening. Of 1509 participants, 55.6% were African American, 35.2% White, 8.1% Hispanic, and 0.5% Asian. Screening resulted in cancer detection and treatment in 2.8%. False positive and procedure as a result of a false positive occurred in 9.2% and 0.8% of participants, respectively with no major complications from diagnostic procedures or treatment. Adherence to annual screening was low, 18.7%, 3.7%, and 0.4% at 1, 2, and 3 years after baseline screening respectively. Multidisciplinary lung cancer screening in a safety-net institution can successfully detect and treat lung cancer with few harms of false-positive screens, procedure after false-positive screens and major complications. However, adherence to annual screening is poor.
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Affiliation(s)
- Cherie P Erkmen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Philadelphia, Pennsylvania.
| | - Simran Randhawa
- Department of Thoracic Surgery, Washington University, St. Louis, Missouri
| | - Freda Patterson
- University of Delaware, Behavioral Health and Nutrition, Newark, Delaware
| | - Rachel Kim
- Department of Surgery, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Mark Weir
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Grace X Ma
- Center for Asian Health, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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Laan BJ, van Horrik TMZXK, Nanayakkara PWB, Geerlings SE. How many urinalysis and urine cultures are necessary? Eur J Intern Med 2021; 83:58-61. [PMID: 32830036 DOI: 10.1016/j.ejim.2020.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Urinalysis and urine culture are two of the most commonly ordered tests. A positive urine test in asymptomatic patients often leads to overtreatment. Antimicrobials for asymptomatic bacteriuria is one of the most common unnecessary treatments. We aimed to explore the current ordering patterns of urinalysis and cultures. METHODS This is a substudy of the multicentre RICAT-trial, a successful quality improvement project to reduce inappropriate use of intravenous and urinary catheters in seven hospitals in the Netherlands. Adult patients with a (central or peripheral) venous or urinary catheter admitted to internal medicine and non-surgical subspecialty wards were eligible for inclusion. Data were collected every other week during baseline (seven months) and intervention periods (seven months). The primary outcome was the proportion of urine cultures performed following a negative urinalysis, i.e. dipstick and/or microscopic analysis, within 24 h. RESULTS Between September 2016 and April 2018, we included 3748 patients, of which 3111 (83%) were admitted from the emergency department. Urinalysis and/or urine cultures were obtained in 2610 (70%) of 3748 patients. 626 (23.7%) of 2636 urine cultures and 1351 (55.8%) of 2419 microscopic analysis were unnecessary performed after a negative urinalysis. Cancelling urine testing orders after a negative dipstick would have saved almost € 19.500 during the study period in these seven hospitals. CONCLUSION Unnecessary urine testing is frequent in non-surgical patients in the Netherlands. We need to take action to reduce unnecessary urinalysis and cultures, and thereby probably reduce overtreatment of asymptomatic bacteriuria.
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Affiliation(s)
- Bart J Laan
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Tessa M Z X K van Horrik
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Amsterdam UMC, Vrije Universiteit Amsterdam, Internal Medicine, Acute Medicine, de Boelelaan 1117, Amsterdam, The Netherlands
| | - Suzanne E Geerlings
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
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Laan BJ, Vos MC, Maaskant JM, van Berge Henegouwen MI, Geerlings SE. Prevalence and risk factors of inappropriate use of intravenous and urinary catheters in surgical and medical patients. J Hosp Infect 2020; 105:698-704. [PMID: 32422310 DOI: 10.1016/j.jhin.2020.04.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previously, the RICAT (Reduction of Inappropriate use of intravenous and urinary CATheters) study had been conducted by ourselves to reduce inappropriate use of intravenous and urinary catheters in medical wards to prevent healthcare-associated infections. AIM To compare surgical and medical wards, and to determine risk factors for inappropriate catheter use. METHODS A cross-sectional study was performed from October, 2017, to May, 2018, in surgical wards of two university hospitals in the Netherlands. Patients were prospectively observed every other week for seven months. Inappropriate use was compared with non-surgical wards in the RICAT study. FINDINGS In all, 409 surgical patients were included, and they were compared with 1781 medical patients. Inappropriate use occurred in 36 (8.5%) out of 425 peripheral intravenous catheters in 373 surgical patients, compared to 400 (22.9%) out of 1747 peripheral intravenous catheters in 1665 medical patients, a difference of 14.4% (95% confidence interval (CI): 11.1-17.8; P < 0.001). Inappropriate use of urinary catheters occurred in 14 (10.4%) out of 134 surgical patients, compared to 105 (32.4%) out of 324 medical patients, a difference of 22.0% (95% CI: 14.7-29.2; P < 0.001). Subgroup analysis in the two university hospitals confirmed these differences. The main risk factor for inappropriate use of peripheral intravenous catheters was admission in medical wards (odds ratio (OR): 3.50; 95% CI: 2.15-5.69), which was also one of the main risk factors for urinary catheters (OR: 2.75; 95% CI: 1.36-5.55). CONCLUSION Inappropriate use of catheters is more common in medical wards compared to surgical wards. Prevention strategies to reduce healthcare-associated infections should primarily focus on sites with high prevalence of inappropriate use.
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Affiliation(s)
- B J Laan
- Internal Medicine, Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - M C Vos
- Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J M Maaskant
- Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - S E Geerlings
- Internal Medicine, Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Menser T, Muniz Castro J, Lopez A, Jones SL, Kash BA, Sherman V, Tariq N. Post-bariatric surgery lab tests: are they excessive and redundant? Surg Endosc 2020; 34:4626-31. [PMID: 31676922 DOI: 10.1007/s00464-019-07216-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Following bariatric surgery, ongoing postoperative testing is required to measure nutritional deficiencies; the purpose of this study was to quantify the prevalence of these nutritional deficiencies based on two-year follow-up tests at recommended time points. METHODS AND PROCEDURES A retrospective data analysis was conducted of all laboratory tests for bariatric patients who underwent surgery between May 2016 and January 2018 with available lab data (n = 397). Results for nine different nutritional labs were categorized into six recommended postoperative time periods based on time elapsed since the procedure date. Binary variables were created for each laboratory result to calculate descriptive statistics of abnormalities for each lab test over time and used in the individual GEE logistic regression models. Grouped logistic regression examined the total nutritional deficiencies of the nine combined nutrients considering total available labs. RESULTS Multiple lab tests indicated a very low frequency of abnormalities (e.g., Vitamin A, Vitamin B12, Copper, and Folate). Many of the nine included nutritional labs had an average deficiency of less than 10% across all time points. The grouped logistic model found preoperative nutritional deficiency to be predictive of postoperative nutritional deficiency (OR 3.70, p < 0.001). CONCLUSIONS We found the vast majority of routine lab test results to be normal at multiple time points. Current practice can add up to significant lab expenses over time. The frequency of postoperative testing in this population may be redundant and of very little value. Unnecessary follow-up laboratory testing costs the patients and the health care system in both time and resources. Patients with preoperative deficiencies appear to be at higher risk for nutritional deficiencies when compared to bariatric surgery patients that did not have preoperative nutritional deficiencies. Future research should focus on defining cost effective postoperative lab testing guidelines for at risk bariatric patients.
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Lei C, Wei W, Liu Z, Xiong Q, Yang C, Yang M, Zhang L, Zhu T, Zhuang X, Liu C, Liu Z, Tian J, Wang K. Mammography-based radiomic analysis for predicting benign BI-RADS category 4 calcifications. Eur J Radiol 2019; 121:108711. [PMID: 31677544 DOI: 10.1016/j.ejrad.2019.108711] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 10/11/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE We developed and validated a radiomic model based on mammography and assessed its value for predicting the pathological diagnosis of Breast Imaging Reporting and Data System (BI-RADS) category 4 calcifications. MATERIALS AND METHODS Patients with a total of 212 eligible calcifications were recruited (159 cases in the primary cohort and 53 cases in the validation cohort). In total, 8286 radiomic features were extracted from the craniocaudal (CC) and mediolateral oblique (MLO) images. Machine learning was used to select features and build a radiomic signature. The clinical risk factors were selected from the independent clinical factors through logistic regression analyses. The radiomic nomogram incorporated the radiomic signature and an independent clinical risk factor. The diagnostic performance of the radiomic model and the radiologists' empirical prediction model was evaluated by the area under the receiver operating characteristic curve (AUC). The differences between the various AUCs were compared with DeLong's test. RESULTS Six radiomic features and the menopausal state were included in the radiomic nomogram, which discriminated benign calcifications from malignant calcifications with an AUC of 0.80 in the validation cohort. The difference between the classification results of the radiomic nomogram and that of radiologists was significant (p < 0.05). Particularly for patients with calcifications that are negative on ultrasounds but can be detected by mammography (MG+/US- calcifications), the identification ability of the radiomic nomogram was very strong. CONCLUSIONS The mammography-based radiomic nomogram is a potential tool to distinguish benign calcifications from malignant calcifications.
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Affiliation(s)
- Chuqian Lei
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China; Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, 510080, China
| | - Wei Wei
- School of Electronics and Information, Xi'an Polytechnic University, Xi'an, 710000, China; Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, 710126, China; CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China
| | - Zhenyu Liu
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China
| | - Qianqian Xiong
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China; Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, 510080, China
| | - Ciqiu Yang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Mei Yang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Liulu Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Teng Zhu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
| | - Xiaosheng Zhuang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China; Shantou University Medical College, Shantou, 515041, Guangdong, China
| | - Chunling Liu
- Department of Radiology, Guangdong Provincial People's Hospital, Guangzhou, 510080, China
| | - Zaiyi Liu
- Department of Radiology, Guangdong Provincial People's Hospital, Guangzhou, 510080, China
| | - Jie Tian
- Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, 710126, China; CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China; University of Chinese Academy of Sciences, Beijing, 100190, China.
| | - Kun Wang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, 510080, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
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Abstract
Many errors can be made in diagnosis: underdiagnosis, misdiagnosis, and overdiagnosis. While underdiagnosis and misdiagnosis are clear errors, in overdiagnosis, a true abnormality is discovered, but detection does not benefit the patient. Harm occurs when patients are further evaluated and treated unnecessarily as a result of making a diagnosis that would never have affected the patient if the diagnosis had not been made. Several phenomena point to potential overdiagnosis: when delayed or missed diagnoses do not result in harm; when there is increased detection of a disease, but no change in the outcome; and when randomized trials show no benefit from the diagnosis. Some might say that there is always benefit in knowing, but the adverse effects of overdiagnosis are well documented. We will need to educate ourselves and our colleagues about the potential for harm from overdiagnosis, and learn how to balance the potential benefit of a diagnosis against the risk of overdiagnosis.
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Affiliation(s)
- Virginia A Moyer
- Magíster en Salud Pública Vicepresidente, Mantenimiento de la Certificación y Calidad. Junta Estadounidense de Pediatría.
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Corral-Gudino L, Rivas-Lamazares A, González-Fernández A, Rodríguez-María M, Aguilera-Sanz C, Tierra-Rodríguez A, Runza-Buznego P, Hernández-Martín E, Ortega-Gil M, Bahamonde-Carrasco A. Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization. Eur J Intern Med 2019; 66:92-98. [PMID: 31230851 DOI: 10.1016/j.ejim.2019.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value. METHODS We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices. RESULTS BR or DR at admission were recommended in 37% (32-44) and 24% (19-30) of the patients respectively. In 81% (71-87) and 33% (21-45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92-98) had VL and 25% (19-32) UC. VL were not used in 10% (6-12), UC had no indications for insertion in 21% (11-35) and for maintenance in 31% (12-46) patients. Fifty-seven percent (49-64) of the patients were administered VTP and 69% (62-76) were prescribed SUP. Twenty-two percent (15-31) of patients with VTP and 52% (43-60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53-75) with BAF was prescribed in 38% (25-52) of them. An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results. CONCLUSION These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.
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Affiliation(s)
- Luis Corral-Gudino
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain; Internal Medicine Department, Hospital Universitario Río Hortega, Calle Dulzaina n°2, 47012 Valladolid, Spain.
| | - Alicia Rivas-Lamazares
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Ana González-Fernández
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Miriam Rodríguez-María
- Hospital Pharmacy Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Carmen Aguilera-Sanz
- Haematology Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Ana Tierra-Rodríguez
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Paula Runza-Buznego
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Ester Hernández-Martín
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Martín Ortega-Gil
- Nurse Supervisor of Quality Improvement, Nurse Division, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
| | - Alberto Bahamonde-Carrasco
- Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
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Dixon B, Gray J, Elliot N, Shand B, Lynn A. A multifaceted programme to reduce the rate of tongue-tie release surgery in newborn infants: Observational study. Int J Pediatr Otorhinolaryngol 2018; 113:156-163. [PMID: 30173975 DOI: 10.1016/j.ijporl.2018.07.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/25/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES A programme was introduced in Canterbury, New Zealand to evaluate the diagnosis and treatment of frenulum releases in newborn infants with suspected tongue-tie (ankyloglossia). The primary goals were to support breastfeeding and ensure that unnecessary surgery was avoided. METHODS Local healthcare professionals reached consensus on a pathway for improving management of infants with tongue-tie and breast-feeding difficulties. This embedded an expert breast-feeding review and assessment of lingual function using a validated method, the Bristol Tongue-tie Assessment Tool (BTAT). Infants with breastfeeding problems related to tongue-tie had a frenotomy at a hospital outpatient clinic. An education programme was developed to support introduction of the new clinical pathway and included seminars and online information for healthcare professionals and the general public. RESULTS Frenotomy intervention rate reduced markedly from 11.3% in 2015 to 3.5% by mid-2017. Feeding methods were not different before or after surgery between infants who received a frenotomy and those who did not. Initially, the BTAT threshold for frenotomy was set at ≤5, however the final clinical pathway combined a breastfeeding assessment and a BTAT threshold of ≤4. The education programs assisted with the changes in practice, while increased use of the clinician guidance and public health information websites confirmed growing awareness of tongue-tie and community breastfeeding support. CONCLUSIONS Establishing consistent multidisciplinary assessment of tongue-tie in infants with feeding difficulties led to a marked reduction in frenotomy intervention rate. 23% of the frenotomy group in the 2016 audit showed a significant improvement in the ability to breastfeed, but overall there was no difference in the feeding pattern of infants who either received or were declined a frenotomy. The development of a supportive education programme and availability of online information about tongue-tie for health professionals and consumers contributed to successful uptake of the new clinical pathway.
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Affiliation(s)
- Bronwyn Dixon
- Neonatal Department, Christchurch Women's Hospital, Christchurch, New Zealand.
| | - Juliet Gray
- Hospital Dental Service, Christchurch Hospital, Christchurch, New Zealand.
| | - Nikki Elliot
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand.
| | - Brett Shand
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand.
| | - Adrienne Lynn
- Neonatal Department, Christchurch Women's Hospital, Christchurch, New Zealand.
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Seo M, Langabeer II JR. Determinants of Potentially Unnecessary Cervical Cancer Screenings in American Women. J Prev Med Public Health 2018; 51:181-187. [PMID: 30071705 PMCID: PMC6078914 DOI: 10.3961/jpmph.18.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 06/01/2018] [Indexed: 11/23/2022] Open
Abstract
Objectives To identify factors responsible for potentially clinically unnecessary cervical cancer screenings in women with prior hysterectomy. Methods A retrospective cross-sectional study was conducted using the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS). This study targeted adult women and examined whether they received a both a Papanicolaou (Pap) test and undergone a hysterectomy in the last three years. We conducted multivariate analyses, including weighted proportions and odds ratios (ORs), based on the modified BRFSS weighting method (raking). The inclusion criteria were adult women (>18 years old) who reported having received a Pap test within the last 3 years. Results Of all women (n=252 391), 72 366 had received a Pap test, and 32 935 of those women (45%, or 12.5 million, weighted) had a prior hysterectomy. We found that age, race/ethnicity, marital status, family income, health status, time since last routine checkup, and health insurance coverage were all significant predictors. Black, non-Hispanic women were 2.23 times more likely to receive Pap testing after a hysterectomy than white women (OR, 2.23; 95% confidence interval [CI], 1.99 to 2.50). Similarly, the odds for Hispanic women were 2.34 times higher (OR, 2.34; 95% CI, 1.97 to 2.80). The odds were also higher for those who were married (OR, 1.17; 95% CI, 1.08 to 1.27), healthier (OR, 1.24; 95% CI, 1.14 to 1.35), and had health insurance (OR, 1.54; 95% CI, 1.28 to 1.84), after controlling for confounders. Conclusions We conclude that women may potentially receive Pap tests even if they are not at risk for cervical cancer, and may not be adequately informed about the need for screenings. We recommend strategies to disseminate recommendations and information to patients, their families, and care providers.
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Affiliation(s)
- Munseok Seo
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA
| | - James R. Langabeer II
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA
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Ena J, Navarro-Corral A, Pasquau F, Zapatero-Gaviria A, Barba-Martín R. [Experience of a single-centre in the preparation of choosing wisely lists in Internal Medicine]. J Healthc Qual Res 2018; 33:96-100. [PMID: 31610984 DOI: 10.1016/j.jhqr.2018.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/18/2017] [Accepted: 01/08/2018] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To identify areas for improvement, using a local list of interventions with low diagnostic and therapeutic usefulness for the 5 Related Diagnostic Groups, as well as the 5 main diagnoses most frequently seen in the hospital outpatient clinic. METHOD A literature review method was used, supplemented with a Delphi process with 2 rounds. In the first round, participants in the selection process identified low-value interventions in relation to the most frequently observed diagnoses. In the second round, those interventions with lower usefulness were selected based on their frequency, cost, and risk to the patient. RESULTS Out of a total of 100 recommendations made by 19 scientific societies, 23 received the highest number of votes in the first round. In the second round, 5 recommendations were selected for inpatients and 5 recommendations for outpatients. CONCLUSIONS A simple method is described for developing a local guide to reduce the use of unnecessary medical interventions.
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Affiliation(s)
- J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, España.
| | - A Navarro-Corral
- Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, España
| | - F Pasquau
- Servicio de Medicina Interna, Hospital Marina Baixa, Villajoyosa, Alicante, España
| | - A Zapatero-Gaviria
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - R Barba-Martín
- Servicio de Medicina Interna, Hospital Rey Juan Carlos, Móstoles, Madrid, España
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DuBois JM, Chibnall JT, Anderson EE, Walsh HA, Eggers M, Baldwin K, Dineen KK. Exploring unnecessary invasive procedures in the United States: a retrospective mixed-methods analysis of cases from 2008-2016. Patient Saf Surg 2017; 11:30. [PMID: 29270224 PMCID: PMC5735893 DOI: 10.1186/s13037-017-0144-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/23/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unnecessary invasive procedures risk harming patients physically, emotionally, and financially. Very little is known about the factors that provide the motive, means, and opportunity (MMO) for unnecessary procedures. METHODS This project used a mixed-methods design that involved five key steps: (1) systematically searching the literature to identify cases of unnecessary procedures reported from 2008 to 2016; (2) identifying all medical board, court, and news records on relevant cases; (3) coding all relevant records using a structured codebook of case characteristics; (4) analyzing each case using a MMO framework to develop a causal theory of the case; and (5) identifying typologies of cases through a two-step cluster analysis using variables hypothesized to be causally related to unnecessary procedures. RESULTS Seventy-nine cases met inclusion criteria. The mean number of documents or sources examined for each case was 36.4. Unnecessary procedures were performed for at least five years in most cases (53.2%); 56.3% of the cases involved 30 or more patients, and 37.5% involved 100 or more patients. In nearly all cases the physician was male (96.2%) and working in private practice (92.4%); 57.0% of the physicians had an accomplice, 48.1% were 50 years of age or older, and 40.5% trained outside the U.S. The most common motives were financial gain (92.4%) and suspected antisocial personality (48.1%), followed by poor problem-solving or clinical skills (11.4%) and ambition (3.8%). The most common environmental factors that provided opportunity for unnecessary procedures included a lack of oversight (40.5%) or oversight failures (39.2%), a corrupt moral climate (26.6%), vulnerable patients (20.3%), and financial conflicts of interest (13.9%). CONCLUSIONS Unnecessary procedures usually appear motivated by financial gain and occur in settings that have oversight problems. Preventive efforts should focus on early detection by peers and institutions, and decisive action by medical boards and federal prosecutors.
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Affiliation(s)
- James M. DuBois
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - John T. Chibnall
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1438 S. Grand Blvd, St. Louis, MO 63104 USA
| | - Emily E. Anderson
- Neiswanger Institute for Bioethics & Health Policy, Loyola University Chicago Stritch School of Medicine, 2160 S. First Avenue, Maywood, IL 60153 USA
| | - Heidi A. Walsh
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - Michelle Eggers
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - Kari Baldwin
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - Kelly K. Dineen
- Creighton University, School of Law, 2500 California Plaza, Omaha, NE 68178 USA
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Trumbic B, Zéphir H, Ouallet JC, Le Page E, Laplaud D, Bensa C, de Sèze J. Is the Choosing Wisely ® campaign model applicable to the management of multiple sclerosis in France? A GRESEP pilot study. Rev Neurol (Paris) 2017; 174:28-35. [PMID: 29128151 DOI: 10.1016/j.neurol.2017.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/11/2017] [Accepted: 06/15/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Launched in the US in 2012, Choosing Wisely® is a campaign promoted by the American Board of Internal Medicine (ABIM) Foundation with the goal of improving healthcare effectiveness by avoiding wasteful or unnecessary medical tests, treatments and procedures. It uses concise recommendations produced by national medical societies to start discussions between physicians and patients on the relevance of these services as part of a shared decision-making process. The Multiple Sclerosis Focus Group (Groupe de Reflexion Autour de la Sclérose en Plaques; GRESEP) undertook a pilot study to assess the relevance and feasibility of this approach in the management of multiple sclerosis (MS) in France. METHODS Recommendations were developed using the formal consensus method from the guidelines of the French National Health Authority (HAS). A steering committee selected the themes and drafted concise evidence reviews. An independent rating group then assessed these recommendations for clarity, relevance and feasibility. RESULTS Seven recommendations were accepted: (1) avoid systematic ordering of multimodal evoked potential studies for diagnosing MS; (2) do not treat MS relapses with low-dose oral corticosteroids; (3) when treating MS relapse with high-dose corticosteroids, the systematic use of the intravenous route is unnecessary if the oral route can be used; (4) systematic hospitalization is not necessary for treating MS relapse with high-dose corticosteroid therapy, particularly if the oral route is used, except for the first treated relapse and the presence of exclusion or non-eligibility criteria; (5) in the absence of clinical signs or symptoms of urinary infection, avoid systematic screening with urine microscopy and culture before the administration of corticosteroid therapy for MS relapse in patients using intermittent self-catheterization; (6) avoid antibiotic treatment of clinically asymptomatic MS patients using intermittent self-catheterization, even if urine microscopy and culture reveal the presence of microorganisms; and (7) avoid introducing symptomatic drug treatment for MS-related fatigue. CONCLUSION This pilot study, the first of its kind in France, has demonstrated the relevance and feasibility of adapting the Choosing Wisely® model to MS by practitioners specializing in the disorder. However, the acceptability of these recommendations by other practitioners in other specialist fields as well as their impact on everyday clinical practices now need to be studied.
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Affiliation(s)
- B Trumbic
- Affinités Santé, 59 Rue du Faubourg Saint-Antoine, 75011 Paris, France; Cap Evidence, 105, rue des Moines, 75017 Paris, France.
| | - H Zéphir
- Pôle de Neurologie, Hôpital Roger-Salengro, CHRU de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - J-C Ouallet
- Pôle des Neurosciences Cliniques, Service de Neurologie, CHU de Bordeaux Pellegrin Tripode, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - E Le Page
- Service de Neurologie, CHU de Rennes, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
| | - D Laplaud
- Service de Neurologie, CHU de Nantes, 44093 Nantes cedex, France; Inserm UMR1064, Pavillon Jean-Monnet - Hôtel-Dieu, 30, boulevard Jean-Monnet, 44093 Nantes 01, France
| | - C Bensa
- Service de Neurologie, Fondation Rothschild, 25, rue Manin, 75019 Paris, France
| | - J de Sèze
- Service de neurologie, CHU de Strasbourg, Inserm UMR 1119, CIC de Strasbourg Inserm 1434, Fédération de Médecine translationnelle de Strasbourg (FMTS), 11, rue Humann, 67000 Strasbourg, France
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Abstract
Within the framework of the Choosing wisely initiative of the German Society for Internal Medicine, all scientific societies associated with internal medicine were requested to highlight the unnecessary or underused medical tests or procedures out of the 60 defined examples, which are of immediate relevance within the doctor-patient interaction. Each of the 12 scientific internal medicine societies compiled and substantiated 2 recommendations. This resulted in a spectrum of important recommendations covering the entire field of internal medicine. In difficult situations these recommendations should contribute to developing and supporting the dialogue with patients on an evidence-based level.
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Affiliation(s)
- U R Fölsch
- Klinik für Innere Medizin 1, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 12, 24105, Kiel, Deutschland.
| | - G Hasenfuß
- Klinik für Kardiologie und Pneumologie, Zentrum für Innere Medizin, Georg-August-Universität Göttingen, Göttingen, Deutschland
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Domínguez Bustillo L, Barrasa Villar JI, Castán Ruíz S, Moliner Lahoz FJ, Aibar Remón C. [Use of ineffective practices in Primary Health Care: professional opinions]. ACTA ACUST UNITED AC 2014; 29:220-8. [PMID: 24928717 DOI: 10.1016/j.cali.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To estimate the frequency of ineffective practices in Primary Health Care (PHC) based on the opinions of clinical professionals from the sector, and to assess the significance, implications and factors that may be contributing to their continuance. MATERIAL AND METHODS An on line survey of opinion from a convenience sample of 575 professionals who had published articles over the last years in Atención Primaria and Semergen medical journals. RESULTS A total of 212 professionals replied (37%). For 70.6% (95% confidence interval [CI] 64.5 to 73.3) the problem of ineffective practices is frequent or very frequent in PHC, and rate their importance with an average score of 7.3 (standard deviation [SD]=1.8) out of 10. The main consequences would be endangering the sustainability of the system (48.1%; 95% CI, 41.2 to 54.9) and harming patients (32.1%; 95% CI, 25.7 to 38.5). These ineffective practices are the result of the behaviour of the patients themselves (28%; 95% CI, 22.6 to 35.0) workload (26.4%; 95% CI, 20.3 to 32.5), and the lack of the continuous education (19.3%; 95% CI, 13.9 to 24.7). Clinical procedures of greatest misuse are the prescribing of antibiotics for certain infections, the frequency of cervical cancer screening, rigorous pharmacological monitoring of type 2 diabetes in patients over 65 years, the use of psychotropic drugs in the elderly, or the use of analgesics in patients with hypertension or renal failure. CONCLUSIONS The use of ineffective procedures in PHC is considered a very important issue that negatively affects many patients and their treatment, and possibly endangering the sustainability of the system and causing harm to patients.
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