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Stanworth SJ, Walwyn R, Grant-Casey J, Hartley S, Moreau L, Lorencatto F, Francis J, Gould N, Swart N, Rowley M, Morris S, Grimshaw J, Farrin A, Foy R. Effectiveness of Enhanced Performance Feedback on Appropriate Use of Blood Transfusions: A Comparison of 2 Cluster Randomized Trials. JAMA Netw Open 2022; 5:e220364. [PMID: 35201305 PMCID: PMC8874348 DOI: 10.1001/jamanetworkopen.2022.0364] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. OBJECTIVE To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. DESIGN, SETTING, AND PARTICIPANTS Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. INTERVENTIONS Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. MAIN OUTCOMES AND MEASURES The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. RESULTS One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]). CONCLUSIONS AND RELEVANCE This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN15490813.
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Affiliation(s)
- Simon J. Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine and Oxford Biomedical Research Center Haematology Theme, University of Oxford, Oxford, United Kingdom
| | - Rebecca Walwyn
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - John Grant-Casey
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Lauren Moreau
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Fabiana Lorencatto
- Division of Psychology and Language Sciences, University College London, London, United Kingdom
| | - Jill Francis
- School of Health Sciences City, University of London, London, United Kingdom
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Natalie Gould
- School of Health Sciences City, University of London, London, United Kingdom
| | - Nick Swart
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Megan Rowley
- Scottish National Blood Transfusion Service, Edinburgh, Edinburgh, United Kingdom
| | - Steve Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Jeremy Grimshaw
- Faculty of Medicine, University of Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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Melaku MS, Aemro A, Aychiluhm SB, Muche A, Bizuneh GK, Kebede SD. Geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia: a spatial and geographically weighted regression analysis. BMC Pregnancy Childbirth 2022; 22:76. [PMID: 35090405 PMCID: PMC8796399 DOI: 10.1186/s12884-021-04364-6] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Maintaining and effectively utilizing maternal continuum of care could save an estimated 860,000 additional mothers and newborn lives each year. In Ethiopia, the number of maternal and neonatal deaths occurred during pregnancy, childbirth, and the postpartum period was very high. It is indisputable that area-based heterogeneity of zero utilization for a standard maternal continuum of care is critical to improve maternal and child health interventions. However, none of the previous studies explored the spatial distribution of zero utilization for maternal continuum of care. Hence, this study was aimed to explore geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia. METHODS A total of 4178 women who gave birth five years preceding the 2016 Ethiopian demographic and health survey were included. ArcGIS version 10.7, SaT Scan version 9.6, and GWR version 4.0 Software was used to handle mapping, hotspot, ordinary least square, Bernoulli model analysis, and to model spatial relationships. Finally, a statistical decision was made at a p-value< 0.05 and at 95% confidence interval. MAIN FINDINGS The proportion of mothers who had zero utilization of a standard maternal continuum of care was 48.8% (95% CI: 47.3-50.4). Hot spot (high risk) regions for zero utilization of maternal continuum of care was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Respondents who had poor wealth index, uneducated mothers, and mothers who declared distance as a big problem could increase zero utilization of maternal continuum of care by 0.24, 0.27, and 0.1 times. CONCLUSION Five women out of ten could not utilize any components of a standard maternal continuum of care. Hot spot (high risk) areas was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Poor wealth index, uneducated mothers, and mothers who declare distance as a big problem were factors significantly associated with zero utilization of maternal continuum of care. Thus, geographical based intervention could be held to curve the high prevalence of zero utilization of maternal continuum of care.
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Affiliation(s)
- Mequannent Sharew Melaku
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Agazhe Aemro
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Setognal Birara Aychiluhm
- Department of Public Health, College of Medicine and Health Sciences, Samara University, Samara, Ethiopia
| | - Amare Muche
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Gizachew Kassahun Bizuneh
- Department of Pharmacognosy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Shimels Derso Kebede
- Department of Health Informatics, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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Punekar SR, Griffin MM, Masri L, Roman SD, Makarov DV, Sherman SE, Becker DJ. Socioeconomic Determinants of the Use of Molecular Testing in Stage IV Colorectal Cancer. Am J Clin Oncol 2021; 44:597-602. [PMID: 34753883 DOI: 10.1097/coc.0000000000000875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Treatment with epidermal growth factor receptor monoclonal antibodies extends life for patients with advanced colorectal cancers (CRCs) whose tumors exhibit wild-type KRAS, but KRAS testing may be underused. We studied the role of socioeconomic factors in the application of KRAS testing. MATERIALS AND METHODS We identified subjects with stage IV colorectal adenocarcinoma diagnosed 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. We used multivariable logistic regression models to evaluate associations between clinical/demographic factors and the rate of KRAS testing. We used multivariable-adjusted Cox proportional hazards models to assess survival. RESULTS We identified 37,676 patients with stage IV CRC, 31.1% of whom were tested for KRAS mutations, of those who had documented KRAS testing, 44% were KRAS mutant. Patients were more likely to be tested if they were younger (odds ratio [OR]=5.10 for age 20 to 29 vs. 80+, 95% confidence interval [CI]: 3.99-6.54, P<0.01), diagnosed more recently (OR=1.92 for 2015 vs. 2010, 95% CI: 1.77-2.08, P<0.01), or lived in an area of high median household income (OR=1.24 for median household income of >$69,311 vs. <$49,265, 95% CI: 1.14-1.35, P<0.01). Patients were less likely to be tested if they had Medicaid (OR=0.83, 95% CI: 0.77-0.88, P<0.01) or were unmarried (OR=0.78, 95% CI: 0.75-0.82, P<0.0001). The risk of death was decreased in patients who received KRAS testing (hazard ratio=0.77, 95% CI: 0.75-0.80, P<0.01). CONCLUSIONS We found a low rate of KRAS testing in CRC patients with those living in low-income areas less likely to be tested, even after controlling for Medicaid insurance. Our study suggests that socioeconomic disparities persist despite Medicaid insurance.
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Affiliation(s)
- Salman R Punekar
- Department of Medical Oncology, NYU Langone Laura and Isaac Perlmutter Cancer Center
| | - Megan M Griffin
- Department of Medical Oncology, NYU Langone Laura and Isaac Perlmutter Cancer Center
| | | | | | - Danil V Makarov
- Urology, VA-NYHHS
- Departments of Urology
- Population Health, NYU Grossman School of Medicine, New York, NY
| | - Scott E Sherman
- Department of Medical Oncology, NYU Langone Laura and Isaac Perlmutter Cancer Center
| | - Daniel J Becker
- Department of Medical Oncology, NYU Langone Laura and Isaac Perlmutter Cancer Center
- Departments of Hematology and Oncology
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Kurihara H, Marrano E, Ceolin M, Chiara O, Faccincani R, Bisagni P, Fattori L, Zago M. Impact of lockdown on emergency general surgery during first 2020 COVID-19 outbreak. Eur J Trauma Emerg Surg 2021; 47:677-682. [PMID: 33944976 PMCID: PMC8093909 DOI: 10.1007/s00068-021-01691-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/29/2021] [Indexed: 12/27/2022]
Abstract
Purpose To evaluate and analyze the impact of lockdown strategy due to coronavirus disease 2019 (COVID-19) on emergency general surgery (EGS) in the Milan area at the beginning of pandemic outbreak. Methods A survey was distributed to 14 different hospitals of the Milan area to analyze the variation of EGS procedures. Each hospital reported the number of EGS procedures in the same time frame comparing 2019 and 2020. The survey revealed that the number of patients during the COVID-19 pandemic outbreak in 2020 was reduced by 19% when compared with 2019. The decrease was statistically significant only for abdominal wall surgery. Interestingly, in 2020, there was an increase of three procedures: surgical intervention for acute mesenteric ischemia (p = 0.002), drainage of perianal abscesses (p = 0.000285), and cholecystostomy for acute cholecystitis (p = 0.08). Conclusions During the first COVID-19 pandemic wave in the metropolitan area of Milan, the number of patients operated for emergency diseases decreased by around 19%. We believe that this decrease is related either to the fear of the population to ask for emergency department (ED) consultation and to a shift towards a more non-operative management in the surgeons ‘decision making’ process. The increase of acute mesenteric ischaemia and perianal abscess might be related to the modification of dietary habits and reduction of physical activity related to the lockdown.
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Affiliation(s)
- Hayato Kurihara
- Emergency Surgery and Trauma Section, Department of Surgery, IRCCS, Humanitas Research Hospital, Rozzano, Italy.
| | - Enrico Marrano
- Emergency Surgery and Trauma Section, Department of Surgery, IRCCS, Humanitas Research Hospital, Rozzano, Italy
| | - Martina Ceolin
- Emergency Surgery and Trauma Section, Department of Surgery, IRCCS, Humanitas Research Hospital, Rozzano, Italy
| | - Osvaldo Chiara
- Universita' di Milano, Chirurgia Generale-Trauma Team ASST Niguarda, Milano, Italy
| | - Roberto Faccincani
- Pronto Soccorso e Chirurgia Generale e Delle Urgenze, IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - Luca Fattori
- Dipartimento di Chirurgia-Chirurgia d'Urgenza, Ospedale San Gerardo ed Universita' Degli Studi Milano-Bicocca, Monza, Italy
| | - Mauro Zago
- General and Emergency Surgery Division, Robotic and Emergency Surgery Department, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
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Pletcher MJ, Olgin JE, Peyser ND, Modrow MF, Lin F, Martin J, Carton T, Beatty AL, Vittinghoff E, Marcus GM. Factors Associated With Access to and Timing of Coronavirus Testing Among US Adults After Onset of Febrile Illness. JAMA Netw Open 2021; 4:e218500. [PMID: 33938937 PMCID: PMC8094007 DOI: 10.1001/jamanetworkopen.2021.8500] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/11/2021] [Indexed: 12/23/2022] Open
Abstract
Importance Active SARS-CoV-2 (coronavirus) transmission continues in the US. It is unclear whether better access to coronavirus testing and more consistent use of testing could substantially reduce transmission. Objective To describe coronavirus testing in persons with new onset of febrile illness and analyze whether there are changes over time and differences by race and ethnicity. Design, Setting, and Participants This cohort study used data from the COVID-19 Citizen Science Study, launched in March 2020, which recruited participants via press release, word-of-mouth, and partner organizations. Participants completed daily surveys about COVID-19 symptoms and weekly surveys about coronavirus testing. All adults (aged at least 18 years) with a smartphone were eligible to join. For this analysis, US participants with new onset of febrile illness from April 2020 to October 2020 were included. Data analysis was performed from November 2020 to March 2021. Main Outcomes and Measures Receipt of a coronavirus test result within 7 days of febrile illness onset. Results Of the 2679 participants included in this analysis, the mean (SD) age was 46.3 (13.4) years, 1983 were female (74%), 2017 were college educated (75%), and a total of 3865 distinct new febrile illness episodes were reported (300 episodes [7.8%] from Hispanic participants, 71 episodes [1.8%] from Black participants, and 3494 episodes [90.4%] from not Black, not Hispanic participants) between April 2 and October 23, 2020. In weekly surveys delivered during the 14 days after fever onset, 12% overall (753 participants) indicated receipt of a test result. Using serial survey responses and parametric time-to-event modeling, it was estimated that by 7 days after onset of febrile illness, a total of 20.5% (95% CI, 19.1%-22.0%) had received a test result. This proportion increased from 9.8% (95% CI, 7.5%-12.0%) early in the epidemic to 24.1% (95% CI, 21.5%-26.7%) at the end of July, but testing rates did not substantially improve since then, increasing to 25.9% (95% CI; 21.6%-30.3%) in late October at the start of the winter surge. Black participants reported receiving a test result about half as often as others (7% [7 of 103] of survey responses vs 12% [53 of 461] for Hispanic vs 13% [693 of 5516] for not Black, not Hispanic; P = .03). This association was not statistically significant in adjusted time-to-event models (hazard ratio = 0.59 vs not Black, not Hispanic participants; 95% CI, 0.26-1.34). Conclusions and Relevance Systematic underuse of coronavirus testing was observed in this cohort study through late October 2020, at the beginning of the winter COVID-19 surge, which may have contributed to preventable coronavirus transmission.
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Affiliation(s)
- Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco
| | - Jeffrey E. Olgin
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco
| | - Noah D. Peyser
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco
| | - Madelaine Faulkner Modrow
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Jeffrey Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | | | - Alexis L. Beatty
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Gregory M. Marcus
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco
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Abstract
BACKGROUND Cost-related medication underuse (CRMU) has been reported within the general population in Canada. In this study, we assessed patterns of CRMU among Canadian adults with cancer. METHODS This is a cross-sectional study using survey data. We accessed data sets from the 2015/16 Canadian Community Health Survey (CCHS) and reviewed the records of adults (≥ 18 yr) with a history of cancer who were prescribed medication in the previous 12 months. We collected information about sociodemographic features, health behaviours and CRMU, and conducted a multivariable logistic regression analysis for factors associated with CRMU. RESULTS A total of 8581 participants were eligible for the current study. In the weighted multivariable logistic regression analysis, the following factors were associated with CRMU: younger age (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.79-3.63), female sex (male sex v. female sex OR 0.62, 95% CI 0.44-0.88), Indigenous racial background (Indigenous v. White OR 2.37, 95% CI 1.49- 3.77), unmarried status (OR 1.59, 95% CI 1.09-2.30), poor self-perceived health (excellent v. poor self-perceived health OR 0.36, 95% CI 0.17-0.77), lower annual income (< $20 000 v. income ≥ $80 000 OR 3.08, 95% CI 1.75-5.41) and lack of insurance for prescription medications (OR 2.49, 95% CI 1.77-3.50). INTERPRETATION The toll of CRMU among adults seems to be unequally carried by women, racial minorities, and younger (< 65 yr) and uninsured patients with cancer. Discussion about a national pharmacare program for people without private insurance is needed.
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Affiliation(s)
- Omar Abdel-Rahman
- Department of Oncology, University of Alberta and Cross Cancer Institute, Edmonton, Alta.
| | - Scott North
- Department of Oncology, University of Alberta and Cross Cancer Institute, Edmonton, Alta
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Spencer-Bonilla G, Chung S, Sarraju A, Heidenreich P, Palaniappan L, Rodriguez F. Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease. J Am Geriatr Soc 2021; 69:979-985. [PMID: 33410499 PMCID: PMC8049971 DOI: 10.1111/jgs.16975] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/14/2020] [Accepted: 11/14/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND/OBJECTIVES Older adults (>75 years of age) represent two-thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi-society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD. DESIGN Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018. SETTING A large multi-specialty health system in Northern California. PARTICIPANTS A total of 24,651 adults older than 75 years with ASCVD. MEASUREMENTS Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors. RESULTS The study cohort included 24,651 patients older than 75 years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins. CONCLUSIONS Despite increasing prescription rates between 2007 and 2018, guideline-recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD.
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Affiliation(s)
| | - Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - Paul Heidenreich
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
- Division of Cardiovascular Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Latha Palaniappan
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
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Seib CD, Meng T, Suh I, Cisco RM, Lin DT, Morris AM, Trickey AW, Kebebew E. Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines. Surgery 2021; 169:87-93. [PMID: 32654861 PMCID: PMC7736152 DOI: 10.1016/j.surg.2020.04.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/29/2020] [Accepted: 04/29/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings. METHODS We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy. RESULTS Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]). CONCLUSION The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, CA.
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Emergency Medicine, Stanford University School of Medicine, CA
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco, CA
| | - Robin M Cisco
- Department of Surgery, Stanford University School of Medicine, CA
| | - Dana T Lin
- Department of Surgery, Stanford University School of Medicine, CA
| | - Arden M Morris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, CA
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Schwarz S, Schäfer W, Horenkamp-Sonntag D, Liebentraut J, Haug U. Follow-up of 3 Million Persons Undergoing Colonoscopy in Germany: Utilization of Repeat Colonoscopies and Polypectomies Within 10 Years. Clin Transl Gastroenterol 2020; 12:e00279. [PMID: 33464730 PMCID: PMC8345921 DOI: 10.14309/ctg.0000000000000279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/03/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Given the sparsity of longitudinal studies on colonoscopy use, we quantified utilization of repeat colonoscopy within 10 years and the proportion of persons with polypectomies at first repeat colonoscopy using a large German claims database. METHODS Based on the German Pharmacoepidemiological Research Database, we identified persons who underwent colonoscopy between 2006 and 2015 (index colonoscopy) and assessed colonoscopies and polypectomies during follow-up. We defined 3 subcohorts based on available procedure/diagnosis codes at index colonoscopy: persons with snare polypectomy, which is reimbursable for lesions ≥5 mm in size (cohort 1), with a forceps polypectomy (cohort 2), and without such procedures/diagnoses (cohort 3). We stratified all analyses by diagnostic vs screening index colonoscopy. RESULTS Overall, we included 3,076,657 persons (cohort 1-3: 15%, 13%, 72%). Among persons with screening index colonoscopy (30%), the proportions with a repeat colonoscopy within 10 years in cohorts 1, 2, and 3 were 78%, 66%, and 43%, respectively, and a snare polypectomy at first repeat colonoscopy was performed in 27%, 17%, and 12%, respectively. In cohort 1, 32% of persons with a (first) repeat colonoscopy after 9 years had a snare polypectomy (after 3 years: 25%). Among persons with diagnostic index colonoscopies, 80%, 78%, and 65% had a repeat colonoscopy, and 27%, 17%, and 10% had a snare polypectomy at first repeat colonoscopy, respectively. DISCUSSION Our study suggests substantial underuse of repeat colonoscopy among persons with previous snare polypectomy and overuse among lower risk groups. One-quarter of persons with a snare polypectomy at baseline had another snare polypectomy at first repeat colonoscopy.
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Affiliation(s)
- Sarina Schwarz
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
| | - Wiebke Schäfer
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
| | | | | | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
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10
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Chokotho L, Wu HH, Shearer D, Lau BC, Mkandawire N, Gjertsen JE, Hallan G, Young S. Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi. Acta Orthop 2020; 91:724-731. [PMID: 32698707 PMCID: PMC8023961 DOI: 10.1080/17453674.2020.1794430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.
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Affiliation(s)
- Linda Chokotho
- Department of Surgery, College of Medicine, University of Malawi
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hao-Hua Wu
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
| | - David Shearer
- Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
| | - Brian C Lau
- Department of Orthopedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - Nyengo Mkandawire
- Department of Surgery, College of Medicine, University of Malawi
- School of Medicine, Flinders University, Adelaide, Australia
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Geir Hallan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Sven Young
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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Abstract
OBJECTIVE The objectives of this study are to refine the measurement of appropriate emergency department (ED) use and to provide a natural observation of appropriate ED use rates based on professional versus patient perspectives. SETTING Taiwan has a population of 23 million, with one single-payer universal health insurance scheme. Taiwan has no limitations on ED use, and a low barrier to ED use may be a surrogate for natural observation of users' perspectives in ED use. PARTICIPANTS In 7 years, there were 1 835 860 ED visits from one million random samples of the National Health Insurance Database. MEASURES Appropriate ED use was determined according to professional standards, measured by the modified Billings New York University Emergency Department (NYU-ED) algorithm, and further analysed after the addition of prudent patient standards, measured by explicit process-based and outcome-based criteria. STATISTICAL ANALYSES The area under the receiver operating characteristic curve (AUC) was used to reflect the performance of appropriate ED use measures, and sensitivity analyses were conducted using different thresholds to determine the appropriateness of ED use. The generalised estimating equation model was used to measure the associations between appropriate ED use based on process and outcome criteria and covariates including sex, age, occupation, health status, place of residence, medical resources area, date and income level. RESULTS Appropriate ED use based on professional criteria was 33.5%, which increased to 63.1% when patient criteria were added. The AUC, which combines both professional and patient criteria, was high (0.85). CONCLUSIONS The appropriate ED use rate nearly doubled when patient criteria were added to professional criteria. Explicit process-based and outcome-based criteria may be used as a supplementary measure to the implicit modified Billings NYU-ED algorithm when determining appropriate ED use.
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Affiliation(s)
- Chih-Yuan Lin
- Neurology, Taipei City Hospital, Taipei, Taiwan
- Institute of Health and Welfare Policy, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yue-Chune Lee
- Institute of Health and Welfare Policy, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Master Program on Trans-disciplinary Long-Term Care and Management, National Yang-Ming University, Taipei, Taiwan
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Pérez-Feal P, Ginarte-Val M, Vázquez-Veiga HA. Derivaciones no justificadas en un servicio de Dermatología: estudio transversal en un hospital de tercer nivel. Aten Primaria 2020; 52:365-366. [PMID: 32143970 PMCID: PMC7231887 DOI: 10.1016/j.aprim.2019.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/26/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Patricia Pérez-Feal
- Servicio de Dermatología, Complejo Hospitalario Universitario de Santiago de Compostela, A Coruña, España.
| | - Manuel Ginarte-Val
- Servicio de Dermatología, Complejo Hospitalario Universitario de Santiago de Compostela, A Coruña, España
| | - Hugo A Vázquez-Veiga
- Servicio de Dermatología, Complejo Hospitalario Universitario de Santiago de Compostela, A Coruña, España
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Hong KL, Babiolakis C, Zile B, Bullen M, Haseeb S, Halperin F, Hohl CM, Magee K, Sandhu RK, Tian SY, Kennedy A, Lobban T, Mariano Z, Dorian P, Angaran P, Evans M, Leong-Sit P, Glover BM. Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial. BMJ Open 2020; 10:e033482. [PMID: 32303514 PMCID: PMC7201301 DOI: 10.1136/bmjopen-2019-033482] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/14/2020] [Accepted: 03/12/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF). DESIGN Appropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics. PARTICIPANTS Participants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia). RESULTS Of the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results. CONCLUSIONS Improved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation. TRIAL REGISTRATION NUMBER NCT03127085.
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Affiliation(s)
- Kathryn Lauren Hong
- Department of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Brigita Zile
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Milena Bullen
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Sohaib Haseeb
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Frank Halperin
- Department of Cardiology, Interior Health Authority, Kelowna, Province of British Columbia, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kirk Magee
- Department of Emergency Medicine, Nova Scotia Health Authority, Halifax, Province of Nova Scotia, Canada
| | - Roopinder K Sandhu
- Department of Cardiology, University of Alberta, Edmonton, Western Canada, Canada
| | - Simon Yu Tian
- Department of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ashley Kennedy
- Wilkes Honors College, Florida Atlantic University, Boca Raton, Florida, USA
| | - Trudie Lobban
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Zana Mariano
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Dorian
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Angaran
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Evans
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
| | - Peter Leong-Sit
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
| | - Benedict M Glover
- Department of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Bryan MA, Hofstetter AM, Simon TD, Zhou C, Williams DJ, Tyler A, Kenyon CC, Vachani JG, Opel DJ, Mangione-Smith R. Vaccination Status and Adherence to Quality Measures for Acute Respiratory Tract Illnesses. Hosp Pediatr 2020; 10:199-205. [PMID: 32041781 PMCID: PMC7041553 DOI: 10.1542/hpeds.2019-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses. METHODS We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models. RESULTS Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference -0.3; 95% confidence interval: -1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (-4.6; 95% confidence interval: -7.5 to -1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status. CONCLUSIONS We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians "do more" for hospitalized children who are not UTD.
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Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington
| | - Annika M Hofstetter
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University and Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Chén C Kenyon
- Department of Pediatrics, School of Medicine, University of Pennsylvania and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Joyee G Vachani
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Douglas J Opel
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
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15
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Abstract
OBJECTIVE To explore the causes and consequences of non-urgent visits to emergency departments in Iran and then suggest solutions from the healthcare providers' viewpoint. DESIGN Qualitative descriptive study with in-depth, open-ended, and semistructured interviews, which were inductively analysed using qualitative content analysis. SETTING A territorial, educational and military hospital in Iran. PARTICIPANTS Eleven healthcare providers including eight nurses, two emergency medicine specialists and one emergency medicine resident. RESULTS Three overarching themes of causes and consequences of non-urgent visits to the emergency department in addition to four suggested solutions were identified. The causes have encompassed the specialised services in emergency department, demand-side factors, and supply-side factors. The consequences have been categorised into three overarching themes including the negative consequences on patients, healthcare providers and emergency departments as well as the health system in general. The possible solutions for limiting and controlling non-urgent visits also involved regulatory plans, awareness-raising plans, reforms in payment mechanisms, and organisational arrangements. CONCLUSION We highlighted the need for special attention to the appropriate use of emergency departments in Iran as a middle-income country. According to the complex nature of emergency departments and in order to control and prevent non-urgent visits, it can be suggested that policy-makers should design and implement a combination of the possible solutions.
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Affiliation(s)
- Mohammadkarim Bahadori
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Research Center for Prevention of Oral and Dental Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Seyyed Meysam Mousavi
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Teymourzadeh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ramin Ravangard
- Health Human Resources Research Center, School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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Oh HC, Chow WL, Gao Y, Tiah L, Goh SH, Mohan T. Factors associated with inappropriate attendances at the emergency department of a tertiary hospital in Singapore. Singapore Med J 2020; 61:75-80. [PMID: 31044259 PMCID: PMC7052005 DOI: 10.11622/smedj.2019041] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Inappropriate attendances (IAs) at emergency departments (ED) are contributed by patients with mild or moderate medical conditions that can be effectively managed by primary care physicians. IAs strain limited ED resources and have an adverse impact on efficiency. This study aimed to identify factors associated with IA at the ED of a tertiary hospital in Singapore. METHODS We conducted a retrospective cohort study of all eligible visits to the aforementioned ED between 1 January 2015 and 31 December 2015. The appropriateness of each attendance was estimated using criteria based on investigations or procedures that were performed on the attendee and the discharge type of that attendance. IAs were then compared against appropriate attendances in these areas: attendee demographics; referral source; time of ED visit; proximity to ED and 24-hour general practitioner clinics; and history of ED visits in 2014. Multivariate analysis was performed on significant variables associated with IAs. RESULTS Among 120,606 attendances, 11,631 (9.6%) were IAs. Multivariate analysis showed that gender, ethnicity, referral source, time of ED visit, nationality and history of frequent visits to the ED were factors associated with IAs. Moreover, the odds of IA were found to be higher among attendees who were younger, were self-referred, or had at least one IA in 2014. CONCLUSION This study identified subgroups in the population who were more likely to contribute to IAs at the ED. These findings offer relevant insights into future research directions and strategies that might potentially reduce avoidable IAs.
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Affiliation(s)
- Hong Choon Oh
- Health Services Research, Changi General Hospital, Singapore
| | - Wai Leng Chow
- Health Services Research, Changi General Hospital, Singapore
| | - Yan Gao
- Health Services Research, Changi General Hospital, Singapore
| | - Ling Tiah
- Accident and Emergency Department, Changi General Hospital, Singapore
| | - Siang Hiong Goh
- Accident and Emergency Department, Changi General Hospital, Singapore
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Lemelin A, Maucort-Boulch D, Castel-Kremer E, Forestier J, Hervieu V, Lorcet M, Boutitie F, Theillaumas A, Robinson P, Duclos A, Lombard-Bohas C, Walter T. Elderly Patients with Metastatic Neuroendocrine Tumors Are Undertreated and Have Shorter Survival: The LyREMeNET Study. Neuroendocrinology 2020; 110:653-661. [PMID: 31586998 DOI: 10.1159/000503901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 04/27/2019] [Accepted: 10/04/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The incidence of neuroendocrine tumors (NETs) is rising, especially in elderly patients. The elderly cancer population presents considerable challenges, yet little is known about the characteristics, treatment patterns, and outcomes of metastatic NET (mNET) patients. METHODS The Lyon Real-life Evidence in Metastatic NeuroEndocrine Tumors study (LyREMeNET, NCT03863106) included consecutive mNET patients, diagnosed between January 1990 and December 2017. The exclusion criteria were nonmetastatic NET, poorly differentiated neuroendocrine carcinoma, and mixed neuroendocrine-nonneuroendocrine neoplasms. We aimed to compare patients ≥70 years old to patients <70 years old. RESULTS A total of 866 patients were included, 198 (23%) were ≥70 years old. There was no significant difference in characteristics except that elderly patients had synchronous metastasis more frequently. Elderly patients received significantly fewer treatments (median of 2.0 vs. 3.0 lines, respectively, p < 0.0001), were significantly less frequently treated by chemotherapy (32 vs. 54%), targeted therapy (16 vs. 30%), peptide receptor radionuclide therapy (5 vs. 16%), and they underwent significantly less frequently locoregional intervention. Median overall survival was significantly shorter in elderly patients (5.2 vs. 9.6 years). The most frequent cause of death was related to disease progression (71%). Multivariate analysis found that, after adjustment for tumor location, tumor grade, and number of metastatic sites, age remained significantly associated with overall survival (HR 1.66, 95% CI 1.26-2.18), indicating a poorer survival in patients ≥70 years old in comparison with younger patients (p = 0.0003). CONCLUSION Patients ≥70 years old have a worse survival, die frequently from their disease, and are undertreated compared to younger patients.
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Affiliation(s)
- Annie Lemelin
- Service de Gastroentérologie et d'Oncologie Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Delphine Maucort-Boulch
- Service de Biostatistique, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Hospices Civils de Lyon, Université Lyon 1, Lyon, France
- Lyon 1 Claude Bernard University, Lyon, France
| | - Elisabeth Castel-Kremer
- Service de Médecine Gériatrique, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Julien Forestier
- Service de Gastroentérologie et d'Oncologie Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Valérie Hervieu
- Service Central d'Anatomie et Cytologie Pathologiques, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
- Lyon 1 Claude Bernard University, Lyon, France
| | - Marianne Lorcet
- Service de Gastroentérologie et d'Oncologie Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Florent Boutitie
- Service de Biostatistique, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Hospices Civils de Lyon, Université Lyon 1, Lyon, France
| | - Aurélie Theillaumas
- Service de Gastroentérologie et d'Oncologie Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | | | - Antoine Duclos
- Service des Données de Santé, Hospices Civils de Lyon, Health Services and Performance Research lab (HESPER EA 7425), Lyon, France
- Lyon 1 Claude Bernard University, Lyon, France
| | - Catherine Lombard-Bohas
- Service de Gastroentérologie et d'Oncologie Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Thomas Walter
- Service de Gastroentérologie et d'Oncologie Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France,
- Lyon 1 Claude Bernard University, Lyon, France,
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Abstract
OBJECTIVES This article reviews the applicability of a customised version of the Appropriateness Evaluation Protocol (AEP) to evaluate the magnitude of inappropriate hospitalisations in two regions of Ukraine. DATA AND METHODS The original AEP was modified to develop a customised tool, which included criteria for the appropriateness of hospitalisation and duration of inpatient stay. The customisation of the tool followed the Delphi procedure. We randomly selected 381 medical records to test the feasibility and reliability of the method and 800 medical records to evaluate the scope of inappropriate hospitalisations. We used descriptive and analytical statistics, receiver operating characteristic curve analysis and Cohen's kappa to check the consistency between the findings of primary reviewers and experts. RESULT We observed high levels of agreement in conclusions of primary reviewers (reference standard) and experts during testing of the reliability and validity of the method. The external validity check showed that the use of the tool by different experts provided high accuracy: 95.1 sensitivity, 76.6 specificity and area under ROC-curve (AUC)=0.948 (р<0.001) for analysis of the appropriateness of admissions; 95.3 sensitivity, 84.7 specificity and AUC=0.900 (р=0.001) for the duration of hospitalisations. Cohen's kappa coefficient (κ) indicated agreement in expert evaluations of 0.915 (95% СІ 0.799 to 1.000) and 0.812 (95% СІ 0.749 to 0.875), respectively.We found that over one-third of admissions (38.1%; 95% СІ 33.9 to 43.5) and over half of total bed-days were unnecessary (57.4%; 95% СІ 56.4 to 58.5). The highest levels of stay were observed in hospitals' general medicine departments (64.6%; 95% СІ 63.0 to 66.3)compared with other departments included in the analysis. CONCLUSION The proposed method is robust in assessing the appropriateness of hospitalisations and duration of inpatient stays. The quantified levels of unnecessary hospital care indicate the need for improving efficiency and quality of care and optimising the excessive hospital capacities in Ukraine.
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Affiliation(s)
- Feng Zhao
- HNP, World Bank Group, Washington, District of Columbia, USA
| | | | - Valery N Lekhan
- Department of Social Medicine and Health Management, Dnipropetrovsk Medical Academy (DMA), Dnipro, Ukraine
| | - Lilia V Kriachkova
- Department of Social Medicine and Health Management, Dnipropetrovsk Medical Academy (DMA), Dnipro, Ukraine
| | - Alona Goroshko
- Department for Development of Benefits Package, National Health Service of Ukraine, Kyiv, Ukraine
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Naouri D, Ranchon G, Vuagnat A, Schmidt J, El Khoury C, Yordanov Y. Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France. BMJ Qual Saf 2019; 29:449-464. [PMID: 31666304 PMCID: PMC7323738 DOI: 10.1136/bmjqs-2019-009396] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 09/03/2019] [Accepted: 09/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France. METHOD The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs. RESULTS Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density. CONCLUSION Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED.
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Affiliation(s)
- Diane Naouri
- Sorbonne Université, AP-HP, Hôpital Saint Antoine, Service d'Accueil des Urgences, Paris, France
- Centre for Research in Epidemiology and Population Health, French National Institute of Health and Medical Research (INSERM U1018), Université Paris-Saclay, Université Paris-Sud, UVSQ, Villejuif, France
| | | | - Albert Vuagnat
- Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France
| | - Jeannot Schmidt
- Emergency Department, Clermont-Ferrand University Hospital, Clermont Ferrand, France
- EA 4679, Université Clermont Auvergne, Clermont Ferrand, France
| | - Carlos El Khoury
- Emergency Department, Médipôle, Villeurbanne, France
- RESCUe-RESUVal, INSERM, HESPER EA 7425, Lyon, France
| | - Youri Yordanov
- Sorbonne Université, AP-HP, Hôpital Saint Antoine, Service d'Accueil des Urgences, Paris, France
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, UMR-S 1136, Paris, France
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Magrath M, Yang E, Ahn C, Mayorga CA, Gopal P, Murphy CC, Gupta S, Agrawal D, Halm EA, Borton EK, Skinner CS, Singal AG. Impact of a Clinical Decision Support System on Guideline Adherence of Surveillance Recommendations for Colonoscopy After Polypectomy. J Natl Compr Canc Netw 2019; 16:1321-1328. [PMID: 30442733 DOI: 10.6004/jnccn.2018.7050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
Background: Surveillance colonoscopy is required in patients with polyps due to an elevated colorectal cancer (CRC) risk; however, studies suggest substantial overuse and underuse of surveillance colonoscopy. The goal of this study was to characterize guideline adherence of surveillance recommendations after implementation of an electronic medical record (EMR)-based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS). Methods: We performed a retrospective cohort study of patients who underwent colonoscopy with polypectomy at a safety-net healthcare system before (n=1,822) and after (n=1,320) implementation of CoRS in December 2013. Recommendations were classified as guideline-adherent or nonadherent according to the US Multi-Society Task Force on CRC. We defined surveillance recommendations shorter and longer than guideline recommendations as potential overuse and underuse, respectively. We used multivariable generalized linear mixed models to identify correlates of guideline-adherent recommendations. Results: The proportion of guideline-adherent surveillance recommendations was significantly higher post-CoRS than pre-CoRS (84.6% vs 77.4%; P<.001), with fewer recommendations for potential overuse and underuse. In the post-CoRS period, CoRS was used for 89.8% of cases and, compared with cases for which it was not used, was associated with a higher proportion of guideline-adherent recommendations (87.0% vs 63.4%; RR, 1.34; 95% CI, 1.23-1.42). In multivariable analysis, surveillance recommendations were also more likely to be guideline-adherent in patients with adenomas but less likely among those with fair bowel preparation and those with family history of CRC. Of 203 nonadherent recommendations, 70.4% were considered potential overuse, 20.2% potential underuse, and 9.4% were not provided surveillance recommendations. Conclusions: An EMR-based CoRS was widely used and significantly improved guideline adherence of surveillance recommendations.
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Massavon W, Wilunda C, Nannini M, Agaro C, Amandi S, Orech JB, De Vivo E, Lochoro P, Putoto G. Community perceptions on demand-side incentives to promote institutional delivery in Oyam district, Uganda: a qualitative study. BMJ Open 2019; 9:e026851. [PMID: 31501099 PMCID: PMC6738676 DOI: 10.1136/bmjopen-2018-026851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To examine the perceptions of community members and other stakeholders on the use of baby kits and transport vouchers to improve the utilisation of childbirth services. DESIGN A qualitative study. SETTING Oyam district, Uganda. PARTICIPANTS We conducted 10 focus group discussions with 59 women and 55 men, and 18 key informant interviews with local leaders, village health team members, health facility staff and district health management team members. We analysed the data using qualitative content analysis. RESULTS Five broad themes emerged: (1) context, (2) community support for the interventions, (3) health-seeking behaviours postintervention, (4) undesirable effects of the interventions and (5) implementation issues and lessons learnt. Context regarded perceived long distances to health facilities and high transport costs. Regarding community support for the interventions, the schemes were perceived to be acceptable and helpful particularly to the most vulnerable. Transport vouchers were preferred over baby kits, although both interventions were perceived to be necessary. Health-seeking behaviours entailed perceived increased utilisation of maternal health services and 'bypassing', promotion of collaboration between traditional birth attendants and formal health workers, stimulation of men's involvement in maternal health, and increased community awareness of maternal health. Undesirable effects of the interventions included increased workload for health workers, sustainability concerns and perceived encouragement to reproduce and dependency. Implementation issues included information gaps leading to confusion, mistrust and discontent, transport voucher scheme design; implementation; and payment problems, poor attitude of some health workers and poor quality of care, insecurity, and a shortage of baby kits. Community involvement was key to solving the challenges. CONCLUSIONS The study provides further insights into the implementation of incentive schemes to improve maternal health services utilisation. The findings are relevant for planning and implementing similar schemes in low-income countries.
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Affiliation(s)
| | - Calistus Wilunda
- Maternal and Child Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
- Division of Epidemiology and Prevention, National Cancer Center Japan, Chuo-ku, Japan
| | - Maria Nannini
- School of Economics and Development, University of Florence, Florence, Italy
| | - Caroline Agaro
- District Health Office, Oyam District Local Government, Loro, Uganda
| | - Simon Amandi
- District Health Office, Oyam District Local Government, Loro, Uganda
| | - John Bosco Orech
- District Health Office, Oyam District Local Government, Loro, Uganda
| | | | | | - Giovanni Putoto
- Operational Research Unit, Doctors with Africa CUAMM, Padua, Italy
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Abstract
IMPORTANCE Misuse and overselling of over-the-counter pharmaceuticals poses a major burden on both private and public health expenditures. OBJECTIVE To seek evidence on whether over-the-counter medication dispensing behavior complies or conflicts with the protocols indicated in practice standards and guidelines of a national professional pharmacy organization. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study was undertaken in 205 pharmacies in the wider Brisbane, Australia, area. Two standardized patient (SP) scenarios were developed to evaluate noncompliant behavior. Data collection for scenario 1 was conducted between November 23 and December 9, 2016. Data collection for scenario 2 was conducted between September 1 and 28, 2017. A 2-sample test of proportions and a probit regression model were used to evaluate the likelihood of noncompliant treatments and overtreatments in each case scenario. Statistical analysis was performed from January 30 to June 21, 2018, and revised in May 2019. MAIN OUTCOMES AND MEASURES Outcomes were the observed likelihood of noncompliant treatments and overtreatments. Noncompliance is defined as treatments not complying with practice standards and guidelines set by the professional pharmacy society. Noncompliant treatments include undertreatment (patient did not receive necessary treatment) and overtreatments (patient was supplied with more than sufficient treatments) in both scenarios. RESULTS In scenario 1, 9 trained female SPs visited 89 pharmacies to request emergency hormonal contraception from pharmacy staff. In 45 cases, SPs reported having unprotected intercourse within the last 24 hours (case 1A), and in 44 cases, SPs reported having unprotected intercourse more than 72 hours ago (case 1B), which is past the efficacy threshold of over-the-counter emergency hormonal contraception. In scenario 2, 11 SPs (5 male and 6 female) visited 150 pharmacies (154 visits in total) to request treatment for family members or a partner with symptoms indicating bacterial conjunctivitis (case 2A; n = 73) or viral conjunctivitis (case 2B; n = 81). In scenario 1-dispensing emergency hormonal contraception when physician referral is recommended-21 of 44 pharmacists (47.7%) in case 1B violated the recommendation by selling the over-the-counter medication. With the inclusion of both no physician referral and emergency hormonal contraception sold, this rate increased to 79.5% (35 of 44 pharmacists). In scenario 2-1 case each of bacterial and viral conjunctivitis-overtreatment occurred in 55 of 154 cases (35.7%). In both scenarios, 140 of 243 pharmacies (57.6%) followed dispensing behavior compliant with the protocol, while 76 of 243 pharmacies (31.3%) involved some form of overtreatment or overselling of medication. Some evidence of an association between sex of SP and pharmacist was also found. CONCLUSIONS AND RELEVANCE Although the market for dispensing over-the-counter medication in Australia is regulated, relatively high rates of overtreatment and some cases of undertreatment were observed in this study. Given the unintended adverse effects, including overuse of antibiotics and corticosteroids, these observations suggest the advisability of regulatory intervention ensuring compliance with professional protocols.
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Affiliation(s)
- Harriet Smith
- School of Economics and Finance, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Stephen Whyte
- School of Economics and Finance, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Behavioural Economics, Society and Technology, Brisbane, Queensland, Australia
| | - Ho Fai Chan
- School of Economics and Finance, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Behavioural Economics, Society and Technology, Brisbane, Queensland, Australia
| | - Gregory Kyle
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Esther T. L. Lau
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lisa M. Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Benno Torgler
- School of Economics and Finance, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Behavioural Economics, Society and Technology, Brisbane, Queensland, Australia
- Center for Research in Economics, Management and the Arts, Zürich, Switzerland
| | - Uwe Dulleck
- School of Economics and Finance, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Behavioural Economics, Society and Technology, Brisbane, Queensland, Australia
- Crawford School of Public Policy, Australian National University, Canberra, Australian Capital Territory, Australia
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Botelho A, Dias IC, Fernandes T, Pinto LMC, Teixeira J, Valente M, Veiga P. Overestimation of health urgency as a cause for emergency services inappropriate use: Insights from an exploratory economics experiment in Portugal. Health Soc Care Community 2019; 27:1031-1041. [PMID: 30734991 DOI: 10.1111/hsc.12720] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 11/30/2018] [Accepted: 01/15/2019] [Indexed: 06/09/2023]
Abstract
Increasing visits to emergency departments add strain to public healthcare systems. The misperception of symptoms' severity can partly explain inappropriate use of hospitals' emergency departments by non-urgent patients. This paper focuses on the misperception of symptoms' severity as a cause for the inappropriate use of emergency departments. It explores the role that informing potential patients of the correct severity level can play in correcting this inefficiency. We implement in an incentivised manner an exploratory economic experiment to elicit the degree of severity of five sets of symptoms, corresponding to frequent causes of emergency department visits. The study was setup in Braga, Northern Portugal, recruiting voluntary participants through civic local organisations. We ask participants to indicate the more suitable health service, before and after revealing the true degree of severity. Results show that there is an overestimation of the degree of severity of some clinical profiles, and when confronted with the real severity, in only half of the cases are choices changed to other health services. Although exploratory, this study provides insights into the potential role of health education policies concerning symptoms' severity but it also highlights the limits of such policies. Furthermore, the use of economic experiments can provide meaningful insights for the design of policies addressing demand-side healthcare inefficiencies.
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Affiliation(s)
| | | | | | | | | | | | - Paula Veiga
- JusGov, University of Minho, Braga, Portugal
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O’Keeffe M, Traeger AC, Hoffmann T, Ferreira GE, Soon J, Maher C. Can nudge-interventions address health service overuse and underuse? Protocol for a systematic review. BMJ Open 2019; 9:e029540. [PMID: 31239308 PMCID: PMC6597741 DOI: 10.1136/bmjopen-2019-029540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/15/2019] [Accepted: 05/24/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Nudge-interventions aimed at health professionals are proposed to reduce the overuse and underuse of health services. However, little is known about their effectiveness at changing health professionals' behaviours in relation to overuse or underuse of tests or treatments. OBJECTIVE The aim of this study is to systematically identify and synthesise the studies that have assessed the effect of nudge-interventions aimed at health professionals on the overuse or underuse of health services. METHODS AND ANALYSIS We will perform a systematic review. All study designs that include a control comparison will be included. Any qualified health professional, across any specialty or setting, will be included. Only nudge-interventions aimed at altering the behaviour of health professionals will be included. We will examine the effect of choice architecture nudges (default options, active choice, framing effects, order effects) and social nudges (accountable justification and pre-commitment or publicly declared pledge/contract). Studies with outcomes relevant to overuse or underuse of health services will be included. Relevant studies will be identified by a computer-aided search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, CINAHL, Embase and PsycINFO databases. Two independent reviewers will screen studies for eligibility, extract data and perform the risk of bias assessment using the criteria recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We will report our results in a structured synthesis format, as recommended by the Cochrane EPOC group. ETHICS AND DISSEMINATION No ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature.
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Affiliation(s)
- Mary O’Keeffe
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Giovanni Esteves Ferreira
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jason Soon
- Royal Australasian College of Physicians, Sydney, New South Wales, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Landa K, Freischlag K, Nussbaum DP, Youngwirth LM, Blazer DG. Underutilization of surgical resection in patients with pancreatic acinar cell carcinoma. HPB (Oxford) 2019; 21:687-694. [PMID: 30514625 DOI: 10.1016/j.hpb.2018.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/10/2018] [Accepted: 10/27/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic acinar cell carcinoma (pACC) is a rare malignancy and surgical utilization has been historically low in these patients. Contemporary outcomes for this patient population remain unknown. METHODS The 1998-2012 National Cancer Data Base was queried for baseline characteristics in patients with pACC. Patients with potentially operable disease (stage I/II) were grouped by surgical resection. Multivariable logistic regression was used to predict factors associated with resection. Survival was estimated using Kaplan-Meier analysis. A proportional hazards model identified factors associated with overall survival. RESULTS 980 patients were identified. Mean age at diagnosis was 64 years. Tumors were more common in men (68%), white patients (88%), and within the pancreatic head (57%). Thirty-four percent of patients with localized disease failed to undergo resection. Five-year survival was higher among patients who underwent resection (42% vs. 9%, p < 0.001). In patients with resectable disease, male sex, older age, black race, tumors within the pancreatic head, lower grade tumors and treatment at non-academic centers are associated with failure to undergo surgery. CONCLUSION Patients with localized pACC have increased survival after resection. However, in this contemporary analysis, resection continues to be underutilized and new efforts to increase resection rates should be undertaken.
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Affiliation(s)
- Karenia Landa
- Duke University Medical Center, Department of Surgery, Durham, NC, USA
| | - Kyle Freischlag
- Duke University Medical Center, School of Medicine, Durham, NC, USA
| | - Daniel P Nussbaum
- Duke University Medical Center, Department of Surgery, Durham, NC, USA
| | | | - Dan G Blazer
- Duke University Medical Center, Department of Surgery, Durham, NC, USA.
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Radecki RP, Foley KF, Elzinga TS, Horak CP, Gant TE, Papp HM, Morris AJ, Hauser NR, Ertz-Berger BL. Pilot of urgent care center evaluation for acute coronary syndrome. Am J Manag Care 2019; 25:e160-e164. [PMID: 31120713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Patients with chest pain and concern for potential coronary ischemia are frequently referred to the emergency department (ED), resulting in substantial resource utilization and cost. The objective of this study was to implement a protocol for urgent care center (UCC) evaluation of potential acute coronary syndrome (ACS) and describe its performance. STUDY DESIGN This is a descriptive, retrospective review of consecutive cases included in a protocol for UCC evaluation of ACS. METHODS Consecutive patient encounters from 4 urgent care facilities of our regional integrated health system were reviewed from a period spanning 4.5 months of the 2017 calendar year. The primary outcome was avoidance of an ED visit within 30 days of the index visit, and the primary safety outcome was serious adverse events (AEs) occurring in the UCC setting. RESULTS There were 802 patients evaluated, with a median age of 55 years, and 58% were female. Seventy-three (9.1%) patients were referred to the ED or hospitalized for any reason at the index visit, 10 (1.2%) of whom were ultimately diagnosed with ACS. Within 30 days, 56 (7.7%) of the remaining 729 patients had ED visits or hospitalization for any reason, 2 (0.2%) of whom received a diagnosis of ACS. Overall, 673 (83.9%) patients were managed without any ED visit. No serious AEs were recorded. CONCLUSIONS Our initial pilot data demonstrate the feasibility of an outpatient UCC evaluation for ACS without refuting the underlying premise of safety.
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Affiliation(s)
- Ryan P Radecki
- Kaiser Permanente Northwest, 500 N Multnomah Ave, Portland, OR 97232.
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Wilson ME, Dobler CC, Zubek L, Gajic O, Talmor D, Curtis JR, Hinds RF, Banner-Goodspeed VM, Mueller A, Rickett DM, Elo G, Filipe M, Szucs O, Novotny PJ, Piers RD, Benoit DD. Prevalence of Disagreement About Appropriateness of Treatment Between ICU Patients/Surrogates and Clinicians. Chest 2019; 155:1140-1147. [PMID: 30922949 DOI: 10.1016/j.chest.2019.02.404] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 07/30/2018] [Revised: 01/24/2019] [Accepted: 02/19/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND ICU patients/surrogates may experience adverse outcomes related to perceived inappropriate treatment. The objective was to determine the prevalence of patient/surrogate-reported perceived inappropriate treatment, its impact on adverse outcomes, and discordance with clinicians. METHODS We conducted a multicenter, prospective, observational study of adult ICU patients. RESULTS For 151 patients, 1,332 patient, surrogate, nurse, and physician surveys were collected. Disagreement between patients/surrogates and clinicians regarding "too much" treatment being administered occurred in 26% of patients. Disagreement regarding "too little" treatment occurred in 10% of patients. Disagreement about perceived inappropriate treatment was associated with prognostic discordance (P = .02) and lower patient/surrogate satisfaction (Likert scale 1-5 of 4 vs 5; P = .02). Patient/surrogate respondents reported "too much" treatment in 8% of patients and "too little" treatment in 6% of patients. Perceived inappropriate treatment was associated with moderate or high respondent distress for 55% of patient/surrogate respondents and 35% of physician/nurse respondents (P = .30). Patient/surrogate perception of inappropriate treatment was associated with lower satisfaction (Family Satisfaction in the ICU Questionnaire-24, 69.9 vs 86.6; P = .002) and lower trust in the clinical team (Likert scale 1-5 of 4 vs 5; P = .007), but no statistically significant differences in depression (Patient Health Questionnaire-2 of 2 vs 1; P = .06) or anxiety (Generalized Anxiety Disorder-7 Scale of 7 vs 4; P = .18). CONCLUSIONS For approximately one-third of ICU patients, there is disagreement between clinicians and patients/surrogates about the appropriateness of treatment. Disagreement about appropriateness of treatment was associated with prognostic discordance and lower patient/surrogate satisfaction. Patients/surrogates who reported inappropriate treatment also reported lower satisfaction and trust in the ICU team.
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Affiliation(s)
- Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN.
| | | | - Laszlo Zubek
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Richard F Hinds
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Valerie M Banner-Goodspeed
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Dee M Rickett
- Department of Critical Care and Palliative Care, Henry Mayo Hospital, Valencia, CA
| | - Gabor Elo
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Mario Filipe
- Department of Anesthesiology and Intensive Therapy, St. Stephen and St. Ladislaus Combined Hospital, Budapest, Hungary
| | - Orsolya Szucs
- Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Paul J Novotny
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ruth D Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Kacem M, Melki S, Nouira S, Khelil M, Sriha Belguith A, Ben Abdelaziz A. For a honest Maghreb care system. Systematic Review of the International Literature on Corruption in the Health care System. Tunis Med 2019; 97:397-406. [PMID: 31729714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Corruption in the health care system is a universal phenomenon, putting at risk the health of populations. The purpose of this work was to synthesize the international literature on corruption in the health sector. METHODS This is a systematic review of literature dealing with articles on health corruption practices, published between July 2008 and June 2018, via two search engines: PubMed and Google Scholar. The extracted data were narratively summarized in three major areas: defining the concept of corruption in health, its typology / manifestations and anti-corruption interventions. RESULTS A total of 23 articles were selected for final analysis. The articles that defined health corruption shared two key aspects: "abuse of power" and "benefit". The main types of corruption were "abuse of therapeutic indication", followed by "bribes" and "falsification". The anti-corruption interventions were synthesized into seven types: creation of an independent multi-interventional agency, support for scientific research, law enforcement, awareness raising, detection, reporting and institutional commitment. CONCLUSION Based on the use of power, corruption in health is a complex phenomenon whose struggle requires a specific and contextualized strategy integrating information, detection and punishment.
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Myers A, Cain A, Franz B, Skinner D. Should Hospital Emergency Departments Be Used as Revenue Streams Despite Needs to Curb Overutilization? AMA J Ethics 2019; 21:E207-E214. [PMID: 30893033 DOI: 10.1001/amajethics.2019.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This case asks how a hospital should balance patients' health needs with its financial bottom line regarding emergency department utilization. Should hospitals engage in proactive population health initiatives if they result in decreased revenue from their emergency departments? Which values should guide their thinking about this question? Drawing upon emerging legal and moral consensus about hospitals' obligations to their surrounding communities, this commentary argues that treating emergency departments purely as revenue streams violates both legal and moral standards.
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Affiliation(s)
| | | | - Berkeley Franz
- A medical sociologist and an assistant professor of community-based health at the Ohio University Heritage College of Osteopathic Medicine in Athens, Ohio
| | - Daniel Skinner
- An assistant professor of health policy at the Ohio University Heritage College of Osteopathic Medicine in Dublin, Ohio, and a co-director of the Health Policy Fellowship, a program of the American Association of Colleges of Osteopathic Medicine
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Wambiya EOA, Atela M, Eboreime E, Ibisomi L. Factors affecting the acceptability of isoniazid preventive therapy among healthcare providers in selected HIV clinics in Nairobi County, Kenya: a qualitative study. BMJ Open 2018; 8:e024286. [PMID: 30573488 PMCID: PMC6303693 DOI: 10.1136/bmjopen-2018-024286] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Despite being globally recommended as an effective intervention in tuberculosis (TB) prevention among people living with HIV, isoniazid preventive therapy (IPT) implementation remains suboptimal, especially in sub-Saharan Africa. This study explored the factors influencing the acceptability of IPT among healthcare providers in selected HIV clinics in Nairobi County, Kenya, a high HIV/TB burden country. DESIGN A qualitative study was conducted using in-depth interviews with healthcare providers in selected HIV clinics. All conversations were audio recorded, transcribed verbatim and analysed using a thematic approach. SETTING The study was conducted in the HIV clinics of three purposefully selected public healthcare facilities in Nairobi County, Kenya between February 2017 and April 2017. PARTICIPANTS Eighteen purposefully selected healthcare providers (clinicians, nurses, pharmacists and counsellors) working in the HIV clinics participated in the study. RESULTS Provider acceptability of IPT was influenced by factors relating to the organisational context, provider training on IPT and their perception on its efficacy, length and clarity of IPT guidelines and standard operation procedures, as well as structural factors (policy, physical and work environment). Inadequate high-level commitment and support for the IPT programme by programme managers and policy-makers were found to be the major barriers to successful IPT implementation in our study context. CONCLUSION This study provides insight into the complexity of factors affecting the IPT implementation in Kenya. Ensuring optimal acceptability of IPT among healthcare providers will require an expanded depth of engagement by policy-makers and IPT programme managers with both providers and patients, as well as on-the-job design specific actions to support providers in implementation. Such high-level commitment and support are consequently essential for quality delivery of the intervention.
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Affiliation(s)
- Elvis Omondi Achach Wambiya
- Research unit, African Population and Health Research Center, Nairobi, Kenya
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Martin Atela
- Research Uptake & Policy Engagement Unit, Partnership for African Social & Governance Research, Nairobi, Kenya
- Public Health department, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Ejemai Eboreime
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Planning Research & Statistics, National Primary Health Care Development Agency, Abuja, Nigeria
| | - Latifat Ibisomi
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Research unit, Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria
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Chen A, Blumenthal DM, Jena AB. Characteristics of Physicians Excluded From US Medicare and State Public Insurance Programs for Fraud, Health Crimes, or Unlawful Prescribing of Controlled Substances. JAMA Netw Open 2018; 1:e185805. [PMID: 30646294 PMCID: PMC6324355 DOI: 10.1001/jamanetworkopen.2018.5805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Each year, billions of dollars are wasted owing to health care fraud, waste, and abuse. Efforts to detect fraud have been increasing, yet we have little information about physicians who have been excluded from Medicare and state public insurance programs for fraud, health crimes, or the unlawful prescribing of controlled substances. OBJECTIVE To examine the characteristics of physicians excluded from Medicare and state public insurance programs for fraud, health crimes, or unlawful prescribing of controlled substances. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study considered all physicians excluded from Medicare and state public insurance programs between 2007 and 2017. The study matched exclusion data to a comprehensive, cross-sectional database of US physicians assembled by Doximity, an online networking service for US physicians. The share of physicians excluded in each state was examined and linear trends of exclusions over time were estimated. Using physician-level multivariable logistic regression models, exclusions (binary variable) were assessed as a function of physician characteristics. MAIN OUTCOMES AND MEASURES Exclusions for fraud, health crimes (defined legally as criminal penalties for acts involving federal health care programs), and substance abuse; and physician characteristics, including age, sex, allopathic vs osteopathic degree, medical school attended, ranking of that medical school, medical school faculty affiliation, practice state, practice location, and specialty. RESULTS Between 2007 and 2017, 2222 physicians (0.29%) were temporarily or permanently excluded from Medicare and state public insurance programs. Fraud, health crimes, and substance abuse exclusions increased, on average, 20% per year (equivalent to 48 [95% CI, 40.4-56.0] convictions/year from a base of 236 convictions in 2007 to 670 convictions in 2017 [an increase of approximately 200% from 2007 to 2017]). Exclusion rates were highest in the West and Southeast. West Virginia had the highest exclusion rate, with 5.77 exclusions per 1000 physicians (32 exclusions among 5720 physicians), while Montana had 0 exclusions during this period. Male physicians, physicians with osteopathic training, older physicians, and physicians in specific specialties (eg, family medicine, psychiatry, internal medicine, anesthesiology, surgery, and obstetrics/gynecology) were more likely to be excluded. CONCLUSIONS AND RELEVANCE The number of physicians excluded from participation in Medicare and state public insurance reimbursement owing to fraud, waste, and abuse increased between 2007 and 2017. Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion. Our results highlight the potential value of using physician characteristics in conjunction with information on medical claims filed by physicians to help identify adverse physician behavior.
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Affiliation(s)
- Alice Chen
- Sol Price School of Public Policy, University of Southern California, Los Angeles
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Daniel M. Blumenthal
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Devoted Health Inc, Waltham, Massachusetts
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital, Boston
- National Bureau of Economic Research, Cambridge, Massachusetts
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Abstract
OBJECTIVES To explore common features of conversations occurring in a sample of emergency calls that result in an ambulance dispatch for a 'primary care sensitive' situation, and better understand the challenges of triaging this cohort. DESIGN A qualitative study, applying conversation analytic methods to routinely recorded telephone calls made through the '999' system for an emergency ambulance. Cases were identified by a primary care clinician, observing front-line UK ambulance service shifts. A sample of 48 '999' recordings were analysed, corresponding to situations potentially amenable to primary care management. RESULTS The analysis focuses on four recurring ways that speakers use talk in these calls. Progress can be impeded when call-taker's questions appear to require callers to have access to knowledge that is not available to them. Accordingly, callers often provide personal accounts of observed events, which may be troublesome for call-takers to 'code' and triage. Certain question formats-notably 'alternative question' formats-appear particularly problematic. Callers deploy specific lexical, grammatical and prosodic resources to legitimise the contact as 'urgent', and ensure that their perception of risk is conveyed. Difficulties encountered in the triage exchange may be evidence of misalignment between organisational and caller perceptions of the 'purpose' of the questions. CONCLUSIONS Previous work has focused on exploring the presentation and triage of life-threatening medical emergencies. Meaningful insights into the challenges of EMS triage can also be gained by exploring calls for 'primary care sensitive' situations. The highly scripted triage process requires precise, 'codeable' responses to questions, which can create challenges when the exact urgency of the problem is unclear to both caller and call-taker. Calling on behalf of someone else may compound this complexity. The aetiology of some common interactional challenges may offer a useful frame for future comparison between calls for 'primary care sensitive' situations and life-threatening emergencies.
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Affiliation(s)
- Matthew James Booker
- Department of Population Health Sciences, Bristol Medical School, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Ali R G Shaw
- Department of Population Health Sciences, Bristol Medical School, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Department of Population Health Sciences, Bristol Medical School, Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Rebecca Barnes
- Department of Population Health Sciences, Bristol Medical School, Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Sezgin G, Georgiou A, Hardie RA, Li L, Pont LG, Badrick T, Franco GS, Westbrook JI, Rinehart N, McLeod A, Pearce C, Shearer M, Whyte R, Deveny E. Compliance with pathology testing guidelines in Australian general practice: protocol for a secondary analysis of electronic health record data. BMJ Open 2018; 8:e024223. [PMID: 30429148 PMCID: PMC6252775 DOI: 10.1136/bmjopen-2018-024223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION In Australia, general practitioners usually are the first point of contact for patients with non-urgent medical conditions. Appropriate and efficient utilisation of pathology tests by general practitioners forms a key part of diagnosis and monitoring. However overutilisationand underutilisation of pathology tests have been reported across several tests and conditions, despite evidence-based guidelines outlining best practice in pathology testing. There are a limited number of studies evaluating the impact of these guidelines on pathology testing in general practice. The aim of our quantitative observational study is to define how pathology tests are used in general practice and investigate how test ordering practices align with evidence-based pathology guidelines. METHODS AND ANALYSIS Access to non-identifiable patient data will be obtained through electronic health records from general practices across three primary health networks in Victoria, Australia. Numbers and characteristics of patients, general practices, encounters, pathology tests and problems managed over time will be described. Overall rates of encounters and tests, alongside more detailed investigation between subcategories (encounter year, patient's age, gender, and location and general practice size), will also be undertaken. To evaluate how general practitioner test ordering coincides with evidence-based guidelines, five key candidate indicators will be investigated: full blood counts for patients on clozapine medication; international normalised ratio measurements for patients on warfarin medication; glycated haemoglobin testing for monitoring patients with diabetes; vitamin D testing; and thyroid function testing. ETHICS AND DISSEMINATION Ethics clearance to collect data from general practice facilities has been obtained by the data provider from the RACGP National Research and Evaluation Ethics Committee (NREEC 17-008). Approval for the research group to use these data has been obtained from Macquarie University (5201700872). This study is funded by the Australian Government Department of Health Quality Use of Pathology Program (Agreement ID: 4-2QFVW4M). Findings will be reported to the Department of Health and disseminated in peer-reviewed academic journals and presentations (national and international conferences, industry forums).
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Affiliation(s)
- Gorkem Sezgin
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Rae-Anne Hardie
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Lisa G Pont
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Tony Badrick
- The Royal College of Pathologists of Australasia Quality Assurance Program, St Leonards, New South Wales, Australia
| | - Guilherme S Franco
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | | | - Adam McLeod
- Outcome Health, Burwood, Victoria, Australia
| | | | | | - Robin Whyte
- Eastern Melbourne Primary Health Network, Box Hill, Victoria, Australia
| | - Elizabeth Deveny
- South Eastern Melbourne Primary Health Network, Heatherton, Victoria, Australia
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Affiliation(s)
- Ingela Wiklund
- Institution of Clinical Sciences, Department of Obstetrics and Gynaecology, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden; International Confederation of Midwives, 2514 AE The Hague, Netherlands
| | - Address Mauakowa Malata
- Office of Vice Chancellor, Malawi University of Science and Technology, Thyolo, Malawi; Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Ngai Fen Cheung
- Shijiazhong Obstetrics and Gynaecology Hospital, Shijiazhong, China
| | - Franka Cadée
- International Confederation of Midwives, 2514 AE The Hague, Netherlands.
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Abstract
INTRODUCTION Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself. METHODS AND ANALYSIS This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions. ETHICS AND DISSEMINATION Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients. PROSPERO REGISTRATION NUMBER CRD42018091986.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
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Glattacker M, Giesler JM, Klindtworth K, Nebe A. Rehabilitation use in multiple sclerosis: Do illness representations matter? Brain Behav 2018; 8:e00953. [PMID: 30106225 PMCID: PMC5991568 DOI: 10.1002/brb3.953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 01/31/2018] [Accepted: 02/20/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Multidisciplinary rehabilitation improves illness outcomes and is recommended in clinical guidelines for multiple sclerosis (MS). However, many people with MS do not make use of rehabilitation. We do not know much about the barriers to the use of rehabilitation in MS, but in other patient groups, illness representations have proven to be predictors of service utilization. Therefore, the aim of our study was to explore whether, in patients with MS, illness representations are associated with self-reports of rehabilitation use in the past and the intention to use rehabilitation in the future, beyond sociodemographic and illness-related factors. MATERIALS AND METHODS Patients were recruited in a cross-sectional nationwide online survey in Germany. Hierarchical binary logistic regression analysis was used to analyze whether illness representations are associated with the use of rehabilitation in the past and the intention to use rehabilitation in the future, over and above socio-demographic and illness-related variables. RESULTS There were 590 patients, who had MS, participating in the study. Illness representations were correlated to both outcome variables beyond sociodemographic and illness-related factors: The probabilities of having the intention to use rehabilitation and of making using of rehabilitation were higher in patients who believed that their MS was controllable by treatment and perceived that their MS would have severe consequences. CONCLUSIONS Our data suggest that addressing patients' illness representations may facilitate the intention to use and the use of multimodal rehabilitation, contributing to better illness outcomes.
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Affiliation(s)
- Manuela Glattacker
- Section of Health Care Research and Rehabilitation ResearchMedical Center—University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Jürgen M. Giesler
- Section of Health Care Research and Rehabilitation ResearchMedical Center—University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Katharina Klindtworth
- Section of Health Care Research and Rehabilitation ResearchMedical Center—University of FreiburgFaculty of MedicineUniversity of FreiburgFreiburgGermany
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Abstract
UNLABELLED Using a large population database, we showed that fragility fractures were highly prevalent in senior women and were associated with significant physical disability. However, treatment rates were low because osteoporosis treatment was not prescribed or not agreed to by the majority of women with prevalent fragility fractures. PURPOSE The purpose of the study is to estimate prevalence of fragility fractures (FF), risk factors, and treatment rates in senior women and to assess impact of FF on physical function and quality of life. METHODS Women aged 65 years and older from the EpiReumaPt study (2011-2013) were evaluated. Rheumatologists collected data regarding FF, clinical risk factors for fractures, and osteoporosis (OP) treatment. Health-related quality of life (EQ5D) and physical function (HAQ) were analyzed. Peripheral dual-energy X-ray absorptiometry was performed. FF was defined as any self-reported low-impact fracture that occurred after 40 years of age. Prevalence estimates of FF were calculated. RESULTS Among 3877 subjects evaluated in EpiReumaPt, 884 were senior women. The estimated prevalence of FF was 20.7%. Lower leg was the most frequent fracture site reported (37.8%) followed by wrist (18.6%). Only 7.1% of the senior women reporting a prevalent FF were under treatment for OP, and 13.9% never had treatment. OP treatment was not prescribed in 47.7% of FF women, and 23.4% refused treatment. Age (OR = 2.46, 95% CI 1.11-5.47), obesity (OR = 2.05, 95% CI 1.14-3.70), and low wrist BMD (OR = 2.29; 95% CI 1.20, 4.35; p = 0.012) were positively associated with prevalent FF. A significantly higher proportion of women in the lowest quintile of wrist bone mineral density reported FF (OR = 2.29, 95% CI 1.20-4.35). FF were associated with greater physical disability (β = 0.33, 95% CI 0.13-0.51) independent of other comorbidities. CONCLUSION FF was frequently reported among senior women as an important cause of physical disability. However, the prevalence of OP treatment was low, which constitutes a public health problem in this vulnerable group.
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Affiliation(s)
- Ana M Rodrigues
- Campus Sant' Ana, Polo de Investigação, Nova Medical School, Edifício Amarelo, Rua do Instituto Bacteriológico no. 5, Universidade Nova de Lisboa, 1150-082, Lisbon, Portugal.
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.
| | | | - Maria José Santos
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Hospital Garcia de Orta, Almada, Portugal
| | - Nélia Gouveia
- Chronic Diseases Research Centre (CEDOC), NOVA Medical School, Universidade Nova de Lisboa (NMS-UNL), Lisbon, Portugal
| | - Viviana Tavares
- Hospital Garcia de Orta, Almada, Portugal
- APOROS-Associação Nacional Contra a Osteoporose, Lisbon, Portugal
| | - Pedro S Coelho
- NOVA Information Managment School (IMS), Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jorge M Mendes
- NOVA Information Managment School (IMS), Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jaime C Branco
- Chronic Diseases Research Centre (CEDOC), NOVA Medical School, Universidade Nova de Lisboa (NMS-UNL), Lisbon, Portugal
- Centro Hospitalar Lisboa Ocidental-EPE, Serviço de Reumatologia do Hospital Egas Moniz-Lisboa, Lisbon, Portugal
| | - Helena Canhão
- Campus Sant' Ana, Polo de Investigação, Nova Medical School, Edifício Amarelo, Rua do Instituto Bacteriológico no. 5, Universidade Nova de Lisboa, 1150-082, Lisbon, Portugal
- NOVA National School of Public Health, Universidade Nova de Lisboa, Lisbon, Portugal
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Parmeter J, Tzioumi D, Woolfenden S. Medical neglect at a tertiary paediatric hospital. Child Abuse Negl 2018; 77:134-143. [PMID: 29353717 DOI: 10.1016/j.chiabu.2018.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/22/2017] [Accepted: 01/05/2018] [Indexed: 06/07/2023]
Abstract
Medical neglect is under-researched and the extent of the problem in Australia is unknown. We conducted a review of the referrals for medical neglect to the Child Protection Unit (CPU) at a tertiary children's hospital in Sydney over a 5 years period, from 2011 to 2016, to determine what medical conditions are being referred, the reason for the medical neglect concern and whether cases are managed in line with American Academy of Pediatrics (AAP) guideline on medical neglect. 61 cases of medical neglect were identified, constituting 4.1% of all referrals to the Child Protection Unit for physical abuse and neglect. There was a wide variety of medical conditions. Most were chronic medical conditions (87%). The top two medical conditions were chronic and complex multi-system disorders (37.7%) and endocrine disorders (18%). The majority of medical neglect were related to concerns that the caregivers were unwilling to follow medical advice (45.9%) or unable to provide necessary medical care (26.2%). In line with the AAP guideline on medical neglect, all cases were managed by addressing communication difficulties (100%) and resource issues were addressed in 80% of cases. A report to statutory child protection agencies was made in 50% of cases. Directly observed therapy and medical contracts were used in 30% and 26% of cases. We conclude that children with chronic medical conditions may be at risk of medical neglect. Communication difficulties were a factor in all cases. Statutory agency intervention is often required.
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Affiliation(s)
- Julia Parmeter
- Sydney Children's Hospital Network, c/o Child Protection Unit, Sydney Children's Hospital, High Street, Randwick, NSW 2031 Australia; UNSW School of Women's and Children's Health, c/o Department of Community Child Health, Sydney Children's Hospital, Cnr Avoca and Barker Streets, Randwick, NSW 2031 Australia.
| | - Dimitra Tzioumi
- Sydney Children's Hospital Network, c/o Child Protection Unit, Sydney Children's Hospital, High Street, Randwick, NSW 2031 Australia; UNSW School of Women's and Children's Health, c/o Department of Community Child Health, Sydney Children's Hospital, Cnr Avoca and Barker Streets, Randwick, NSW 2031 Australia
| | - Susan Woolfenden
- Sydney Children's Hospital Network, c/o Child Protection Unit, Sydney Children's Hospital, High Street, Randwick, NSW 2031 Australia; UNSW School of Women's and Children's Health, c/o Department of Community Child Health, Sydney Children's Hospital, Cnr Avoca and Barker Streets, Randwick, NSW 2031 Australia
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Abstract
OBJECTIVE To assess whether provider organizations exhibit distinct profiles of low-value service provision. DATA SOURCES 2007-2011 Medicare fee-for-service claims and enrollment data. STUDY DESIGN Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variation across organizations, persistence within organizations over time, and correlations in use of different types of low-value services within organizations were estimated via multilevel modeling, with adjustment for beneficiary sociodemographic and clinical characteristics. PRINCIPAL FINDINGS Organizations provided 45.6 low-value services per 100 beneficiaries on average, with considerable variation across organizations (90th/10th percentile ratio, 1.78; 95 percent CI, 1.72-1.84), including substantial between-organization variation within hospital referral regions (90th/10th percentile ratio, 1.66; 95 percent CI, 1.60-1.71). Low-value service use within organizations was highly correlated over time (r, 0.98; 95 percent CI, 0.97-0.99) and positively correlated between 13 of 15 pairs of service categories (average r, 0.26; 95 percent CI, 0.24-0.28), with the greatest correlation between low-value imaging and low-value cardiovascular testing and procedures (r, 0.54). CONCLUSIONS Use of low-value services in provider organizations exhibited substantial variation, high persistence, and modest consistency across service types. These findings are consistent with organizations shaping the practice patterns of affiliated physicians.
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Affiliation(s)
| | | | - Bruce E. Landon
- Department of Health Care PolicyHarvard Medical SchoolBostonMA
- Division of General Internal Medicine and Primary CareDepartment of MedicineBeth Israel Deaconess Medical CenterBostonMA
| | | | - J. Michael McWilliams
- Department of Health Care PolicyHarvard Medical SchoolBostonMA
- Division of General Internal Medicine and Primary CareDepartment of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
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Matsumoto CL, O'Driscoll T, Blakeloch B, Kelly L. Characterizing high-frequency emergency department users in a rural northwestern Ontario hospital: a 5-year analysis of volume, frequency and acuity of visits. Can J Rural Med 2018; 23:99-105. [PMID: 30272550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION High-frequency emergency department users contribute substantially to urban emergency department workloads. The scope of this issue in rural emergency care provision is largely unknown. METHODS We retrospectively analyzed emergency department visits at the Sioux Lookout Meno Ya Win Health Centre and associated primary care data from 2010 to 2014 for high-frequency (≥ 6 annual visits) and non-high-frequency(< 6 annual visits) emergency department users. RESULTS High-frequency use of the emergency department was stable over the study period. High-frequency users constituted 7.2% of the emergency department patient population and accounted for 31.3% of the emergency department workload and 24.3% of hospital admissions. High-frequency users had similar clinical presentations as non-high-frequency users but required fewer admissions per emergency department visit (5.3% vs. 7.6%, p < 0.001). High-frequency users had more low-acuity presentations and concurrently accessed primary care services twice as often as non-high-frequency users. Females outnumbered males across all age categories in both user groups. CONCLUSION High-frequency emergency department use is an important issue for rural hospitals. High use of this rural emergency department was not associated with limited use of primary care services. Aside from accepting that "they will always be with us," more research, particularly qualitative, is needed to understand why some patients frequently visit a rural emergency department.
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Affiliation(s)
| | | | | | - Len Kelly
- Anishinaabe Bimaadiziwin Research Program, Sioux Lookout, Ont
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Abstract
Emergency telephone calls for an ambulance (999 calls) are usually dealt with first-come first-served. We have devised and assessed criteria that ambulance dispatch might use to prioritize responses. Data were collected retrospectively on consecutive patients presenting to an accident and emergency (A&E) department after a 999 call. An unblinded researcher abstracted data including age, date, time, caller, location, reason for call and A&E diagnosis and each case was examined for ten predetermined criteria necessitating an immediate ambulance response--namely, cardiac arrest; chest pain; shortness of breath; altered mental status/seizure; abdominal/loin pain >65 years old; fresh haematemesis; fall >2m; stabbing; major burns. 471 patients were recruited, 55% male, median age 50 years. 406 calls came from bystanders or the patients themselves, 36 from general practitioners, 8 from other hospitals and 21 from the police. 52% of patients were admitted. 44% met at least one of the above criteria. Most patients did not meet the criteria for an immediate ambulance response but might nonetheless be suitable for an urgent response. The criteria used in this study have the advantage of being based on the history provided by the caller. The introduction of a priority-based dispatch system could reduce response times to those who are seriously ill, and also improve road safety.
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Affiliation(s)
- S Thakore
- Accident and Emergency Department, Ninewells Hospital, Dundee DD1 9SY, Scotland, UK
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O'Dowd A. Managers agree temporary cover after ambulance service collapses. BMJ 2017; 359:j4573. [PMID: 28974525 DOI: 10.1136/bmj.j4573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cahn MA, Harvey SM, Town MA. American Indian and Alaska Native Men's Use of Sexual Health Services, 2006-2010. Perspect Sex Reprod Health 2017; 49:181-189. [PMID: 28758709 DOI: 10.1363/psrh.12034] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 04/17/2017] [Accepted: 04/24/2017] [Indexed: 06/07/2023]
Abstract
CONTEXT American Indian and Alaska Native men experience poorer sexual health than white men. Barriers related to their sex and racial identity may prevent them from seeking care; however, little is known about this population's use of sexual health services. METHODS Sexual health service usage was examined among 923 American Indian and Alaska Native men and 5,322 white men aged 15-44 who participated in the 2006-2010 National Survey of Family Growth. Logistic regression models explored differences in service use by race and examined correlates of use among American Indians and Alaska Natives. RESULTS Among men aged 15-19 and those aged 35-44, men with incomes greater than 133% of the federal poverty level, men with private insurance, those living in the Northeast and those living in rural areas, American Indians and Alaska Natives were more likely than whites to use STD or HIV services (odds ratios, 1.5-3.2). The odds of birth control service use did not differ by race. Differences in service use were found among American Indian and Alaska Native men: For example, those with a usual source of care had elevated odds of using sexual health services (1.9-3.4), while those reporting no recent testicular exam had reduced odds of using these services (0.3-0.4). CONCLUSIONS This study provides baseline data on American Indian and Alaska Native men's use of sexual health services. Research exploring these men's views on these services is needed to help develop programs that better serve them.
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Affiliation(s)
- Megan A Cahn
- Postdoctoral research fellow, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR
| | - S Marie Harvey
- Associate dean for research and graduate programs and distinguished professor, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR
| | - Matthew A Town
- Adjunct faculty, School of Community Health, College of Urban and Public Affairs, Portland State University, Portland, OR
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Matsumoto CL, O'Driscoll T, Madden S, Blakelock B, Lawrance J, Kelly L. Defining "high-frequency" emergency department use: Does one size fit all for urban and rural areas? Can Fam Physician 2017; 63:e395-e399. [PMID: 28904050 PMCID: PMC5597030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To suggest a functional definition for identification of "high-frequency" emergency department (ED) users in rural areas. DESIGN Retrospective analysis of secondary data. SETTING Sioux Lookout Meno Ya Win Health Centre in northwestern Ontario. PARTICIPANTS All ED visitors (N = 7121) in 2014 (N = 17 911 visits) in one rural hospital. MAIN OUTCOME MEASURES The number of patients and visits identified using different definitions of high-frequency use. RESULTS: By using the most common definition of high-frequency use (≥ 4 annual visits) for our hospital data, we identified 16.7% of ED patients. Using 6 or more annual visits as the definition, we identified 7.9% of ED patients; these patients accounted for 31.3% of the ED visit workload. Using the definition of 6 or more identifies less than 10% of the patients, which is a similar result to using the lower visit standard (≥ 4) in urban centres. CONCLUSION We suggest that the definition for high-frequency visitors to a rural ED should be 6 or more annual visits. Other useful subsets might include very high-frequency users (12 to 19 annual visits) and super users (≥ 20 annual visits).
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Affiliation(s)
- Cai Lei Matsumoto
- Epidemiologist with the Sioux Lookout First Nations Health Authority in Ontario
| | - Teresa O'Driscoll
- Assistant Professor in the Division of Clinical Sciences at the Northern Ontario School of Medicine in Sioux Lookout
| | - Sharen Madden
- Associate Professor in the Division of Clinical Sciences at the Northern Ontario School of Medicine
| | - Brittany Blakelock
- Research intern for the Anishinaabe Bimaadiziwin Research Program and is a nurse at the Sioux Lookout Meno Ya Win Health Centre
| | - Jennifer Lawrance
- Past Vice President of Quality and Clinical Support Services at Sioux Lookout Meno Ya Win Health Centre
| | - Len Kelly
- Research consultant for the Sioux Lookout Meno Ya Win Health Centre.
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Abstract
Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.
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Affiliation(s)
- Paul Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, QLD, Australia.
| | - Sharon Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Lyndal Trevena
- Discipline of General Practice, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Leonila Dans
- University of the Philippines Manila, Manila, Philippines
| | - Gordon Guyatt
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Ontario, ON, Canada
| | - Adam G Elshaug
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Robert Janett
- Harvard Clinical and Translational Science Center, Boston, MA, USA
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46
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 518] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Cardona-Morrell M, Kim JCH, Brabrand M, Gallego-Luxan B, Hillman K. What is inappropriate hospital use for elderly people near the end of life? A systematic review. Eur J Intern Med 2017; 42:39-50. [PMID: 28502866 DOI: 10.1016/j.ejim.2017.04.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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: 01/29/2017] [Revised: 03/25/2017] [Accepted: 04/19/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Older people with advance chronic illness use hospital services repeatedly near the end of life. Some of these hospitalizations are considered inappropriate. AIM To investigate extent and causes of inappropriate hospital admission among older patients near the end of life. METHODS English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-December 2016) covering community and nursing home residents aged ≥60years admitted to hospital. OUTCOMES measurements of inappropriateness. A 17-item quality score was estimated independently by two authors. RESULTS The definition of 'Inappropriate admissions' near the end of life incorporated system factors, social and family factors. The prevalence of inappropriate admissions ranged widely depending largely on non-clinical reasons: poor availability of alternative sites of care or failure of preventive actions by other healthcare providers (1.7-67.0%); family requests (up to 10.5%); or too late an admission to be of benefit (1.7-35.0%). The widespread use of subjective parameters not routinely collected in practice, and the inclusion of non-clinical factors precluded the true estimation of clinical inappropriateness. CONCLUSIONS Clinical inappropriateness and system factors that preclude alternative community care must be measured separately. They are two very different justifications for hospital admissions, requiring different solutions. Society has a duty to ensure availability of community alternatives for the management of ambulatory-sensitive conditions and facilitate skilling of staff to manage the terminally ill in non-acute settings. Only then would the evaluation of local variations in clinically inappropriate admissions and inappropriate length of stay be possible to undertake.
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Affiliation(s)
- Magnolia Cardona-Morrell
- South Western Sydney Clinical School, The Simpson Centre for Health Services Research and Ingham Institute for Applied Medical Research, Level 3, Ingham Institute Building, 1 Campbell Street, Liverpool, NSW 2170, Australia.
| | - James C H Kim
- Department of General Practice, Medical School, Western Sydney University, Building 30, Narellan Rd, Campbelltown Campus, NSW 2560, Australia.
| | - Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, DK-6700 Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, Entrance 64, ground floor, DK-5000 Odense C, Denmark.
| | - Blanca Gallego-Luxan
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW 2113, Australia.
| | - Ken Hillman
- South Western Sydney Clinical School, The Simpson Centre for Health Services Research and Ingham Institute for Applied Medical Research, Level 3, Ingham Institute Building, 1 Campbell Street, Liverpool, NSW 2170, Australia; Intensive Care Unit, Liverpool Hospital, Level 2, Elizabeth Street, Liverpool, NSW 2170, Australia.
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48
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Briggs R, Coughlan T, Doherty J, Collins DR, O'Neill D, Kennelly SP. Investigation and diagnostic formulation in patients admitted with transient loss of consciousness. Ir Med J 2017; 110:563. [PMID: 28737304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Several commonly completed tests have low diagnostic yield in the setting of transient loss of consciousness (T-LOC). We estimated the use and cost of inappropriate investigations in patients admitted with T-LOC and assessed if these patients were given a definitive diagnosis for their presentation. We identified 80 consecutive patients admitted with T-LOC to a university teaching hospital. Eighty-eight percent (70/80) had a computerized topography (CT) brain scan and 49% (34/70) of these scans were inappropriate based on standard guidelines. Almost half (17/80) of electroencephalograms (EEG) and 82% (9/11) of carotid doppler ultrasound performed were not based on clinical evidence of seizure or stroke respectively. Forty-four percent (35/80) of patients had no formal diagnosis documented for their presentation. Inappropriate investigation in T-LOC is very prevalent in the acute hospital, increasing cost of patient care. In addition, there is poor diagnostic formulation for T-LOC making recurrent events more likely in the absence of definitive diagnoses.
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Affiliation(s)
- R Briggs
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | - T Coughlan
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | - J Doherty
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | - D R Collins
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | - D O'Neill
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | - S P Kennelly
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
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Giesen MJ, Keizer E, van de Pol J, Knoben J, Wensing M, Giesen P. The impact of demand management strategies on parents' decision-making for out-of-hours primary care: findings from a survey in The Netherlands. BMJ Open 2017; 7:e014605. [PMID: 28487458 PMCID: PMC5623343 DOI: 10.1136/bmjopen-2016-014605] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore the potential impact of demand management strategies on patient decision-making in medically non-urgent and urgent scenarios during out-of-hours for children between the ages of 0 and 4 years. DESIGN AND METHODS We conducted a cross-sectional survey with paper-based case scenarios. A survey was sent to all 797 parents of children aged between 0 and 4 years from four Dutch general practitioner (GP) practices. Four demand management strategies (copayment, online advice, overview medical cost and GP appointment next morning) were incorporated in two medically non-urgent and two urgent case scenarios. Combining the case scenarios with the demand management strategies resulted in 16 cases (four scenarios each with four demand management strategies). Each parent randomly received a questionnaire with three different case scenarios with three different demand strategies and a baseline case scenario without a demand management strategy. RESULTS The response rate was 47.4%. The strategy online advice led to more medically appropriate decision-making for both non-urgent case scenarios (OR 0.26; CI 0.11 to 0.58) and urgent case scenarios (OR 0.16; CI 0.08 to 0.32). Overview of medical cost (OR 0.59; CI 0.38 to 0.92) and a GP appointment planned the next morning (OR 0.57; CI 0.34 to 0.97) had some influence on patient decisions for urgent cases, but not for non-urgent cases. Copayment had no influence on patient decisions. CONCLUSION Online advice has the highest potential to reduce medically unnecessary use. Furthermore it enhanced safety of parents' decisions on seeking help for their young children during out-of-hours primary care. Valid online information on health symptoms for patients should be promoted.
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Affiliation(s)
- Marie-Jeanne Giesen
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
- TiasNimbas Business School, Tilburg University, Tilburg, the Netherlands
| | - Ellen Keizer
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Julia van de Pol
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joris Knoben
- Institute for Management Research, Radboud University, Nijmegen, the Netherlands
| | - Michel Wensing
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Paul Giesen
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
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50
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MacKichan F, Brangan E, Wye L, Checkland K, Lasserson D, Huntley A, Morris R, Tammes P, Salisbury C, Purdy S. Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice. BMJ Open 2017; 7:e013816. [PMID: 28473509 PMCID: PMC5623418 DOI: 10.1136/bmjopen-2016-013816] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). DESIGN Ethnographic case study combining non-participant observation, informal and formal interviewing. SETTING Six general practitioner (GP) practices located in three commissioning organisations in England. PARTICIPANTS AND METHODS Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). RESULTS Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. CONCLUSIONS This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.
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Affiliation(s)
- Fiona MacKichan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emer Brangan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lesley Wye
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Daniel Lasserson
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Alyson Huntley
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard Morris
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Peter Tammes
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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