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Almasoud NF, Aldosari MA, Mahmoud AS, Alendijani YA, Alkhenizan AH. Inappropriate laboratory test utilization in outpatient tertiary care: Implications for value-based healthcare. Saudi Med J 2024; 45:356-361. [PMID: 38657991 DOI: 10.15537/smj.2024.45.4.20230512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 02/16/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVES To assess the rate of inappropriate repetition of laboratory testing and estimate the cost of such testing for thyroid stimulating hormone (TSH), total cholesterol, vitamin D, and vitamin B12 tests. METHODS A retrospective cohort study was carried out in the Family Medicine and Polyclinic Department at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. Clinical and laboratory data were collected between 2018-2021 for the 4 laboratory tests. The inappropriate repetition of tests was defined according to international guidelines and the costs were calculated using the hospital prices. RESULTS A total of 109,929 laboratory tests carried out on 23,280 patients were included in this study. The percentage of inappropriate tests, as per the study criteria, was estimated to be 6.1% of all repeated tests. Additionally, the estimated total cost wasted amounted to 2,364,410 Saudi Riyals. Age exhibited a weak positive correlation with the total number of inappropriate tests (r=0.196, p=0.001). Furthermore, significant differences were observed in the medians of the total number of inappropriate tests among genders and nationalities (p<0.001). CONCLUSION The study identified significantly high rates of inadequate repetitions of frequently requested laboratory tests. Urgent action is therefore crucial to overcoming such an issue.
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Affiliation(s)
- Nouf F Almasoud
- From the Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed A Aldosari
- From the Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed S Mahmoud
- From the Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Yaser A Alendijani
- From the Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah H Alkhenizan
- From the Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
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Sweet AAR, Beks RB, de Jong MB, van Baal MCPM, IJpma FFA, Hietbrink F, Beeres FJP, Leenen LPH, Groenwold RHH, Houwert RM. Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review. J Trauma Acute Care Surg 2021; 91:427-434. [PMID: 33605708 DOI: 10.1097/ta.0000000000003118] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients. METHODS A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal. RESULTS Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention. CONCLUSION In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed. LEVEL OF EVIDENCE Systematic review study, level IV.
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Affiliation(s)
- Arthur A R Sweet
- From the Department of Surgery (A.A.R.S., M.B.d.J., M.C.P.v.B., F.H., L.P.H.L., R.M.H.), University Medical Center Utrecht, Utrecht; Department of Surgery (R.B.B.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Surgery (F.F.A.I.), University Medical Center Groningen, Groningen, the Netherlands; Department of Orthopedics and Trauma Surgery (F.J.P.B.), Luzerner Kantonsspital, Luzern, Switzerland; Department of Clinical Epidemiology (R.H.H.G.), Leiden University Medical Center, Leiden, the Netherlands
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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI
- University of Michigan, Institute for Health Policy and Innovation (IHPI), Ann Arbor, MI
| | - Michael S Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI
- University of Michigan, Institute for Health Policy and Innovation (IHPI), Ann Arbor, MI
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Rodrigues Mendonça D, Villa Nova Aguiar C, Lins-Kusterer L, Lemos Correia LC, Martins Tourinho Costa L, Silva Menezes M. [Implementation of the Choosing Wisely Program in the General Surgery Residency]. ACTA MEDICA PORT 2021; 34:95-102. [PMID: 33200979 DOI: 10.20344/amp.12948] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The practice of unnecessary conduct and waste in Health is an important topic, not often addressed during undergraduate training. Medical education has a fundamental role in student and doctors' training concerning cost-conscious attitudes for good health care. The aim of this study was to describe and assess the implementation of the Choosing Wisely campaign within a General Surgery residency program. MATERIAL AND METHODS This was an interventional study involving residency advisors and specialty residents. Recommendations based on three procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients were identified by residency advisors with the use of the Delphi method and were grouped by frequency and by nature according to the Choosing Wisely layout. Educational actions such as workshops and banner advertising in addition to training activities regarding cost-conscious healthcare were carried out. This subject was also included in the theoretical evaluation of the residency program. RESULTS The leading five recommendations were related to (i) computed tomography overuse (versus ultrasound imaging) in patients with suspected acute appendicitis, (ii) multithreaded computed tomography overuse in patients with low-risk trauma, (iii) longer than recommended antibiotic prophylaxis in surgical patients, (iv) longer than recommended preoperative fasting period and (v) upper gastrointestinal endoscopy overuse in surgical patients without an adequate clinical evidence or without the presence of warning signs. Awareness and reflection among participants were improved, leading to high grades in final evaluation. DISCUSSION Changes in training regarding quality of care and cost awareness should start throughout undergraduate training, within a learning environment focused on a reflective and evidence-based practice. All the benefits and harms to patients were taken into account in the recommendations that emerged from this study. CONCLUSION The inclusion of this initiative in the General Surgery residency, involving reflective discussions on campaign recommendations regarding procedures frequently used in clinical practice, with no benefits and involving unnecessary risks for patients may lead to more cost-conscious procedures.
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Affiliation(s)
- Dilton Rodrigues Mendonça
- Programa de Pós-Graduação em Medicina e Saúde Humana. Escola Bahiana de Medicina e Saúde Pública. Salvador. Bahia. Brasil
| | - Carolina Villa Nova Aguiar
- Programa de Pós-Graduação em Medicina e Saúde Humana. Escola Bahiana de Medicina e Saúde Pública. Salvador. Bahia. Brazil
| | - Liliane Lins-Kusterer
- Departamento de Medicina Preventiva e Social. Faculdade de Medicina da Bahia. Universidade Federal da Bahia. Salvador. Bahia. Brazil
| | - Luis Claudio Lemos Correia
- Programa de Pós-Graduação em Medicina e Saúde Humana. Escola Bahiana de Medicina e Saúde Pública. Salvador. Bahia. Brazil
| | | | - Marta Silva Menezes
- Programa de Pós-Graduação em Medicina e Saúde Humana. Escola Bahiana de Medicina e Saúde Pública. Salvador. Bahia. Brazil
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Hong YR, Salloum RG, Yadav S, Smith G, Mainous AG. Patient-Provider Discussion About Cancer Treatment Costs and Out-of-Pocket Spending: Implications for Shared Decision Making in Cancer Care. Value Health 2020; 23:1592-1598. [PMID: 33248514 DOI: 10.1016/j.jval.2020.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 04/20/2020] [Revised: 08/03/2020] [Accepted: 08/08/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Patient-provider discussion about treatment costs has been recognized as a key component of shared clinical decision making in cancer care. This study examined the association of patient-provider cost discussion with out-of-pocket spending among cancer survivors. METHODS Using data from the 2016-2017 Medical Expenditure Panel Survey-Experiences with Cancer Survivorship Supplement, cancer survivors in the United States who reported having a detailed discussion about treatment costs were identified. Multivariable generalized linear model with gamma distribution and log-link was fitted to analyze average total out-of-pocket spending between those who had the discussion and those who did not. We also examined whether having the cost discussion is associated with the likelihood of reporting receipt of all cancer care they believed was necessary using a multivariable logistic regression model. All analyses controlled for patient socioeconomic and health-related characteristics. RESULTS Among 1525 individuals, representing 14.6 million cancer survivors in the United States (mean age, 65.5 years; 59% women; 80.4% white), only 10.4% (95% confidence interval [CI], 8.7%-12.1%) reported having the detailed cost discussion with their providers during their cancer care. Having a cost discussion was associated with a -33.8% reduction in (95% CI, -38.2% to -29.6%; an absolute difference of -$478) average total out-of-pocket spending. The probability of receiving all necessary patient-reported cancer care was not different between those who had the discussion and those who did not. CONCLUSION Detailed patient-provider cost discussions were associated with lower average total out-of-pocket spending. Patients who had detailed cost discussions with providers did not seem to sacrifice the appropriate utilization of necessary cancer treatments.
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Affiliation(s)
- Young-Rock Hong
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL, USA; UF Health Cancer Center, Gainesville, FL, USA.
| | - Ramzi G Salloum
- UF Health Cancer Center, Gainesville, FL, USA; Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA
| | - Sandhya Yadav
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL, USA
| | - Grace Smith
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Arch G Mainous
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL, USA; Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, USA
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Riporto VA, Lefebvre T, Bertoletti L, Martinez M. Follow-up of guidelines and impact on the management of suspected deep vein thrombosis in emergency departments. J Med Vasc 2020; 45:326-333. [PMID: 33248535 DOI: 10.1016/j.jdmv.2020.10.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/13/2020] [Indexed: 06/12/2023]
Abstract
AIMS To evaluate the implementation of the European Society of Cardiology (ESC) guidelines concerning the diagnostic management of deep vein thrombosis (DVT) in emergency departments (ED); and to estimate the additional financial cost and the increase in the time spent in the ED if the guidelines are not followed. PATIENTS AND METHODS Retrospective, bi-centric study including all patients directly admitted or referred to the ED for a suspected isolated DVT, between April 1, 2019, and July 30, 2019. The diagnostic management was compared to the 2017 ESC's guidelines. RESULTS 107 patients were included, 13 had DVT (12%) and three had superficial venous thrombosis (3%). A total of 26 patients (24%) had a diagnostic management according to guidelines. In 72 patients (67%), no assessment of clinical probability score was found. Among the 35 patients in whom a clinical probability score was calculated, 5 patients had an unnecessary D-dimer assay and 2 patients had unjustified imaging. The median time spent in the ED was 185minutes when the recommendations were followed, and 250minutes when they were not (P=0.317). The total estimated additional cost was €232.20. CONCLUSION The rate of adherence to the guidelines is low, mainly due to the absence of calculation of a clinical probability. This leads, in addition to the risk of diagnostic error, to an increase in the time spent in the EDs and inappropriate use of the technical platform, resulting in additional costs of care.
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Affiliation(s)
- V-A Riporto
- Pôle Urgences, centre hospitalier du Forez, BP 219, 42605 Montbrison, France
| | - T Lefebvre
- Réseau d'urgence Ligérien Ardèche Nord (REULIAN), centre hospitalier Le Corbusier, 42700 Firminy, France
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne; inserm, UMR1059, Université Jean Monnet; inserm, CIC-1408, CHU de Saint-Etienne; INNOVTE, CHU de Saint-Étienne, 42055 Saint-Etienne, France
| | - M Martinez
- Pôle Urgences, centre hospitalier du Forez, BP 219, 42605 Montbrison, France; Réseau d'urgence Ligérien Ardèche Nord (REULIAN), centre hospitalier Le Corbusier, 42700 Firminy, France.
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Ganguli I, Lupo C, Mainor AJ, Wang Q, Orav EJ, Rosenthal MB, Sequist TD, Colla CH. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit. JAMA Netw Open 2020; 3:e2029891. [PMID: 33306120 PMCID: PMC7733154 DOI: 10.1001/jamanetworkopen.2020.29891] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. OBJECTIVE To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. EXPOSURE Receipt of a given test within 1 week before or after the AWV. MAIN OUTCOMES AND MEASURES Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. RESULTS Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. CONCLUSIONS AND RELEVANCE In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Affiliation(s)
- Brendan M Reilly
- From the Geisel School of Medicine, Dartmouth College, Hanover, NH
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O'Sullivan S, Bowe S, O'Riordan T, Murphy A, Murphy M, Heffron C, Bourke JF. Skin Cancer Excision Is More Efficient and Cost Effectivein a Specialist Secondary Care Service. Ir Med J 2020; 113:38. [PMID: 32815680] [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: 06/11/2023]
Abstract
Aim To compare the relative efficiencies of skin excisions in primary and secondary care. Methods We compared the benign: malignant ratio for specimens referred by General Practice, General Surgery and the Skin Cancer Service to the regional pathology laboratory over one month. We used cost minimization analysis to compare the relative efficiencies of the services. Results 620 excisions were received: 139 from General Practice, 118 from General Surgery and 363 from the Skin Cancer Service. The number (%) of malignant lesions was 13 (9.4%) from General Practice, 18 (15.2%) from General Surgery and 137 (37.7%) from the Skin Cancer Service. Excision was cheaper in General Practice at €84.58 as compared to €97.49 in the hospital day surgical unit. However, the cost per malignant lesion excised was €1779.80 in general practice versus €381.78 in the Skin Cancer Service. Conclusion Our results indicate that moving skin cancer treatment to General Practice may result in an excess of benign excisions and therefore be both less efficient and less cost effective.
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Affiliation(s)
- S O'Sullivan
- Dept. of Dermatology, South Infirmary-Victoria University Hospital, Cork
| | - S Bowe
- Dept. of Dermatology, South Infirmary-Victoria University Hospital, Cork
| | - T O'Riordan
- Dept. of Economics, Cork University Business School, University College Cork
| | - A Murphy
- Dept. of Economics, Cork University Business School, University College Cork
| | - M Murphy
- Dept. of Dermatology, South Infirmary-Victoria University Hospital, Cork
| | - C Heffron
- Dept. of Histopathology, Cork University Hospital, Cork
| | - J F Bourke
- Dept. of Dermatology, South Infirmary-Victoria University Hospital, Cork
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Orland KJ, Boissonneault A, Schwartz AM, Goel R, Bruce RW, Fletcher ND. Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department. JAMA Netw Open 2020; 3:e1921202. [PMID: 32058553 DOI: 10.1001/jamanetworkopen.2019.21202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. OBJECTIVE To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. MAIN OUTCOMES AND MEASURES Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. RESULTS Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). CONCLUSIONS AND RELEVANCE The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.
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Affiliation(s)
- Keith J Orland
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Adam Boissonneault
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Schwartz
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rahul Goel
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Robert W Bruce
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nicholas D Fletcher
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia
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Morgan T, Wu J, Ovchinikova L, Lindner R, Blogg S, Moorin R. A national intervention to reduce imaging for low back pain by general practitioners: a retrospective economic program evaluation using Medicare Benefits Schedule data. BMC Health Serv Res 2019; 19:983. [PMID: 31864352 PMCID: PMC6925437 DOI: 10.1186/s12913-019-4773-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 11/22/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder. METHODS The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS. RESULTS The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed. CONCLUSIONS The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.
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Affiliation(s)
- Tessa Morgan
- NPS MedicineWise, Sydney, New South Wales Australia
| | - Jianyun Wu
- NPS MedicineWise, Sydney, New South Wales Australia
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Thornhill R, Chang J, Selleck M, Senthil M, Solomon N, Namm JP, Garberoglio CA, Lum S. From Evidence to Practice: Are Low-Risk Breast Cancer Patients still Enduring Unnecessary Costs of Radiation? Am Surg 2019; 85:1414-1418. [PMID: 31908229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Radiation is routinely recommended after conservative surgery for breast cancer, despite long-standing Level I evidence showing no survival benefit for elderly patients with favorable disease using endocrine therapy. We sought to evaluate radiation use and costs in patients eligible for omission of radiation. A retrospective single-institution review from 2005 to 2017 was performed of women aged ≥70 years, with cT1N0M0, who were ER/PR positive and HER-2 negative, and receiving breast-conserving surgery. Patient, tumor, and treatment characteristics were compared by use of radiation. Cost estimates used Medicare's 2019 fee schedule. Of 84 patients meeting the study criteria, 72.6 per cent received radiation and 56 per cent received endocrine therapy, with four recurrences (4.9% radiated and 4.4% not radiated, P = 0.9). Early and late grade I radiation toxicities occurred in 67.2 per cent and 26.2 per cent of radiated patients, respectively. Younger age (P = 0.01), receipt of endocrine therapy (P < 0.0001), and axillary surgery (P < 0.0001) were significantly associated with radiation use. There were no significant differences in radiation use based on race/ethnicity, language, comorbidities, BMI, or pathologic tumor size. Estimated total radiation cost was $646,426. Radiation remains overused and endocrine therapy, underused in breast cancer patients eligible to avoid radiation. As gatekeepers for radiation oncology referrals, surgeons can diminish both physical and financial costs of radiation in eligible patients.
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Abstract
IMPORTANCE The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains. OBJECTIVES To estimate current levels of waste in the US health care system in 6 previously developed domains and to report estimates of potential savings for each domain. EVIDENCE A search of peer-reviewed and "gray" literature from January 2012 to May 2019 focused on the 6 waste domains previously identified by the Institute of Medicine and Berwick and Hackbarth: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. For each domain, available estimates of waste-related costs and data from interventions shown to reduce waste-related costs were recorded, converted to annual estimates in 2019 dollars for national populations when necessary, and combined into ranges or summed as appropriate. FINDINGS The review yielded 71 estimates from 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature. Computations yielded the following estimated ranges of total annual cost of waste: failure of care delivery, $102.4 billion to $165.7 billion; failure of care coordination, $27.2 billion to $78.2 billion; overtreatment or low-value care, $75.7 billion to $101.2 billion; pricing failure, $230.7 billion to $240.5 billion; fraud and abuse, $58.5 billion to $83.9 billion; and administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: failure of care delivery, $44.4 billion to $97.3 billion; failure of care coordination, $29.6 billion to $38.2 billion; overtreatment or low-value care, $12.8 billion to $28.6 billion; pricing failure, $81.4 billion to $91.2 billion; and fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion. CONCLUSIONS AND RELEVANCE In this review based on 6 previously identified domains of health care waste, the estimated cost of waste in the US health care system ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste, excluding savings from administrative complexity, ranged from $191 billion to $286 billion, representing a potential 25% reduction in the total cost of waste. Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in US health care expenditures.
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Affiliation(s)
| | | | - Natasha Parekh
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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14
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Hofstede H, van der Burg HAM, Mulder BC, Bohnen AM, Bindels PJE, de Wit NJ, de Schepper EIT, van Vugt SF. Reducing unnecessary vitamin testing in general practice: barriers and facilitators according to general practitioners and patients. BMJ Open 2019; 9:e029760. [PMID: 31594878 PMCID: PMC6797438 DOI: 10.1136/bmjopen-2019-029760] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 11/13/2022] Open
Abstract
OBJECTIVE There has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of patients. So far, there is little evidence of effective strategies to reduce this overtesting in general practice. Therefore, the aim of this qualitative study was to explore the barriers and facilitators for reducing the number of (unnecessary) vitamin D and B12 laboratory tests ordered. DESIGN AND SETTING This qualitative study, based on a grounded theory design, used semistructured interviews among general practitioners (GPs) and patients from two primary care networks (147 GPs, 195 000 patients). These networks participated in the Reducing Vitamin Testing in Primary Care Practice (REVERT) study, a clustered randomized trial comparing two de-implementation strategies to reduce test ordering in primary care in the Netherlands. PARTICIPANTS Twenty-one GPs, with a maximum of 1 GP per practice who took part in the REVERT study, and 22 patients (who were invited by their GP during vitamin-related consultations) were recruited, from which 20 GPs and 19 patients agreed to participate in this study. RESULTS The most important factor hampering vitamin-test reduction programmes is the mismatch between patients and medical professionals regarding the presumed appropriate indications for testing for vitamin D and B12. In contrast, the most important facilitator for vitamin-test reduction may be updating GPs' knowledge about test indications and their awareness of their own testing behaviour. CONCLUSION To achieve a sustainable reduction in vitamin testing, guidelines with clear and uniform recommendations on evidence-based indications for vitamin testing, combined with regular (individual) feedback on test-ordering behaviour, are needed. Moreover, the general public needs access to clear and reliable information on vitamin testing. Further research is required to measure the effect of these strategies on the number of vitamin test requests. TRIAL REGISTRATION NUMBER WAG/mb/16/039555.
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Affiliation(s)
- H Hofstede
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H A M van der Burg
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - B C Mulder
- Strategic Communication Group, Wageningen University, Wageningen, The Netherlands
| | - A M Bohnen
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - P J E Bindels
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - N J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E I T de Schepper
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S F van Vugt
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Ganguli I, Simpkin AL, Lupo C, Weissman A, Mainor AJ, Orav EJ, Rosenthal MB, Colla CH, Sequist TD. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open 2019; 2:e1913325. [PMID: 31617925 PMCID: PMC6806665 DOI: 10.1001/jamanetworkopen.2019.13325] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [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: 12/19/2022] Open
Abstract
IMPORTANCE Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. OBJECTIVE To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. DESIGN, SETTING, AND PARTICIPANTS Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. MAIN OUTCOMES AND MEASURES Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. RESULTS This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. CONCLUSIONS AND RELEVANCE The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Arabella L. Simpkin
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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16
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Chami N, Sweetman A. Payment models in primary health care: A driver of the quantity and quality of medical laboratory utilization. Health Econ 2019; 28:1166-1178. [PMID: 31309648 DOI: 10.1002/hec.3927] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 08/14/2017] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 06/10/2023]
Abstract
Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed-effects specification to address selection, it is estimated that the switch to capitation leads to a short-run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.
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Affiliation(s)
- Nadine Chami
- Department of Economics, Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
| | - Arthur Sweetman
- Department of Economics, Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
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17
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Lechtig A, Barghi A, Wolf BT, Weaver M, Wixted JJ, Rodriguez EK, Appleton PT. The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures. Injury 2019; 50:1448-1451. [PMID: 31320108 DOI: 10.1016/j.injury.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/07/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients treated with hip hemiarthroplasty for low energy femoral neck fractures routinely undergo hip radiographs at each postoperative clinic visit regardless of history and physical findings. No studies to date have evaluated the effectiveness of this accepted practice. The goal of this study was to identify the postoperative utility of both history and physical (H/P) and hip radiographs in the treatment course of patients treated with hip hemiarthroplasty for low energy femoral neck fractures. METHODS A retrospective chart review was performed on consecutive patients treated with hip hemiarthroplasty for low energy femoral neck fractures. An abnormal H/P and hip radiographs as well as a change in treatment course were recorded at each clinic or emergency department visit. RESULTS Five hundred and eighty-three patients met inclusion criteria, consisting of 1177 clinic and 50 emergency department (ED) visits. An abnormal radiograph in the presence of a normal H/P did not lead to a change in treatment course. An abnormal H/P alone changed treatment course in 28 (3%) clinic visits and 18 (36%) ED visits. An abnormal H/P and the presence of an abnormal hip radiograph changed the treatment course in 23 (2%) clinic visits and 18 (36%) ED visits. In only one case - 0.3% of abnormal radiographs or 0.08% of 1177 clinic visits - did an abnormal hip radiograph change treatment course in the setting of an abnormal H/P within 6 months from surgery. The average cost of a series of hip and pelvis radiographs was $242. CONCLUSIONS Abnormal radiographs do not change treatment course in the presence of a normal H/P. Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient.
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Affiliation(s)
- Aron Lechtig
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Ameen Barghi
- Harvard Medical School, Boston, MA, 02115, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States.
| | - Bryce T Wolf
- Maine Ortho, 1601 Congress Street, Portland, ME, 04102, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Michael Weaver
- Brigham and Woman's Hospital, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - John J Wixted
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Edward K Rodriguez
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Paul T Appleton
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
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18
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Tchou MJ, Hall M, Shah SS, Johnson DP, Schroeder AR, Antoon JW, Genies MC, Quinonez R, Miller CW, Shah SP, Brady PW. Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses. Pediatrics 2019; 144:e20181644. [PMID: 31171587 PMCID: PMC6615522 DOI: 10.1542/peds.2018-1644] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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] [Accepted: 04/11/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts. METHODS We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing. RESULTS In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis. CONCLUSIONS Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio;
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Samir S Shah
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - James W Antoon
- Children's Hospital, University of Illinois, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Marquita C Genies
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Christopher W Miller
- Division of Pediatric Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Snehal P Shah
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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19
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Zemyarska MS. Is it ethical to provide IVF add-ons when there is no evidence of a benefit if the patient requests it? J Med Ethics 2019; 45:346-350. [PMID: 30745435 DOI: 10.1136/medethics-2018-104983] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/25/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
In vitro fertilisation (IVF) 'add-ons' are therapeutic or diagnostic tools developed in an endeavour to improve the success rate of infertility treatment. However, there is no conclusive evidence that these interventions are a beneficial or effective adjunct of assisted reproductive technologies. Additionally, IVF add-ons are often implemented in clinical practice before their safety can be thoroughly ascertained. Yet, patients continue to request and pay large sums for such additional IVF tools. Hence, this essay set out to examine if it is ethical to provide IVF add-ons when there is no evidence of a benefit if the patient requests it. In order to determine what is ethical-namely, morally good and righteous, the question was considered in relation to three key values of medical ethics-autonomy, beneficence and non-maleficence. It was determined that providing IVF add-ons might be morally acceptable in specific circumstances, if true informed consent can be given, there is a potential of cost-effective physiological or psychological benefit and the risk of harm is minimal, particularly with regard to the unborn child.
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20
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Moosa MA, Gill RC, Jangda I, Sayyed RH, Zafar H. Is pelvis x-ray essential in stable trauma patients? Step towards lowering the treatment cost. J PAK MED ASSOC 2019; 69(Suppl 1):S33-S36. [PMID: 30697016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To determine the diagnostic accuracy of clinical examination in detecting pelvic fractures in patients with blunt trauma.. METHODS The cross-sectional prospective study was conducted at Aga Khan University Hospital, Karachi, from January to June 2015, and comprised alert, awake blunt-trauma patients. Pelvis examination findings were compared to routine pelvic X-rays. SPSS 19 was used for data analysis.. RESULTS Of the 133 patients, 122 (92%) were males. Overall mean age was 37 ±14.2 years. There were 14 (10%) patients who were true positives with pelvic fracture diagnosis on both clinical examination and pelvic X-ray, while 14 (10%) were false negative on examination. Clinical examination missed 2 patients with evidence of fracture on X-ray and were considered false positive. Besides, 103 (77.4%) patients were true negative as both clinical exam and X-ray showed no evidence of fracture. CONCLUSION Omitting pelvic X-ray in the recommended protocol can avoid unnecessary financial burden and reduce undesirable radiation exposure..
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Affiliation(s)
| | | | - Iqra Jangda
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | | | - Hasnain Zafar
- Department of Surgery, Aga Khan University, Karachi, Pakistan
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21
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Wilson AD, Kelly MJ, Henderson E, McBain L, Jayathissa S, Loring B. Reducing inappropriate urine testing at Hutt Valley District Health Board using Choosing Wisely principles. N Z Med J 2019; 132:11-20. [PMID: 31851657] [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: 06/10/2023]
Abstract
AIM Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.
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Affiliation(s)
| | - Matthew J Kelly
- Infectious Disease Physician, Hutt Valley District Health Board, Lower Hutt
| | - Emma Henderson
- Infectious Disease Pharmacist, Hutt Valley District Health Board, Lower Hutt
| | - Lynn McBain
- Head of Department, Department of Primary Health Care and General Practice, University of Otago, Wellington
| | - Sisira Jayathissa
- Chief Medical Officer, Hutt Valley District Health Board, Lower Hutt
| | - Belinda Loring
- Consultant Public Health Physician, Choosing Wisely, Auckland
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22
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Hirota Y, Suzuki S, Ohira Y, Shikino K, Ikusaka M. The Effectiveness of Cost Reduction with Charge Displays on Test Ordering under the Health Insurance System in Japan: A Study Using Paper-based Simulated Cases for Residents and Clinical Fellows. Intern Med 2019; 58:187-193. [PMID: 30210103 PMCID: PMC6378163 DOI: 10.2169/internalmedicine.0738-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To determine whether or not displaying the cost of tests can help reduce charges on test ordering in Japan. Methods This study was conducted under the setting of a simulated first visit of an outpatient for general internal medicine in a secondary medical institution in Japan. We randomly assigned 27 residents and clinical fellows to Team A or B. The first half, without charges displayed on the ordering system, was designated the "non-display group," and the participants of Team A selected tests for each paper-based simulated case (Q1-Q14), while the participants of Team B selected tests for Q15-Q28. The second half, which had charges displayed, was designated the "display group," and the participants of Team A selected tests for Q15-Q28, while the participants of Team B selected tests for Q1-Q14. The main outcome measure was the difference in the cost of tests per paper-based simulated case between the non-display and display groups. Results The median (interquartile range) cost of tests per paper-based simulated case was 12,255 yen (5,040-23,695 yen) in the non-display group versus 9,425 yen (2,320-21,700 yen) in the display group, showing a decrease of 2,830 yen with charges being displayed (p=0.002). Conclusion Displaying the charges when ordering tests in paper-based simulated cases resulted in cost reduction. The adoption of this intervention may reduce health insurance costs under the health insurance system in Japan, which has features such as universal health coverage and universal access to care.
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Affiliation(s)
- Yusuke Hirota
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shingo Suzuki
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yoshiyuki Ohira
- Department of General Medicine, Chiba University Hospital, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Japan
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Meirick T, Shah AS, Dolan LA, Weinstein SL. Determining the Prevalence and Costs of Unnecessary Referrals in Adolescent Idiopathic Scoliosis. Iowa Orthop J 2019; 39:57-61. [PMID: 31413675 PMCID: PMC6604530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs. METHODS We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was "unnecessary," defined as a Cobb angle <20 degrees. Patient and provider costs were estimated. Patient costs included transportation expenses and parental lost wages. Provider costs included orthopaedic evaluation, diagnostic imaging, and overhead. Transportation costs were based on actual driving distances and the Internal Revenue Service standard mileage rate. Parental lost wages and the cost of evaluation by an orthopaedic surgeon were calculated with time-driven activity-based costing. Diagnostic imaging costs were calculated with a traditional activity-based costing methodology. RESULTS Three hundred thirty-seven patients were included. The prevalence of unnecessary referrals was 39% (n=131). 17% of patients had a Cobb angle <10 degrees and 22% had a Cobb angle between 10-20 degrees. Males were more likely to be referred unnecessarily than females, 49% to 35% (p=0.02) as were non-Caucasians (54% vs. 37%, p=0.04). No difference was noted related to source of insurance (private or public, p=0.18). The average total cost of an unnecessary referral was $782.13 USD, including $231.07 in patient costs and $551.06 in provider costs. CONCLUSIONS Nearly 40% of all referrals for AIS were deemed unnecessary. The average cost of an unnecessary referral is approximately $780, imposing significant costs on both patients and the healthcare system.Level of Evidence: III.
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Affiliation(s)
- Thomas Meirick
- The University of Iowa Hospitals and Clinics, Department of Orthopaedics and Rehabilitation, Iowa City, IA USA
| | - Apurva S. Shah
- Children’s Hospital of Philadelphia, Division of Orthopaedics, Philadelphia, PA USA
| | - Lori A. Dolan
- The University of Iowa Hospitals and Clinics, Department of Orthopaedics and Rehabilitation, Iowa City, IA USA
| | - Stuart L. Weinstein
- The University of Iowa Hospitals and Clinics, Department of Orthopaedics and Rehabilitation, Iowa City, IA USA
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Plaster AL, Hamill ME, Lollar DI, Love KM, Faulks ER, Freeman DW, Benson AD, Nussbaum MS, Collier BR. The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury. Am Surg 2018; 84:1825-1831. [PMID: 30747641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.
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Barry WE, Barin EN, Marshall LC, Doherty M, Nguyen E, McLaughlin C, Kaplan L, Stein JE, Jensen AR. Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization. Am Surg 2018; 84:1555-1559. [PMID: 30747668] [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: 06/09/2023]
Abstract
Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59-0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.
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Affiliation(s)
- Wesley E Barry
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
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Hicks LK, O'Brien P, Sholzberg M, Veloce N, Trafford A, Sinclair D. Tackling overutilization of hospital tests and treatments: Lessons learned from a grassroots approach. Healthc Manage Forum 2018; 31:186-190. [PMID: 30133329 DOI: 10.1177/0840470418781172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Recent data suggest unnecessary medical testing and treatment is relatively common in Canada. A number of harms to patients can arise as a result of unnecessary tests and treatments. In addition to patient harm, unnecessary tests and treatments add to the cost of medical care. Inspired by the Choosing Wisely campaign, St. Michael's Hospital in Toronto, Ontario, developed a hospital-wide program to address many different forms of overutilization at our hospital. The program prioritizes harm reduction over cost-containment and aims to create sustainable change through grassroots clinician engagement. This article will review important lessons learned from the St. Michael's experience.
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Affiliation(s)
- Lisa K Hicks
- 1 St. Michael's Hospital, Toronto, Ontario, Canada
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Michelle Sholzberg
- 1 St. Michael's Hospital, Toronto, Ontario, Canada
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Doug Sinclair
- 1 St. Michael's Hospital, Toronto, Ontario, Canada
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Leslie M, Khayatzadeh-Mahani A, Webb C, Avery G. Negotiating "unnecessary": Microclinical, macropolitical, and coproduction approaches to defining necessity in care. Can Fam Physician 2018; 64:562-563. [PMID: 30108069 PMCID: PMC6189878] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Myles Leslie
- Assistant Professor in the Department of Community Health Sciences in the Cumming School of Medicine and Associate Director of Research in the School of Public Policy at the University of Calgary in Alberta.
| | | | - Charles Webb
- Family physician in Vancouver, BC, and President of the Vancouver Medical Association
| | - Granger Avery
- Family physician in Port McNeill, BC, and Past President of the Canadian Medical Association
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Salinas M, Lopez-Garrigos M, Flores E, Leiva-Salinas C. Uncritical Request of Thyroid Laboratory Tests May Result in a Major Societal Economic Burden: Results from a Large Population Study in Spain. Clin Lab 2018; 63:1139-1145. [PMID: 28792688 DOI: 10.7754/clin.lab.2017.170101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Our aim is to study the regional variability in the request of thyroid laboratory tests from primary care facilities in Spain and to investigate a potential inappropriate request and its economic societal impact. METHODS Spain is divided into 17 autonomous communities (AACCs) which are in turn divided in Health Departments that cover a geographic area and its population and a laboratory that attends the needs of every inhabitant. Each participating laboratory was required to report the number of thyroid tests requested from primary care during year 2014 and to provide organizational data. The request of every test per 1000 inhabitants and ratio of related tests (free thyroxine (FT4)/thyrotropin (TSH), triiodothironine (FT3)/TSH, antithyroglobulin antibody (ATG)/antiperoxidase antibody (TPO)) were calculated and compared in different AACCs with more than 4 participants. The economic costs taking into account reagent cost were calculated. RESULTS 110 laboratories participated (27,798,262 inhabitants). Close to 6 million TSH tests were requested, representing an expense of more than 10 million euros. That corresponds to 18 million euros when extrapolating for the whole Spanish population, only in reagent cost. The number of TSH requests per 1000 inhabitants in the different AACCs ranged from 198 to 289. FT4 was ordered more than twice as frequently in some regions compared to others. TPO request per 1000 inhabitants ranged from 0.2 to 11.2. CONCLUSIONS There was a significant over-request and regional variability of thyroid laboratory tests in primary care in Spain, resulting in a high economic impact on society.
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Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. Am J Med 2018; 131:760-763. [PMID: 29601803 DOI: 10.1016/j.amjmed.2018.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Received: 11/14/2017] [Revised: 02/21/2018] [Accepted: 03/01/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Arjun Gupta
- Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas; Parkland Hospital, Dallas, Tex
| | - Zhouwen Tang
- Parkland Hospital, Dallas, Tex; Division of Gastroenterology, University Texas Southwestern Medical Center, Dallas; Digestive & Liver Specialists of Houston, Tex
| | - Deepak Agrawal
- Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas; Parkland Hospital, Dallas, Tex; Division of Gastroenterology, University Texas Southwestern Medical Center, Dallas.
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Viney R, Mansour DJ. Cost savings from simple interventions to reduce unnecessary urinary investigations. BMJ Sex Reprod Health 2018; 44:221-222. [PMID: 29192013 DOI: 10.1136/bmjsrh-2017-101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Rachael Viney
- Northumbria GP Training Programme, Health Education North East, Newcastle upon Tyne, UK
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Ekblom K, Petersson A. Introduction of cost display reduces laboratory test utilization. Am J Manag Care 2018; 24:e164-e169. [PMID: 29851448] [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: 06/08/2023]
Abstract
OBJECTIVES To study the effects on the number of laboratory tests ordered after introduction of cost display (showing the cost in the computerized test ordering system at test ordering and test result delivery) and cost charge (requiring all primary healthcare centers to pay full laboratory costs of the ordered tests). STUDY DESIGN The study included cost display for secondary healthcare centers (inpatient hospitals, emergency departments, and outpatient specialist providers) as well as publicly and privately operated primary healthcare centers (sites of nonemergency, nonspecialist healthcare). After 3 months, cost charge was introduced by management for all primary healthcare centers. METHODS Information on laboratory test cost was appended to the laboratory test name in the test ordering system, resulting in cost display both at the moment of test ordering and at the presentation of the test result. Numbers of laboratory tests were obtained from the laboratory information system and calculated as tests per physician visit. Cost charge was managed through the established laboratory invoicing system. RESULTS In the publicly operated primary healthcare centers, neither of the interventions had any effect on laboratory test volume, nor did cost display have an effect in the privately operated primary healthcare centers. However, introduction of cost charge significantly decreased laboratory test ordering in the privately operated primary healthcare centers. In contrast, secondary healthcare centers lowered test volumes when cost display was introduced. CONCLUSIONS The results support cost awareness and cost charge as means of reducing laboratory utilization. However, the outcome varies with the setting.
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Affiliation(s)
- Kim Ekblom
- Department of Clinical Chemistry and Transfusion Medicine, Växjö Central Hospital, SE-35185 Växjö, Sweden.
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van der Pol LM, Dronkers CEA, van der Hulle T, den Exter PL, Tromeur C, Heringhaus C, Mairuhu ATA, Huisman MV, van den Hout WB, Klok FA. The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department. J Thromb Haemost 2018; 16:725-733. [PMID: 29431911 DOI: 10.1111/jth.13972] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 10/24/2017] [Indexed: 08/31/2023]
Abstract
Essentials The YEARS algorithm was designed to simplify the diagnostic workup of suspected pulmonary embolism. We compared emergency ward turnaround time of YEARS and the conventional algorithm. YEARS was associated with a significantly shorter emergency department visit time of ˜60 minutes. Treatment of pulmonary embolism was initiated 53 minutes earlier with the YEARS algorithm SUMMARY: Background Recently, the safety of the YEARS algorithm, designed to simplify the diagnostic work-up of pulmonary embolism (PE), was demonstrated. We hypothesize that by design, YEARS would be associated with a shorter diagnostic emergency department (ED) visit time due to simultaneous assessment of pre-test probability and D-dimer level and reduction in number of CT scans. Aim To investigate whether implementation of the YEARS diagnostic algorithm is associated with a shorter ED visit time compared with the conventional algorithm and to evaluate the associated cost savings. Methods We selected consecutive outpatients with suspected PE from our hospital included in the YEARS study and ADJUST-PE study. Different time-points of the diagnostic process were extracted from the to-the-minute accurate electronic patients' chart system of the ED. Further, the costs of the ED visits were estimated for both algorithms. Results All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS: patients were discharged earlier from the ED; 54 min (95% CI, 37-70) for patients managed without computed tomography pulmonary angiography (CTPA) and 60 min (95% CI, 44-76) for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 53 min (95% CI, 22-82) faster than those managed according to the conventional algorithm. Total costs were reduced by on average €123 per visit. Conclusion YEARS was shown to be associated with a shorter ED visit time compared with the conventional diagnostic algorithm, leading to faster start of treatment in the case of confirmed PE and savings on ED resources.
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Affiliation(s)
- L M van der Pol
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - T van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - P L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Tromeur
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Heringhaus
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - A T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - W B van den Hout
- Department of Medical Decision Making and Quality of CareLeiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Zhang H, Song Y, Zhang X, Hu J, Yuan S, Ma J. Extent and cost of inappropriate use of tumour markers in patients with pulmonary disease: a multicentre retrospective study in Shanghai, China. BMJ Open 2018; 8:e019051. [PMID: 29490961 PMCID: PMC5855297 DOI: 10.1136/bmjopen-2017-019051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The currently implemented healthcare reform in China requires substantial capital investment. Although overtreatment results in serious waste, inappropriate laboratory use is widespread, and overuse of tumour markers (TMs) has attracted increasing attention. DESIGN Retrospective study. SETTING The respiratory, thoracic surgery and oncology departments of three hospitals in Shanghai from 2014 to 2015. PARTICIPANTS Patients with chronic obstructive pulmonary disease (COPD) and primary bronchogenic lung cancer (PLC). Based on clinical guidelines and physician experience, the criteria of suitability of TM examinations were determined, and the number, cost and proportion of inappropriate TM requests were analysed. RESULTS The area under the receiver operating characteristic curve for carcinoembryonic antigen+cytokeratin fragment 21-1+squamous cell carcinoma antigen+neuron-specific enolase in patients with COPD and PLC was 0.813, in accordance with the cost-effectiveness principle, indicating good clinical and health economics values. In the 2706 patients, 12 496-16 956 (58.27%-79.06%) of TM requests were inappropriate. Furthermore, the involved expense was 650 200-1 014 156 yuan, accounting for 7.69%-12.00% of examination expenses and 1.35%-2.11% of hospitalisation costs. CONCLUSIONS We found that the inappropriate use of TMs was widespread for patients with pulmonary disease. Clinicians should use TMs strictly according to the guidelines to effectively manage laboratory resources and control costs.
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Affiliation(s)
- Haichen Zhang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Clinical Laboratory, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Yunxiao Song
- Department of Clinical Laboratory, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Xiong Zhang
- Department of Information Service, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Jun Hu
- Department of Respiratory Medicine, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Suwei Yuan
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin Ma
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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O'Donnell TFX, Shean KE, Deery SE, Bodewes TCF, Wyers MC, O'Brien KL, Matyal R, Schermerhorn ML. A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross. J Vasc Surg 2018; 67:442-448. [PMID: 28756046 PMCID: PMC5785583 DOI: 10.1016/j.jvs.2017.05.108] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/12/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Preoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. METHODS We queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. RESULTS Between 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3. CONCLUSIONS Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kerry L O'Brien
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Robina Matyal
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injuryprediction rules: on the basis of cost and effectiveness. Turk J Med Sci 2017; 47:1770-1777. [PMID: 29306237 DOI: 10.3906/sag-1703-206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background/aim: Head injuries are commonly seen in the pediatric population. Noncontrast enhanced cranial CT is the method of choice to detect possible traumatic brain injury (TBI). Concerns about ionizing radiation exposure make the evaluation more challenging. The aim of this study was to evaluate the effectiveness of the Pediatric Emergency Care Applied Research Network (PECARN) rules in predicting clinically important TBI and to determine the amount of medical resource waste and unnecessary radiation exposure.Materials and methods: This retrospective study included 1041 pediatric patients presented to the emergency department. The patients were divided into subgroups of "appropriate for cranial CT", "not appropriate for cranial CT" and "cranial CT/observation of patient; both are appropriate". To determine the effectiveness of the PECARN rules, data were analyzed according to the presence of pathological findings Results: "Appropriate for cranial CT" results can predict pathology presence 118,056-fold compared to the "not appropriate for cranial CT" results. With "cranial CT/observation of patient; both are appropriate" results, pathology presence was predicted 11,457-fold compared to "not appropriate for cranial CT" results.Conclusion: PECARN rules can predict pathology presence successfully in pediatric TBI. Using PECARN can decrease resource waste and exposure to ionizing radiation.
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Mukerji G, Weinerman A, Schwartz S, Atkinson A, Stroud L, Wong BM. Communicating wisely: teaching residents to communicate effectively with patients and caregivers about unnecessary tests. BMC Med Educ 2017; 17:248. [PMID: 29228940 PMCID: PMC5725805 DOI: 10.1186/s12909-017-1086-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 06/07/2017] [Accepted: 11/27/2017] [Indexed: 05/20/2023]
Abstract
BACKGROUND With rising healthcare costs and a focus on quality, there is a growing need to promote resource stewardship in medical education. Physicians need to be able to communicate effectively with patients/caregivers seeking tests and treatments that are unnecessary. This study aimed to evaluate the impact of an interactive workshop on residents' knowledge of resource stewardship and communication skills when counseling patients/caregivers about requests for unnecessary testing. METHODS Participants were 83 Internal Medicine and Pediatrics residents at the University of Toronto in 2014-15. The evaluation compared resource stewardship knowledge and communication skills of 57 (69%) residents that attended the resource stewardship workshop to 26 residents (31%) who did not. Knowledge and communication skills assessment consisted of a written test and a structured assessment using standardized patient raters, respectively. A linear regression was applied to determine predictors of overall communication skills performance. RESULTS Workshop attendance resulted in better performance on the knowledge test (4.3 ± 1.9 vs. 3.1 ± 1.7 out of 8, p = 0.01), but not better performance on the communication skills assessment (4.1 ± 0.8 vs. 4.0 ± 0.9 out of 5, p = 0.56). Higher training level (p = 0.01) and knowledge test scores (p = 0.046) were independent predictors of better overall communication skills, after adjusting for gender, training level, workshop attendance, knowledge and self-reported prior feedback on communication skills. CONCLUSIONS An interactive workshop can improve knowledge of resource stewardship, but improving communication skills with patients/caregivers about unnecessary testing may require additional training or reinforcement in the clinical learning environment. These teaching and assessment approaches can support the integration of education on resource stewardship into medical education.
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Affiliation(s)
- Geetha Mukerji
- Department of Medicine, University of Toronto and Women’s College Hospital Institute of Health Systems Solutions and Virtual Care, 76 Grenville Street, Room 3414, Toronto, ON M5S 1B2 Canada
| | - Adina Weinerman
- Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Sarah Schwartz
- Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON Canada
| | - Adelle Atkinson
- Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON Canada
| | - Lynfa Stroud
- Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Brian M. Wong
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON Canada
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Affiliation(s)
- Aaron E Carroll
- Aaron E. Carroll, MD, MS, is a professor of pediatrics at Indiana University School of Medicine
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Elmer J, Yamane D, Hou PC, Wilcox SR, Bajwa EK, Hess DR, Camargo CA, Greenberg SM, Rosand J, Pallin DJ, Goldstein JN, Takhar SS. Cost and Utility of Microbiological Cultures Early After Intensive Care Unit Admission for Intracerebral Hemorrhage. Neurocrit Care 2017; 26:58-63. [PMID: 27605253 DOI: 10.1007/s12028-016-0285-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fever is common among intensive care unit (ICU) patients. Clinicians may use microbiological cultures to differentiate infectious and aseptic fever. However, their utility depends on the prevalence of infection; and false-positive results might adversely affect patient care. We sought to quantify the cost and utility of microbiological cultures in a cohort of ICU patients with spontaneous intracerebral hemorrhage (ICH). METHODS We performed a secondary analysis of a cohort with spontaneous ICH requiring mechanical ventilation. We collected baseline data, measures of systemic inflammation, microbiological culture results for the first 48 h, and daily antibiotic usage. Two physicians adjudicated true-positive and false-positive culture results using standard criteria. We calculated the cost per true-positive result and used logistic regression to test the association between false-positive results with subsequent antibiotic exposure. RESULTS Overall, 697 subjects were included. A total of 233 subjects had 432 blood cultures obtained, with one true-positive (diagnostic yield 0.1 %, $22,200 per true-positive) and 11 false-positives. True-positive urine cultures (5 %) and sputum cultures (13 %) were more common but so were false-positives (6 and 17 %, respectively). In adjusted analysis, false-positive blood and sputum results were associated with increased antibiotic exposure. CONCLUSIONS The yield of blood cultures early after spontaneous ICH was very low. False-positive results significantly increased the odds of antibiotic exposure. Our results support limiting the use of blood cultures in the first two days after ICU admission for spontaneous ICH.
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Affiliation(s)
- Jonathan Elmer
- Departments of Emergency Medicine and Critical Care Medicine, University of Pittsburgh, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
| | - David Yamane
- Department of Anesthesiology and Critical Care Medicine, George Washington University Hospital, Washington, DC, USA
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Surgical Intensive Care Unit, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan R Wilcox
- Divisions of Emergency Medicine and Pulmonary, Critical Care and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Dean R Hess
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sukhjit S Takhar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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Bindraban RS, van Beneden M, Ten Berg MJ, Nanayakkara PWB. Long-term sustainability of a multi-step intervention to reduce unnecessary diagnostic testing. Eur J Intern Med 2017; 44:e38-e39. [PMID: 28734562 DOI: 10.1016/j.ejim.2017.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 07/17/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Renuka S Bindraban
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands; Department of Clinical Chemistry, University Medical Center Utrecht, The Netherlands
| | - Marlou van Beneden
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maarten J Ten Berg
- Department of Clinical Chemistry, University Medical Center Utrecht, The Netherlands
| | - Prabath W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Abstract
Our objective was to determine the clinical value of obtaining a chest radiograph after removal of a chest tube. We conducted a retrospective chart review of pediatric general surgical patients with a chest tube in place after a thoracic procedure over a 3-year time period. Postremoval films were considered to be of value if they led to a change in clinical management. Of 468 patients who had a thoracic procedure, 281 patients had a chest tube and a postremoval film. In 263 patients (93.6%) there was no change in the postremoval film result compared with baseline. Only two patients (0.7%) required an intervention based on symptoms, not based on the postremoval film. Eliminating routine postremoval radiographs after chest tube removal in pediatric patients will lessen radiation exposure and provide cost savings with no adverse impact on outcome.
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Hollingworth W, Busby J, Butler CC, O'Brien K, Sterne JAC, Hood K, Little P, Lawton M, Birnie K, Thomas-Jones E, Harman K, Hay AD. The Diagnosis of Urinary Tract Infection in Young Children (DUTY) Study Clinical Rule: Economic Evaluation. Value Health 2017; 20:556-566. [PMID: 28407997 PMCID: PMC5406157 DOI: 10.1016/j.jval.2017.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 01/06/2017] [Accepted: 01/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To estimate the cost-effectiveness of a two-step clinical rule using symptoms, signs and dipstick testing to guide the diagnosis and antibiotic treatment of urinary tract infection (UTI) in acutely unwell young children presenting to primary care. METHODS Decision analytic model synthesising data from a multicentre, prospective cohort study (DUTY) and the wider literature to estimate the short-term and lifetime costs and healthcare outcomes (symptomatic days, recurrent UTI, quality adjusted life years) of eight diagnostic strategies. We compared GP clinical judgement with three strategies based on a 'coefficient score' combining seven symptoms and signs independently associated with UTI and four strategies based on weighted scores according to the presence/absence of five symptoms and signs. We compared dipstick testing versus laboratory culture in children at intermediate risk of UTI. RESULTS Sampling, culture and antibiotic costs were lowest in high-specificity DUTY strategies (£1.22 and £1.08) compared to clinical judgement (£1.99). These strategies also approximately halved urine sampling (4.8% versus 9.1% in clinical judgement) without reducing sensitivity (58.2% versus 56.4%). Outcomes were very similar across all diagnostic strategies. High-specificity DUTY strategies were more cost-effective than clinical judgement in the short- (iNMB = £0.78 and £0.84) and long-term (iNMB =£2.31 and £2.50). Dipstick tests had poorer cost-effectiveness than laboratory culture in children at intermediate risk of UTI (iNMB = £-1.41). CONCLUSIONS Compared to GPs' clinical judgement, high specificity clinical rules from the DUTY study could substantially reduce urine sampling, achieving lower costs and equivalent patient outcomes. Dipstick testing children for UTI is not cost-effective.
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Affiliation(s)
| | - John Busby
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kathryn O'Brien
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Kerenza Hood
- South East Wales Trials Unit (SEWTU Centre for Trials Research), Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Michael Lawton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kate Birnie
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit (SEWTU Centre for Trials Research), Cardiff University, Cardiff, UK
| | - Kim Harman
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, NIHR School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Frigini LA, Hoxhaj S, Wintermark M, Gibby C, De Rosen VL, Willis MH. R-SCAN: CT Angiographic Imaging for Pulmonary Embolism. J Am Coll Radiol 2017; 14:637-640. [PMID: 28284675 DOI: 10.1016/j.jacr.2017.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 01/01/2017] [Accepted: 01/09/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | - Shkelzen Hoxhaj
- Division of Emergency Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Max Wintermark
- Neuroradiology Division, Department of Radiology, Stanford University, Palo Alto, California
| | - Conrad Gibby
- Department of Radiology, Baylor College of Medicine, Houston, Texas
| | | | - Marc H Willis
- Department of Radiology, Baylor College of Medicine, Houston, Texas
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Sambandam SN, Khanna V, Rohinikumar G, Mounasamy V. Pre-discharge postoperative radiographs after primary total knee replacement : tradition or science? Acta Orthop Belg 2017; 83:132-139. [PMID: 29322905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Consistent evidence exists on the inutility of immediate postoperative radiographs after a total knee replacement (TKR). We hypothesized that eliminating the pre-discharge film would not have any effect on the postoperative patient outcomes. Retrospective analysis of prospectively collected data was performed on 220 knees. Patients undergoing a simple primary TKR operated by 2 surgeons (Surgeon A and B) from January 2013 to July 2015 were divided into 2 groups (Groups 1 and 2 having 112 and 108 knees respectively). While Surgeon A routinely asked for the second postoperative day pre-discharge radiograph, Surgeon B directly performed weight bearing radiographs 6 weeks postoperatively. Greater knee pain was seen in Group 1 (p = 0.01). No changes in rehabilitation protocols based on pre-discharge radiographs, complications, medico-legal issues or revision surgery could be identified in any patient. The quality of the pre-discharge radiographs was adequate in 65 of the 112 knees (58%). A cost reduction of approximately $220 per patient was observed with the exclusion of the pre-discharge film. Eliminating routine inpatient pre-discharge radio-graphs after simple primary TKR does not alter the rehabilitation protocol, identify any of the standard complication or have any medico-legal implications. On the contrary, these films seem to increase postoperative pain and costs.
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Juric-Sekhar G, Upton MP, Swanson PE, Westerhoff M. Cytomegalovirus (CMV) in gastrointestinal mucosal biopsies: should a pathologist perform CMV immunohistochemistry if the clinician requests it? Hum Pathol 2017; 60:11-15. [PMID: 27666768 DOI: 10.1016/j.humpath.2016.09.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/31/2016] [Accepted: 09/02/2016] [Indexed: 01/01/2023]
Abstract
Cytomegalovirus (CMV) causes clinically significant gastrointestinal (GI) injury. CMV inclusions can be identified on routine hematoxylin and eosin (H&E) stain, but immunohistochemistry (IHC) is also available for identifying CMV in tissue. The advent of accountable care organization models of care bring into question whether it is cost-effective for immunohistochemistry to be performed upfront at the request of clinicians and whether the quality of viral detection is compromised when the diagnosis of CMV is predicated on histologic review. In this study, a retrospective review of GI biopsies with CMV evaluations was performed. There were 449 cases with clinical requests to rule out CMV and 238 CMV analyses initiated by the pathologist without a clinical request. Among the cases that included a clinician's request, 37 had CMV detected. Immunostaining was performed on 26 cases, while a diagnosis based on readily identifiable viral inclusions on H&E-stained slides was made in 11. Among pathologist-initiated work-ups, 15 were CMV+, 3 of which had inclusions identified by H&E only. Among 38 CMV cases for which IHC had been performed, 27 had overt viral inclusions obvious on H&E. Seventy-two cases revealed uninflamed GI mucosa, and although a clinical concern about CMV infection was present, a CMV IHC work-up was not initially performed; all were negative for CMV by IHC and H&E. Clinical suspicion for CMV has a high yield for CMV detection, but "upfront" testing is likely unnecessary. Careful histopathologic review by a pathologist remains critical in the efficient and cost-effective detection of CMV.
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Affiliation(s)
| | - Melissa P Upton
- Department of Pathology, University of Washington, Seattle, WA, 98195 USA
| | - Paul E Swanson
- Department of Pathology, University of Washington, Seattle, WA, 98195 USA
| | - Maria Westerhoff
- Department of Pathology, University of Washington, Seattle, WA, 98195 USA.
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Grant A, Dreischulte T, Guthrie B. Process evaluation of the data-driven quality improvement in primary care (DQIP) trial: active and less active ingredients of a multi-component complex intervention to reduce high-risk primary care prescribing. Implement Sci 2017; 12:4. [PMID: 28061794 PMCID: PMC5219764 DOI: 10.1186/s13012-016-0531-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 12/06/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Two to 4% of emergency hospital admissions are caused by preventable adverse drug events. The estimated costs of such avoidable admissions in England were £530 million in 2015. The data-driven quality improvement in primary care (DQIP) intervention was designed to prompt review of patients vulnerable from currently prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and anti-platelets and was found to be effective at reducing this prescribing. A process evaluation was conducted parallel to the trial, and this paper reports the analysis which aimed to explore response to the intervention delivered to clusters in relation to participants' perceptions about which intervention elements were active in changing their practice. METHODS Data generation was by in-depth interview with key staff exploring participant's perceptions of the intervention components. Analysis was iterative using the framework technique and drawing on normalisation process theory. RESULTS All the primary components of the intervention were perceived as active, but at different stages of implementation: financial incentives primarily supported recruitment; education motivated the GPs to initiate implementation; the informatics tool facilitated sustained implementation. Participants perceived the primary components as interdependent. Intervention subcomponents also varied in whether and when they were active. For example, run charts providing feedback of change in prescribing over time were ignored in the informatics tool, but were motivating in some practices in the regular e-mailed newsletter. The high-risk NSAID and anti-platelet prescribing targeted was accepted as important by all interviewees, and this shared understanding was a key wider context underlying intervention effectiveness. CONCLUSIONS This was a novel use of process evaluation data which examined whether and how the individual intervention components were effective from the perspective of the professionals delivering changed care to patients. These findings are important for reproducibility and roll-out of the intervention. TRIAL REGISTRATION ClinicalTrials.gov, NCT01425502 .
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Affiliation(s)
- Aileen Grant
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK.
| | - Tobias Dreischulte
- Medicines Governance Unit, NHS Tayside, Dundee, UK
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
| | - Bruce Guthrie
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK
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Foster DS, Gupta R. Choosing Wisely. W V Med J 2016; 112:12. [PMID: 29368497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Abstract
OBJECTIVE: The misdiagnosis and inappropriate treatment of benign positional vertigo have resulted in significant costs to the medical system. In the current medical-economic climate, there is an increased emphasis on cost control. Recent studies have shown that the canalith repositioning procedure (CRP) is effective; the next step is to show the impact of CRP in cost-effective management of benign positional vertigo. METHODS: Forty-six of 100 patients who underwent CRP for benign positional vertigo responded to a survey regarding the financial impact of their disease. They were asked to subjectively estimate the sum of all disease-related expenses. Objective substantiation of this number was estimated by tabulating physician data, laboratory data, and failed treatment costs. RESULTS: The subjective figure totaled $2684.74 per individual. Summation of the tangible objective figures yielded $2009.63 per patient, corroborating the subjective figure. CONCLUSIONS: Because CRP is a relatively simple procedure that can obviate many wasted expenses in most patients, we believe that it is very cost-effective and should be incorporated into routine practice.
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Affiliation(s)
- J C Li
- Department of Otolaryngology, Palm Beach Gardens Medical Center, Jupiter, Florida, USA
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