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Kronlage SC, Lomis MJ, Whitaker EA. Clinic Carpal Tunnel Release Surgery Outcomes and High-Value Care. Cureus 2023; 15:e42254. [PMID: 37605705 PMCID: PMC10440051 DOI: 10.7759/cureus.42254] [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] [Accepted: 07/13/2023] [Indexed: 08/23/2023] Open
Abstract
As healthcare costs continue to rise, the importance of delivering high-value healthcare increases. The volume of carpal tunnel release surgeries performed annually generates a significant cost burden for the healthcare system. The fundamental expenses of carpal tunnel release surgery are facility fees, anesthesia fees, and surgeon fees. Performing open carpal tunnel release surgeries in the clinic utilizing local anesthesia and field sterilization minimizes facility and anesthesia costs. We compared patient outcomes, as measured by infection and revision rates, between hospital-based, ambulatory surgery center-based, and clinic-based carpal tunnel release operations. Three hundred and eighty-eight patients were treated with isolated mini-open carpal tunnel release procedures by three fellowship-trained hand surgeons: 12 patients had hospital-based procedures, 229 had ASC-based procedures, and 147 had clinic-based procedures. All procedures were performed using a mini-open approach. No patients were diagnosed with deep infections post-procedurally, irrespective of venue. Our results show no significant difference in outcomes between venues. Therefore, we conclude that the outcomes of open carpal tunnel release surgeries performed in the clinic were not inferior to carpal tunnel release operations performed at the ambulatory surgery center or the hospital. The cost savings from field sterilization, local anesthesia, and the absence of a facility fee provide an opportunity to expand high-value care.
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Affiliation(s)
- Steven C Kronlage
- Hand and Upper Extremity Surgery, Andrews Institute for Orthopaedic and Sports Medicine, Gulf Breeze, USA
| | - Mitchell J Lomis
- College of Medicine, Augusta University Medical College of Georgia, Athens, USA
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2
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Stillerman A, Altman L, Peña G, Cua G, Goben A, Walden AL, Atkins MS. Advancing Trauma-Informed Care in Hospitals: The Time Is Now. Perm J 2023; 27:16-20. [PMID: 36428252 PMCID: PMC10013720 DOI: 10.7812/tpp/22.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Audrey Stillerman
- Department of Family and Community Medicine, Office of Community Engagement and Neighborhood Health Partnerships, University of Illinois Chicago, Chicago, IL, USA.,Illinois ACEs Response Collaborative, Chicago, IL, USA
| | - Lara Altman
- Illinois ACEs Response Collaborative, Chicago, IL, USA.,School of Education and Social Policy, Northwestern University, Evanston, IL, USA
| | - Gabriela Peña
- Office of the Vice Chancellor for Diversity, Equity, and Engagement, University of Illinois Chicago, Chicago, IL, USA
| | - Grace Cua
- Center for Clinical and Translational Science, University of Illinois Chicago, Chicago, IL, USA
| | - Abigail Goben
- Library of the Health Sciences-Chicago, University of Illinois Chicago, Chicago, IL, USA
| | - Angela L Walden
- Office of the Vice Chancellor for Diversity, Equity, and Engagement, University of Illinois Chicago, Chicago, IL, USA
| | - Marc S Atkins
- Center for Clinical and Translational Science, University of Illinois Chicago, Chicago, IL, USA.,Institute for Juvenile Research, University of Illinois Chicago, Chicago, IL, USA
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3
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Matchett CL, Nordhues HC, Bashir MU, Merry SP, Sawatsky AP. Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study. J Gen Intern Med 2023; 38:42-48. [PMID: 35411536 PMCID: PMC9849602 DOI: 10.1007/s11606-022-07556-8] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/30/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). OBJECTIVE The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. DESIGN The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. PARTICIPANTS The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. APPROACH The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. KEY RESULTS GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. CONCLUSIONS IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.
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Affiliation(s)
- Caroline L Matchett
- Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA.
| | - Hannah C Nordhues
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Usmaan Bashir
- Division of General Medicine, Geriatrics and Palliative Care, University of Virginia Health, Charlottesville, VA, USA
| | - Stephen P Merry
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam P Sawatsky
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
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4
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Carey ME, Gilmore BL, Lawler MJ, Hoddwells M, Hale AJ, Repp AB. Integrating High-Value Care Concepts into Preclinical Medical Education: A Practical Approach. J Med Educ Curric Dev 2023; 10:23821205231173490. [PMID: 37163150 PMCID: PMC10164249 DOI: 10.1177/23821205231173490] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 04/17/2023] [Indexed: 05/11/2023]
Abstract
Objectives Although some US medical schools have incorporated high-value care into their preclinical curriculum, there is no standardized approach and major curricular overhaul can be prohibitively onerous. The objectives of this study were to develop a feasible and effective high-value care curriculum, integrate it into an existing pre-clinical course, and assess student and faculty perceptions of the educational value of the curriculum. Methods Between 2019 and 2021, University of Vermont preclinical medical students participating in the Students & Trainees Advocating for Resource Stewardship (STARS) program collaborated with the faculty director of the preclinical pathophysiology course to identify Choosing Wisely® recommendations relevant to course topics. For each recommendation, STARS students created a case-based, multiple-choice question, answer key and rationale to accompany standard course materials. At each year's course completion, participating students and faculty were invited to complete a survey to assess their perceptions of the curriculum. Results Seventeen case-based questions were integrated into existing pathophysiology course sessions each year. Over the 3-year period, 420 students and 35 teaching faculty participated in the course, and 171 (40.7%) students and 24 (68.6%) faculty completed the post-course survey. Among student respondents, 80% agreed the curriculum increased their awareness of high-value care, 79% agreed they would be more likely to apply high-value care concepts during their medical career, and 92% agreed it was valuable to discuss Choosing Wisely® recommendations during the second year of medical school. Conclusion A student-led initiative to incorporate high-value care content within an existing pre-clinical course was well-received by medical students, who reported increased awareness of and intention to apply high-value care principles. This model may offer a feasible and effective approach to high-value care education in the absence of an extensive formal curriculum.
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Affiliation(s)
- Magalie E. Carey
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittany L. Gilmore
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Michael J. Lawler
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Max Hoddwells
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Andrew J. Hale
- Department of Medicine, The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Allen B. Repp
- Department of Medicine, The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Saenger PM, Ornstein KA, Garrido MM, Lubetsky S, Bollens-Lund E, DeCherrie LV, Leff B, Siu AL, Federman AD. Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period. J Am Geriatr Soc 2022; 70:1374-1383. [PMID: 35212391 DOI: 10.1111/jgs.17706] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 09/08/2021] [Revised: 12/20/2021] [Accepted: 01/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. METHODS A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. RESULTS Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p = 0.01) lower. CONCLUSIONS HaH combined with 30-day post-acute transition care was less costly than inpatient care.
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Affiliation(s)
- Pamela M Saenger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health and Partnered Evidence-based Policy Resource Center (PEPReC), Boston VA Healthcare System, Boston, Massachusetts, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Alex D Federman
- Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Cihakova D, Streiff MB, Menez SP, Chen TK, Gilotra NA, Michos ED, Marr KA, Karaba AH, Robinson ML, Blair PW, Dioverti MV, Post WS, Cox AL, R Antar AA. High-value laboratory testing for hospitalized COVID-19 patients: a review. Future Virol 2021. [PMID: 34567235 PMCID: PMC8457535 DOI: 10.2217/fvl-2020-0316] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/03/2021] [Indexed: 01/08/2023]
Abstract
We present here an evidence-based review of the utility, timing, and indications for laboratory test use in the domains of inflammation, cardiology, hematology, nephrology and co-infection for clinicians managing the care of hospitalized COVID-19 patients. Levels of IL-6, CRP, absolute lymphocyte count, neutrophils and neutrophil-to-lymphocyte ratio obtained upon admission may help predict the severity of COVID-19. Elevated LDH, ferritin, AST, and d-dimer are associated with severe illness and mortality. Elevated cardiac troponin at hospital admission can alert clinicians to patients at risk for cardiac complications. Elevated proBNP may help distinguish a cardiac complication from noncardiac etiologies. Evaluation for co-infection is typically unnecessary in nonsevere cases but is essential in severe COVID-19, intensive care unit patients, and immunocompromised patients. Doctors managing the complex care of individuals with COVID-19 need timely evidence to guide which lab tests to send to predict outcomes and prevent and treat COVID-19 complications involving the heart, blood clots, the kidney, and other infections that occur during the hospital course. Several lab tests such as IL-6, CRP and white blood cell subset counts may help predict the severity of COVID-19 during the patient’s hospital course if obtained when the patient first presents to the hospital. Other tests such as LDH, ferritin and AST are also associated with severe illness and mortality but have less evidence for their utility beyond IL-6, CRP and other tests. A test related to blood coagulation, d-dimer, is also associated with COVID-19 severity, and it may be used if the patient is suspected of having a blood clot. Two heart biomarkers – cardiac troponin and proBNP – may help doctors diagnose and manage heart-related complications of COVID-19. Patients in the hospital with COVID-19 may be susceptible to other infections, but testing for these is most useful in patients with severe disease, such as those in the intensive care unit. Specific recommendations for testing for viral, bacterial and fungal infections are presented here. The judicious use of laboratory testing can help identify patients at high risk for severe or critical COVID-19 and aid in prevention, diagnosis and treatment of common COVID-19 complications.
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Affiliation(s)
- Daniela Cihakova
- Department of Pathology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Michael B Streiff
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Steven P Menez
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Teresa K Chen
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Nisha A Gilotra
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Erin D Michos
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Kieren A Marr
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Andrew H Karaba
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Matthew L Robinson
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Paul W Blair
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA.,Austere environments Consortium for Enhanced Sepsis Outcomes, Henry M. Jackson Foundation, 6700 Rockledge Drive, Bethesda, MD 20817, USA
| | - Maria V Dioverti
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Wendy S Post
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Andrea L Cox
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
| | - Annukka A R Antar
- Department of Medicine, Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
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7
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Ryskina KL, Dynan L, Stein R, Fieldston E, Palakshappa D. Diagnostic Testing During Pediatric Hospitalizations: The Role of Attending In-House Coverage and Daytime Exposure. Acad Pediatr 2020; 20:508-515. [PMID: 31648058 PMCID: PMC7170750 DOI: 10.1016/j.acap.2019.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/05/2018] [Revised: 09/19/2019] [Accepted: 09/25/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Overuse of diagnostic tests is of particular concern for pediatric academic medical centers. Our objective was to measure variation in testing based on proportion of hospitalization during the day versus night and the association between attending in-house coverage on the teaching service and test utilization for hospitalized pediatric patients. METHODS Electronic health record data from 11,567 hospitalizations to a large, Northeastern, academic pediatric hospital were collected between January 2007 and December 2010. The patient-level dataset included orders for laboratory and imaging tests, information about who placed the order, and the timing of the order. Using a cross-sectional effect modification analysis, we estimated the difference in test utilization attributable to attending in-house coverage. RESULTS We found that admission to the teaching service was independently associated with higher utilization of laboratory and imaging tests. However, the number of orders was 0.76 lower (95% confidence interval:-1.31 to -0.21, P = .006) per 10% increase in the proportion in the share of the hospitalization that occurred during daytime hours on the teaching services, which is attributable to direct attending supervision. CONCLUSIONS Direct attending care of hospitalized pediatric patients at night was associated with slightly lower diagnostic test utilization.
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Affiliation(s)
- Kira L. Ryskina
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Linda Dynan
- Department of Economics and Finance, Northern Kentucky University, Highland Heights, KY; and Anderson Center for Health System Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Rebecca Stein
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Evan Fieldston
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, PA
| | - Deepak Palakshappa
- Division of General Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
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Patel T, Karle E, Krvavac A. Avoiding Unnecessary Repeat Laboratory Testing. Cureus 2019; 11:e5872. [PMID: 31763095 PMCID: PMC6834110 DOI: 10.7759/cureus.5872] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We present a 44-year-old Caucasian female with a history of diabetes mellitus admitted to the intensive care unit (ICU) for refractory hypoglycemia with an initial blood glucose of 39 mg/dl. The initial evaluation included a random insulin level, C-peptide, Hemoglobin A1c, and a sulfonylurea screen that were ordered when the patient's blood sugar was 39 mg/dL. She was discharged after demonstrating euglycemia. The test results for sulfonylurea screen, insulin, and C-peptide levels were obtained one day after discharge. The insulin level was elevated, and C-peptide was inappropriately low, establishing the diagnosis of surreptitious exogenous insulin use. Four days after discharge, the patient was readmitted to the same ICU with a similar presentation of refractory hypoglycemia. Once again, the sulfonylurea screen, along with the insulin and C-peptide levels were ordered as there was no mention of the previously obtained results in the discharge summary. The discrepancy between random insulin and C-peptide levels reaffirmed the diagnosis of surreptitious exogenous use of insulin. As high-value medical care becomes a focal point in medicine, the costs, root causes, and impacts of inappropriate laboratory testing must be understood. Upwards of 25% of ordered laboratory tests are unnecessary. Physicians' failure to follow-up on results of correctly ordered tests and repeat testing despite established diagnosis is a significant cause of unneeded laboratory testing. Best practice guidelines recommend a reduction in unnecessary laboratory testing by implementing computer-based solutions to maximize the identification of duplicate requests and to promote clinical education at the time of laboratory test ordering.
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Affiliation(s)
- Tarang Patel
- Internal Medicine, University of Missouri Healthcare, Columbia, USA
| | - Ethan Karle
- Internal Medicine, University of Missouri Healthcare, Columbia, USA
| | - Armin Krvavac
- Pulmonary & Critical Care, University of Missouri Healthcare, Columbia, USA
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Narayan AK, Rosenkrantz AB, Wang GX, Daye D, Durand DJ. Trends in Hospital Performance on the Medicare National Outpatient Imaging Metrics: A 5-Year Longitudinal Cohort Analysis. J Am Coll Radiol 2019; 16:1604-11. [PMID: 31125543 DOI: 10.1016/j.jacr.2019.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/10/2019] [Accepted: 04/18/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Medicare established its Hospital Outpatient Quality Reporting Program (HOQRP) to promote and incentivize quality care and appropriate utilization in the hospital outpatient setting. The program includes "imaging efficiency" metrics evaluating appropriate utilization of imaging examinations. Our purpose was to evaluate the longitudinal performance of the nation's hospitals on the HOQPR's imaging efficiency metrics. METHODS Data were obtained from CMS Hospital Compare for hospitals participating in the Medicare HOQRP during both initial (January 1, 2011, to December 31, 2011) and follow-up (July 1, 2015, to June 30, 2016) periods. The six reported imaging efficiency metrics were: MRI lumbar spine for low back pain, mammography follow-up rates, abdomen and chest CT double scans (imaging with and without intravenous contrast), cardiac imaging for preoperative risk assessment for low-risk surgery, and simultaneous use of brain and sinus CT. Differences in imaging efficiency metrics were calculated using fixed effects linear regression models. RESULTS Baseline and follow-up data were available for 3,960 hospitals. Median changes were MRI lumbar spine for low back pain: +3.6% (range: -27.9% to +31.4%; P < .001); mammography follow-up: -0.3% (range: -69.5% to +62.6%; P = .03); double scan abdomen CT: -1.9% (range: -73.5% to +32.3%; P < .001); double scan chest CT: -0.4% (range: -73.2% to +28.0%; P < .001); preoperative cardiac imaging: -0.7% (range: -10.0% to +9.9%; P < .001); simultaneous brain and sinus CT: -0.9% (range: -11.8% to +7.8%; P < .001). CONCLUSION Medicare's nationwide hospital outpatient imaging efficiency reporting initiative was associating with worse performance in lumbar spine MRI utilization and small improvements in double CT scans. Because quality metrics are increasingly imposed on health care providers, health service researchers will need to rigorously evaluate their effectiveness before and during early implementation.
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Abstract
Guidelines for continuous cardiac monitoring (CCM) have focused almost exclusively on cardiac diagnoses, thus limiting their application to a general medical population. In this study, a retrospective chart review was performed to identify the reasons that general medical patients, cared for on hospitalist-led inpatient teaching teams between April 2017 and February 2018, were initiated and maintained on CCM, and to determine the incidence of clinically significant arrhythmias in this patient population. The three most common reasons for telemetry initiation were sepsis (24%), arrhythmias (12%), and hypoxia (10%). Most patients remained on telemetry for more than 48 hours (62%) and a significant number of patients were on telemetry until they were discharged from the hospital (39%). Of the cumulative total of more than 20,573 hours of CCM provided to this patient population, 37% of patients demonstrated only normal sinus rhythm and 3% had a clinically significant arrhythmia that affected management.
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Affiliation(s)
- Debbie W Chen
- Internal Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - Robert Park
- Internal Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - Sarah Young
- Internal Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - Divya Chalikonda
- Internal Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA
| | | | - Gretchen Diemer
- Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
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11
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Ryskina KL, Holmboe ES, Shea JA, Kim E, Long JA. Physician Experiences With High Value Care in Internal Medicine Residency: Mixed-Methods Study of 2003-2013 Residency Graduates. Teach Learn Med 2018; 30:57-66. [PMID: 28753038 PMCID: PMC5803790 DOI: 10.1080/10401334.2017.1335207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Phenomenon: High healthcare costs and relatively poor health outcomes in the United States have led to calls to improve the teaching of high value care (defined as care that balances potential benefits of interventions with their harms including costs) to physicians-in-training. Numerous interventions to increase high value care in graduate medical education were implemented at the national and local levels over the past decade. However, there has been little evaluation of their impact on physician experiences during training and perceived preparedness for practice. We aimed to assess trends in U.S. physician experiences with high value care during residency over the past decade. APPROACH This mixed-methods study used a cross-sectional survey mailed July 2014 to January 2015 to 902 internists who completed residency in 2003-2013, randomly selected from the American Medical Association Masterfile. Quantitative analyses of survey responses and content analysis of free-text comments submitted by respondents were performed. FINDINGS A total of 456 physicians (50.6%) responded. Fewer than one fourth reported being exposed to teaching about high value care at least frequently (23.6%, 106/450). Only 43.8% of respondents (193/446) felt prepared to use overtreatment guidelines in conversations with patients, whereas 85.8% (379/447) felt prepared to participate in shared decision making with patients at the conclusion of their training, and 84.4% (380/450) reported practicing generic prescribing. Physicians who completed residency more recently were more likely to report practicing generic prescribing and feeling well prepared to use overtreatment guidelines in conversations with patients (p < .01 for both). Insights: In a national survey, recent U.S. internal medicine residency graduates were more likely to experience high value care during training, which may reflect increased national and local efforts in this area. However, being exposed to high value care as a trainee may not translate into specific tools for practice. In fact, many U.S. internists reported inadequate exposure to prepare them for patient discussions about costs and the use of overtreatment guidelines in practice.
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Affiliation(s)
- Kira L Ryskina
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Eric S Holmboe
- b Accreditation Council for Graduate Medical Education , Chicago , Illinois , USA
| | - Judy A Shea
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Esther Kim
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Judith A Long
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
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Keveson B, Clouser RD, Hamlin MP, Stevens P, Stinnett-Donnelly JM, Allen GB. Adding value to daily chest X-rays in the ICU through education, restricted daily orders and indication-based prompting. BMJ Open Qual 2017; 6:e000072. [PMID: 29435503 PMCID: PMC5717964 DOI: 10.1136/bmjoq-2017-000072] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 12/03/2022] Open
Abstract
Background Chest X-rays (CXRs) are traditionally obtained daily in all patients on invasive mechanical ventilation (IMV) in the intensive care unit (ICU). We sought to reduce overutilisation of CXRs obtained in the ICU, using a multifaceted intervention to eliminate automated daily studies. Methods We first educated ICU staff about the low diagnostic yield of automated daily CXRs, then removed the ‘daily’ option from the electronic health records-based ordering system, and added a query (CXR indicated or not indicated) to the ICU daily rounding checklist to prompt a CXR order when clinically warranted. We built a report from billing codes, focusing on all CXRs obtained on IMV census days in the medical (MICU) and surgical (SICU) ICUs, excluding the day of admission and days that a procedure warranting CXR was performed. This generated the number of CXRs obtained every 1000 ‘included’ ventilator days (IVDs), the latter defined as not having an ‘absolute’ clinical indication for CXR. Results The average monthly number of CXRs on an IVD decreased from 919±90 (95% CI 877 to 963) to 330±87 (95% CI 295 to 354) per 1000 IVDs in the MICU, and from 995±69 (95% CI 947 to 1055) to 649±133 (95% CI 593 to 697) in the SICU. This yielded an estimated 1830 to 2066 CXRs avoided over 2 years and an estimated annual savings of $191 600 to $224 200. There was no increase in reported adverse events. Conclusion ICUs can safely transition to a higher value strategy of indication-based chest imaging by educating staff, eliminating the ‘daily’ order option and adding a simplified prompt to avoid missing clinically indicated CXRs.
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Affiliation(s)
- Benjamin Keveson
- Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Ryan D Clouser
- Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Mark P Hamlin
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Pamela Stevens
- James M. Jeffords Institute for Quality and Operational Effectiveness, University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Gilman B Allen
- Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
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Urja P, Nippoldt EH, Barak V, Valenta C. High-Value Care in the Evaluation of Stroke. Cureus 2017; 9:e1532. [PMID: 28983441 PMCID: PMC5624564 DOI: 10.7759/cureus.1532] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Value-based care emphasizes achieving the greatest overall health benefit for every dollar spent. We present an interesting case of stroke, which made us consider how frequently health care providers are utilizing value-based care. A 73-year-old Caucasian, who was initially admitted for a hypertensive emergency, was transferred to our facility for worsening slurring of speech and left-sided weakness. The patient had an extensive chronic cerebrovascular disease, including multiple embolic type strokes, mainly in the distribution of the right temporal-occipital cerebral artery and transient ischemic attacks (TIAs). The patient had a known history of patent foramen ovale (PFO) and occlusion of the right internal carotid artery. He was complicated by intracranial hemorrhage while on anticoagulation for pulmonary embolism. He was chronically on dual antiplatelet therapy (aspirin and clopidogrel) and statin. Following the transfer, stroke protocol, including the activation of the stroke team, a computed tomography (CT) imaging study, and the rapid stabilization of the patient was initiated. His vitals were stable, and the physical examination was significant for the drooping of the left angle of the mouth, a nonreactive right pupil consistent with the previous stroke, a decreased strength in the left upper and lower extremities, and a faint systolic murmur. His previous stroke was shown to be embolic, involving both the right temporal and occipital regions, which was re-demonstrated in a CT scan. A magnetic resonance imaging (MRI) scan of the brain showed a new, restricted diffusion in the right pons that was compatible with an acute stroke as well as diffusely atherosclerotic vessels with a focal stenosis of the branch vessels. A transthoracic echocardiogram demonstrated no new thrombus in the heart. A transesophageal echocardiogram (TEE) showed known PFO, and repeat hypercoagulation evaluation was negative, as it was in his previous cerebrovascular accident (CVA) evaluation. Appropriate medical treatment with antiplatelets, as indicated by the acute stroke guidelines, was started. The patient was not eligible for thrombolysis. Value-based care emphasizes the decreased usage in investigations or health care of options that do not contribute to the overall health and well-being of the patient. Given our patient's past medical history and the results of previous investigations, we questioned the value of ordering a hypercoagulable evaluation and TEE in our patient. The need for an evaluation of the hypercoagulable state in an elderly patient with ischemic stroke or TIA remains unknown. Our patient had a complete hypercoagulable evaluation done six years earlier. Repeating the hypercoagulable evaluation would not contribute to the treatment decisions and, as a result, would not satisfy the basic criteria for value-based care.The importance of a repeat TEE is uncertain in the evaluation of embolism for a known cause of stroke. Additionally, no change in management was anticipated regardless of the TEE findings, therefore, repeating TEE in our patient was an inappropriate use of resources. Being mindful of value-based care can reduce overall health care costs, maintain our role of being responsible stewards of our limited resources, and continue to provide high-value care for our patients.
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Affiliation(s)
- Prakrity Urja
- Creighton University Medical Center, CHI Creighton University
| | | | - Virginia Barak
- School of Medicine, Creighton University School of Medicine
| | - Carrie Valenta
- Creighton University Medical Center, CHI Creighton University
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Hom J, Kumar A, Evans KH, Svec D, Richman I, Fang D, Smeraglio A, Holubar M, Johnson T, Shah N, Renault C, Ahuja N, Witteles R, Harman S, Shieh L. A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback. Postgrad Med J 2017; 93:725-729. [PMID: 28663352 DOI: 10.1136/postgradmedj-2016-134617] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 04/18/2017] [Accepted: 06/04/2017] [Indexed: 11/03/2022]
Abstract
PURPOSE Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns. DESIGN Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments. RESULTS The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001). CONCLUSIONS We successfully implemented a novel high value care curriculum that specifically targets intern physicians.
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Affiliation(s)
- Jason Hom
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Andre Kumar
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kambria H Evans
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - David Svec
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ilana Richman
- Center for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Daniel Fang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Andrea Smeraglio
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Marisa Holubar
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Tyler Johnson
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neil Shah
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Cybele Renault
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neera Ahuja
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Stephanie Harman
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Lisa Shieh
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
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Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Woo VG, Lundeen T, Matula S, Milstein A. Achieving higher-value obstetrical care. Am J Obstet Gynecol 2017; 216:250.e1-250.e14. [PMID: 28041927 DOI: 10.1016/j.ajog.2016.12.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 07/25/2016] [Revised: 09/22/2016] [Accepted: 12/22/2016] [Indexed: 11/29/2022]
Abstract
Obstetrical care in the United States is unnecessarily costly. Birth is 1 of the most common reasons for healthcare use in the United States and 1 of the top expenditures for payers every year. However, compared with other Organization for Economic Cooperation and Development countries, the United States spends substantially more money per birth without better outcomes. Our team at the Clinical Excellence Research Center, a center that is focused on improving value in healthcare, spent a year studying ways in which obstetrical care in the United States can deliver better outcomes at a lower cost. After a thoughtful discovery process, we identified ways that obstetrical care could be delivered with higher value. In this article, we recommend 3 redesign steps that foster the delivery of higher-value maternity care: (1) to provide long-acting reversible contraception immediately after birth, (2) to tailor prenatal care according to women's unique medical and psychosocial needs by offering more efficient models such as fewer in-person visits or group care, and (3) to create hospital-affiliated integrated outpatient birth centers as the planned place of birth for low-risk women. For each step, we discuss the redesign concept, current barriers and implementation solutions, and our estimation of potential cost-savings to the United States at scale. We estimate that, if this model were adopted nationally, annual US healthcare spending on obstetrical care would decline by as much as 28%.
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Affiliation(s)
- Victoria G Woo
- Clinical Excellence Research Center, Stanford University, Stanford, CA; Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Oakland, CA
| | - Tiffany Lundeen
- Clinical Excellence Research Center, Stanford University, Stanford, CA; Global Health Sciences, University of California, San Francisco, CA
| | - Sierra Matula
- Clinical Excellence Research Center, Stanford University, Stanford, CA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University, Stanford, CA
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Abstract
Waste in the NHS is estimated to account for 20% of health expenditure. This article examines the literature on reducing waste, analyses some approaches to waste reduction, and identifies the role that nurses and other health professionals can play in developing a sustainable NHS. For the purposes of the article, and to inform nursing practice, the definition of, and discussion about, waste is broader than that outlined by the Department for Environment, Food and Rural Affairs (Defra) controlled waste regulations, and the Royal College of Nursing classification. It includes clinical waste, waste arising out of clinical practice, service delivery and care, infrastructure, and carbon emissions.
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Downing NL, Adler-Milstein J, Palma JP, Lane S, Eisenberg M, Sharp C, Longhurst CA. Health information exchange policies of 11 diverse health systems and the associated impact on volume of exchange. J Am Med Inform Assoc 2017; 24:113-122. [PMID: 27301748 PMCID: PMC7654085 DOI: 10.1093/jamia/ocw063] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 02/13/2016] [Accepted: 03/30/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Provider organizations increasingly have the ability to exchange patient health information electronically. Organizational health information exchange (HIE) policy decisions can impact the extent to which external information is readily available to providers, but this relationship has not been well studied. OBJECTIVE Our objective was to examine the relationship between electronic exchange of patient health information across organizations and organizational HIE policy decisions. We focused on 2 key decisions: whether to automatically search for information from other organizations and whether to require HIE-specific patient consent. METHODS We conducted a retrospective time series analysis of the effect of automatic querying and the patient consent requirement on the monthly volume of clinical summaries exchanged. We could not assess degree of use or usefulness of summaries, organizational decision-making processes, or generalizability to other vendors. RESULTS Between 2013 and 2015, clinical summary exchange volume increased by 1349% across 11 organizations. Nine of the 11 systems were set up to enable auto-querying, and auto-querying was associated with a significant increase in the monthly rate of exchange (P = .006 for change in trend). Seven of the 11 organizations did not require patient consent specifically for HIE, and these organizations experienced a greater increase in volume of exchange over time compared to organizations that required consent. CONCLUSIONS Automatic querying and limited consent requirements are organizational HIE policy decisions that impact the volume of exchange, and ultimately the information available to providers to support optimal care. Future efforts to ensure effective HIE may need to explicitly address these factors.
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Affiliation(s)
- N Lance Downing
- Department of Medicine, Stanford University School of Medicine
| | | | - Jonathan P Palma
- Department of Medicine, Stanford University School of Medicine
- Department of Pediatrics, Stanford University School of Medicine
| | - Steven Lane
- Palo Alto Medical Foundation/Sutter Health, Palo Alto, CA
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Abstract
ISSUE Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. EVIDENCE Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. IMPLICATIONS Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.
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Affiliation(s)
- Grace C Huang
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Carrie D Tibbles
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Lori R Newman
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Richard M Schwartzstein
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
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Tackett S, Stelzner C, McGlynn E, Mehrotra A. The impact of health plan physician-tiering on access to care. J Gen Intern Med 2011; 26:440-5. [PMID: 21181287 PMCID: PMC3055960 DOI: 10.1007/s11606-010-1607-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 10/26/2010] [Accepted: 11/22/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND In an attempt to improve quality and control costs, health plans are creating tiered products that encourage enrollees to seek care from "high-value" physicians. However, tiered products may limit access to care because patients may have to travel unreasonable distances to visit the nearest high-value physician. OBJECTIVE To assess geographic access to high-value physicians, particularly for disadvantaged populations. DESIGN Cross-sectional observational study. PARTICIPANTS Physicians and adult patients in Massachusetts. MAIN MEASURES Travel time from census block centroid to nearest physician address under two scenarios: patients can see (1) any physician or (2) only high-value physicians. KEY RESULTS Among the physicians, 768 (20.9%) primary care physicians (PCPs), 225 (26.6%) obstetricians/gynecologists, 69 (10.3%) cardiologists, and 31 (6.0%) general surgeons met the definition of high-value. Statewide mean travel times to the nearest PCP, obstetrician/gynecologist, cardiologist, or general surgeon under the two scenarios (any physician vs. only high-value physicians) were 2.8 vs. 4.8, 6.0 vs. 7.2, 7.0 vs. 12.4, and 6.6 vs. 14.8 minutes, respectively. Across the four specialties, between 89.4%-99.4% of the population lived within 30 minutes of the nearest high-value physician. Rural populations had considerably longer travel times to see high-value physicians, but other disadvantaged populations generally had shorter travel times than comparison groups. CONCLUSIONS Most patients in Massachusetts are likely to have reasonable geographic access to high-value physicians in tiered health plans. However, local demographics, especially rural residence, should be taken into consideration when applying tiered health plans broadly. Future work should investigate whether patients can and will switch to receive care from high-value physicians.
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Affiliation(s)
- Sean Tackett
- University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA 15213 USA
| | | | | | - Ateev Mehrotra
- University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA 15213 USA
- RAND Health, Pittsburgh, PA USA
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