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Sahu B, Madani G. Imaging inequality: exploring the differences in radiology between high- and low-income countries. Clin Radiol 2024; 79:399-403. [PMID: 38616473 DOI: 10.1016/j.crad.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/02/2024] [Indexed: 04/16/2024]
Affiliation(s)
- B Sahu
- Imperial College Healthcare NHS Trust, United Kingdom.
| | - G Madani
- Imperial College Healthcare NHS Trust, United Kingdom.
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Kim Y, Ganduglia-Cazaban C, Tamirisa N, Lucci A, Krause TM. Contemporary Analysis of Reexcision and Conversion to Mastectomy Rates and Associated Healthcare Costs for Women Undergoing Breast-Conserving Surgery. Ann Surg Oncol 2024; 31:3649-3660. [PMID: 38319511 PMCID: PMC11076367 DOI: 10.1245/s10434-024-14902-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE This study was designed to provide a comprehensive and up-to-date understanding of population-level reoperation rates and incremental healthcare costs associated with reoperation for patients who underwent breast-conserving surgery (BCS). METHODS This is a retrospective cohort study using Merative™ MarketScan® commercial insurance data and Medicare 5% fee-for-service claims data. The study included females aged 18-64 years in the commercial cohort and females aged 18 years and older in the Medicare cohort, who underwent initial BCS for breast cancer in 2017-2019. Reoperation rates within a year of the initial BCS and overall 1-year healthcare costs stratified by reoperation status were measured. RESULTS The commercial cohort included 17,129 women with a median age of 55 (interquartile range [IQR] 49-59) years, and the Medicare cohort included 6977 women with a median age of 73 (IQR 69-78) years. Overall reoperation rates were 21.1% (95% confidence interval [CI] 20.5-21.8%) for the commercial cohort and 14.9% (95% CI 14.1-15.7%) for the Medicare cohort. In both cohorts, reoperation rates decreased as age increased, and conversion to mastectomy was more prevalent among younger women in the commercial cohort. The mean healthcare costs during 1 year of follow-up from the initial BCS were $95,165 for the commercial cohort and $36,313 for the Medicare cohort. Reoperations were associated with 24% higher costs in both the commercial and Medicare cohorts, which translated into $21,607 and $8559 incremental costs, respectively. CONCLUSIONS The rates of reoperation after BCS have remained high and have contributed to increased healthcare costs. Continuing efforts to reduce reoperation need more attention.
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Affiliation(s)
- Youngran Kim
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA.
| | - Cecilia Ganduglia-Cazaban
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Trudy Millard Krause
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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Lattimore CM, Meneveau MO, Desai R, Camacho TF, Squeo GC, Showalter SL. Are There Disparities in Breast Reconstruction After Contralateral Prophylactic Mastectomy? J Surg Res 2024; 298:277-290. [PMID: 38636184 PMCID: PMC11144118 DOI: 10.1016/j.jss.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/26/2023] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Despite national guidelines against contralateral prophylactic mastectomy (CPM) in low- to moderate-risk breast cancer, CPM use continues to rise. Breast reconstruction improves health-related quality of life and satisfaction among women undergoing mastectomy. Given the lack of data regarding factors associated with reconstruction after CPM and the known benefits of reconstruction, we sought to investigate whether disparities exist in receipt of reconstruction after CPM. METHODS The 2004-2017 National Cancer Database was queried to identify women diagnosed with breast cancer who underwent unilateral mastectomy with CPM. Patients were divided into two groups: those who underwent planned reconstruction at any timepoint and those who did not. A secondary analysis comparing types of reconstruction (tissue, implant, combined) was conducted. Patient, tumor, and demographic characteristics were analyzed using chi-square test and odds ratios were calculated using generalized estimating equations. RESULTS The cohort included 1,73,249 women: 95,818 (55.3%) underwent reconstruction and 77,431 (45.7%) did not. Both the rate CPM and the proportion of women undergoing reconstruction after CPM increased between 2004 and 2017. Of the women who had reconstruction, 40,840 (51.7%) received implants, 29,807 (37.7%) had tissue, and 8352 (10.6%) had combined reconstruction. After adjusted analysis, factors associated with reconstruction were young age, Hispanic ethnicity, private insurance, and living in an area with the highest education and median income (P < 0.01). Patients who underwent reconstruction were less likely to have radiation (P < 0.01) and chemotherapy (P < 0.01), more likely to have stage I disease (P < 0.01), and to be treated at an integrated cancer center (P < 0.01). CONCLUSIONS Reconstruction after CPM is disproportionately received by younger women, Hispanics, those with private insurance, and higher socioeconomic status and education. While the rate of reconstruction after CPM is increasing, there remain significant disparities. Conscious efforts must be made to eliminate these disparities, especially given the known benefits of reconstruction after mastectomy.
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Affiliation(s)
- Courtney M Lattimore
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Max O Meneveau
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Raj Desai
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia
| | - T Fabian Camacho
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia
| | - Gabriella C Squeo
- Department of Plastic and Maxillofacial Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Shayna L Showalter
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
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Lai Y, Zeng W, Liao J, Yu Y, Liu X, Wu K. Retrospective analyses of routine preoperative blood testing in a tertiary eye hospital: could Choosing Wisely work in China? Br J Ophthalmol 2024; 108:897-902. [PMID: 37468212 DOI: 10.1136/bjo-2022-322431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/21/2023]
Abstract
AIMS To explore the possibility of implementing Choosing Wisely on ocular patients in China by investigating the prevalence of abnormalities in routine preoperative blood tests (RPBTs) and its turnaround time (TAT). METHODS Data from 102 542 ocular patients between January 2016 and December 2018, at Zhongshan Ophthalmic Center, were pooled from the laboratory information system. The test results were divided into normal and abnormal, including critical values. Ocular diseases were stratified into 11 subtypes based on the primary diagnosis. The TAT of 243 350 blood tests from January 2017 to December 2018 was categorised into transportation time and intralaboratory time. RESULTS RPBT was grouped into complete blood count (CBC), blood biochemistry (BBC), blood coagulation (BCG) and blood-borne pathogens (BBP), completed for 97.22%, 87.66%, 94.41% and 95.35% of the recruited patients (male, 52 549 (51.25%); median(IQR) age, 54 (29-67) years), respectively. Stratified by the test items, 9.19% (95% CI 9.07% to 9.31%) were abnormal results, and 0.020% (95% CI 0.019% to 0.022%) were critical; most abnormalities were on the CBC, while glucose was the most common critical item. Classified by the patients' primary diagnosis, 76.97% (95% CI 76.71% to 77.23%) had at least one abnormal result, and 0.28% (95% CI 0.25% to 0.32%) were critical; abnormal findings were reported in 45.29% (95% CI 44.98% to 45.60%), 54.97% (95% CI 54.65% to 55.30%), 30.29% (95% CI 30.00% to 30.58%) and 11.32% (95% CI 11.12% to 11.52%) for the CBC, BBC, BCG and BBP tests, respectively. The median transportation time and intralaboratory TAT of the samples were 12 min and 78 min respectively. CONCLUSION Blood abnormalities are common in ocular patients. With acceptable timelines, RPBT is still indispensable in China for patient safety.
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Affiliation(s)
- Yunxi Lai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Weiting Zeng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Jingyu Liao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Yubin Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Xiuping Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Kaili Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
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Raudasoja A, Tikkinen KAO, Bellini B, Ben-Sheleg E, Ellen ME, Francesconi P, Hussien M, Kaji Y, Karlafti E, Koizumi S, Ouahrani E, Paier-Abuzahra M, Savopoulos C, Spary-Kainz U, Komulainen J, Sipilä R. Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey. BMC PRIMARY CARE 2024; 25:159. [PMID: 38724909 PMCID: PMC11084097 DOI: 10.1186/s12875-024-02382-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/11/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. METHODS Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. RESULTS Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. CONCLUSIONS More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.
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Affiliation(s)
- Aleksi Raudasoja
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Eliana Ben-Sheleg
- Department of Epidemiology, Biostatistics and Community Health Sciences, University of the Negev, Be'er Sheva, Israel
- Israel Implementation Science and Policy Engagement Centre (IS-PEC), Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Moriah E Ellen
- Department of Health Policy and Management, and Israel Implementation Science and Policy Engagement Centre (IS-PEC), Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Muaad Hussien
- Department of Medicine, Mälarsjukhuset Hospital, Eskilstuna, Sweden
| | - Yuki Kaji
- Department of General Medicine, Division of Behavioral Sciences, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Eleni Karlafti
- Emergency Department, and 1st Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Shunzo Koizumi
- Shichijo Clinic, Saga Medical School, Kyoto, Saga, Japan
| | - Emir Ouahrani
- Department of geriatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Muna Paier-Abuzahra
- Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
| | - Christos Savopoulos
- 1st Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ulrike Spary-Kainz
- Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
| | | | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
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Rung JM, Aliu O, Barrett TS, LeJeune K, Farah TG. Prevalence and Cost of Routine Preoperative Care for Low-Risk Cataract Surgery a Decade after Choosing Wisely. Ophthalmology 2024; 131:577-588. [PMID: 38092081 DOI: 10.1016/j.ophtha.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/07/2023] [Accepted: 12/01/2023] [Indexed: 01/30/2024] Open
Abstract
PURPOSE Examine the frequency and cost of procedural clearance tests and examinations in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the United States. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts postsurgical adverse events. DESIGN Retrospective healthcare claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania. PARTICIPANTS Members aged ≥ 65 years who were continuously enrolled 6 months before and after undergoing cataract surgery from 2018 to 2021 and had approved surgery claims. METHODS Preoperative exams or tests occurring in the 30 days before surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., Current Procedural Terminology codes for blood panels and preprocedural International Classification of Diseases, 10th Revision, Clinical Modification codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling. MAIN OUTCOME MEASURES Total costs, prevalence, and strength of association as indicated by odds ratios. RESULTS Up to 42% of members undergoing cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed in isolation or along with clearance visits. The combined costs for the preoperative visits and tests were $4.3 million (approximately $107-$114 per impacted member). There was little difference in member characteristics between those receiving and not receiving preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member's care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two. CONCLUSIONS Rates of routine preoperative testing before cataract surgery appear similar to those prior to the implementation of the Choosing Wisely campaign, which was meant to reduce this use. Additionally, preoperative evaluations, many likely unnecessary, were common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
| | - Oluseyi Aliu
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Keith LeJeune
- Highmark Health, Pittsburgh, Pennsylvania; Allegheny Health Network, Pittsburgh, Pennsylvania
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Bharel S, McGillen B, Salas R, Pandya DS. Health Systems Science Integration in Graduate Medical Education: A Pathway to Quintuple Aim Success for Independent Practice. Am J Med 2024:S0002-9343(24)00221-3. [PMID: 38614273 DOI: 10.1016/j.amjmed.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 04/05/2024] [Indexed: 04/15/2024]
Affiliation(s)
- Sonia Bharel
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Brian McGillen
- Department of Medicine, PennState Health Milton S. Hershey Medical Center, Hershey, PA
| | - Rachel Salas
- Department of Neurology, Johns Hopkins Medicine, Baltimore, MD
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Khodayar-Pardo P, Miguez-Navarro MC, Martín Espín I. Actions to Avoid in Pain Management and Sedoanalgesia Procedures in Pediatric Emergencies. Pediatr Emerg Care 2024; 40:e23-e29. [PMID: 37725762 DOI: 10.1097/pec.0000000000003053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
OBJECTIVES The aim of this study was to show the process of elaboration and the results obtained of the list of "do not do" recommendations for pain management and sedoanalgesia procedures in pediatric patients within the Working Group on Analgesia and Sedation of the Spanish Society of Pediatric Emergencies (Grupo de Trabajo de Analgesia y Sedación de la Sociedad Española de Urgencias de Pediatría [GTAS-SEUP]). METHODS The process of drawing up the list was carried out in 3 phases: (1) "brainstorming," open to all members of the GTAS-SEUP; (2) selection of recommendations, after a modified Delphi methodology; and (3) drafting and consensus of the final document. RESULTS Initially, 57 proposed recommendations were obtained, which were reduced to 39 by unifying those that were similar. Of the 14 "do not do" in pain management, 6 were accepted: 3 in the first round and 3 in the second round. Of the 25 "do not do" recommendations for sedoanalgesia procedures, 6 were accepted: 4 in the first round and 2 in the second round. The final text consisted of 12 actions to avoid, 6 referring to pain management and 6 to sedoanalgesia procedures. CONCLUSIONS The list of "do not do" recommendations for pain management and sedoanalgesia procedures in the pediatric patient is a consensual tool, within the GTAS-SEUP. These recommendations promote an improvement in the quality of care offered to these patients, based on avoiding unnecessary measures, which can sometimes be harmful.
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El Fadel O, Goldberg ZN, Jain A, Venkat N, Upadhyaya A, Mack S, Kaminski M, Papanagnou D, Ziring D, Hayden G. Integrating Choosing Wisely, Value-Based Care Principles, Into Undergraduate Medical Education: A Pilot Study. Cureus 2024; 16:e56912. [PMID: 38528995 PMCID: PMC10963070 DOI: 10.7759/cureus.56912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Healthcare spending represents a large portion of the GDP of the United States. Value-based care (VBC) seeks to decrease waste in health care spending, yet this concept is insufficiently taught to medical students. The Choosing Wisely Students and Trainees Advocating for Resource Stewardship (STARS) campaign promotes initiatives that integrate knowledge of VBC into undergraduate medical education (UME). This study sought to determine the most effective strategy to educate medical students on key principles of VBC as taught by the STARS campaign. METHODS Choosing Wisely principles were incorporated into the UME curriculum of an academic medical institution via the creation of eight new learning objectives (LOs) for case-based learning (CBL) sessions and lectures. Medical students completed an annual 10-question survey from 2019 to 2022 and 10 formal examination questions during the preclinical (years 1 and 2) curriculum after exposure to varying quantities of LOs. Pearson correlation, chi-square, and logistic regression were employed to determine the association between increased LOs in the curriculum and (1) campaign awareness and (2) knowledge of VBC principles. RESULTS A total of 700 survey responses over a four-year period (2019 to 2022) were analyzed. Student awareness of the campaign and knowledge of VBC principles increased year over year during the survey period (39% to 92% and 64% to 74%, respectively). There were significant associations between increased LOs in the curriculum and (1) campaign awareness (0.828, p<0.0001) and (2) knowledge of VBC principles (0.934, p<0.001). Students also performed well on formal examination questions related to VBC principles (mean: 81.5% and mean discrimination index: 0.18). CONCLUSION Integration of VBC-focused LOs is significantly associated with awareness of the Choosing Wisely STARS campaign and knowledge of VBC principles taught by the campaign. Collaborative initiatives to increase exposure to VBC education may improve students' knowledge of these principles during medical school.
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Affiliation(s)
- Omar El Fadel
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | | | - Amiti Jain
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Nitya Venkat
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Anjali Upadhyaya
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Shale Mack
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Mitchell Kaminski
- Family and Community Medicine, Thomas Jefferson University, Philadelphia, USA
| | | | - Deborah Ziring
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Geoffrey Hayden
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
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Antunez AG, Rowe KA, Bain PA, Doherty GM, Dossett LA. Behavioral Interventions on Surgeons' Preoperative Decision-Making: A Scoping Review and Critical Analysis. J Surg Res 2024; 295:547-558. [PMID: 38086255 PMCID: PMC10922393 DOI: 10.1016/j.jss.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/20/2023] [Accepted: 11/12/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Consensus is lacking regarding the optimal strategy to influence surgeons' behaviors to reduce low-value surgical care. Comprehensively describing the existing body of literature that seeks to intervene on surgeons' preoperative decision-making may aid in structuring future behavior change strategies. METHODS We performed a scoping review using four databases (Medical Literature Analysis and Retrieval System Online, Embase, Web of Science, and Cumulated Index to Nursing and Allied Health Literature) for articles that tested the effect of behavioral-based interventions on any aspect of surgeons' decision-making in the preoperative setting. Abstracted data were characterized by summative descriptions and analyzed using the Tailored Implementation for Chronic Disease framework, mapping aspects of deimplementation strategies in the studies onto the determinant(s) that they altered. Data abstraction and mapping tools were piloted and iteratively revised before two researchers independently assessing studies and categorizing determinants, and then meeting to discuss their decisions. RESULTS There were 1460 articles identified from the initial search, with 17 full text articles ultimately included in the scoping review. Eight studies relied on a multidisciplinary preoperative conference to accomplish their aims, while five were multifaceted in their approach to deimplementation, and four studies used only a clinical decision support tool to accomplish their aims. Mapping determinants addressed in these studies onto the Tailored Implementation for Chronic Disease framework demonstrated that most strategies attempted to close knowledge gaps, leverage communication between providers, and broadcast institutional prioritization of change. CONCLUSIONS There is a small but growing field of implementation and deimplementation strategies in preoperative surgical decision-making, and different approaches may be equally effective in varied clinical contexts. Deliberate measurement and comparison of outcomes, as well as selection of control groups, are areas for improvement in future work.
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Affiliation(s)
- Alexis G Antunez
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Katherine A Rowe
- Massachusetts General Hospital Department of Surgery, Boston, Massachusetts
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, Massachusetts
| | - Gerard M Doherty
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Teele SA, Tremoulet P, Laussen PC, Danaher-Garcia N, Salvin JW, White BAA. Complex decision making in an intensive care environment: Perceived practice versus observed reality. J Eval Clin Pract 2024; 30:337-345. [PMID: 37767761 DOI: 10.1111/jep.13930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 09/01/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
RATIONALE Advancing our understanding of how decisions are made in cognitively, socially and technologically complex hospital environments may reveal opportunities to improve healthcare delivery, medical education and the experience of patients, families and clinicians. AIMS AND OBJECTIVES Explore factors impacting clinician decision making in the Boston Children's Hospital Cardiac Intensive Care Unit. METHODS A convergent mixed methods design was used. Quantitative and qualitative data sources consisted of a faculty survey, direct observations of clinical rounds in a specific patient population identified by a clinical decision support system (CDSS) and semistructured interviews (SSIs). Deductive and inductive coding was used for qualitative data. Qualitative data were translated into images using social network analysis which illustrate the frequency and connectivity of the codes in each data set. RESULTS A total of 25 observations of eight faculty-led interprofessional teams were performed between 12 February and 31 March 2021. Individual patient characteristics were noted by faculty in SSIs to be the most important factor in their decision making, yet ethnographic observations suggested faculty cognitive traits, team expertise and value-based decisions were more heavily weighted. The development of expertise was impacted by role modeling. Decisions were perceived to be influenced by the system and environment. CONCLUSIONS Clinician perception of decision making was not congruent with the observed behaviours in a complicated and dynamic system. This study identifies important considerations in clinical curricula as well as the design and implementation of CDSS. Our method of using social network analysis to visualize components of decision making could be adopted to explore other complex environments.
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Affiliation(s)
- Sarah A Teele
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, USA
| | | | - Peter C Laussen
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Danaher-Garcia
- Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, USA
| | - Joshua W Salvin
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bobbie Ann A White
- Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, USA
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Rappaport DI, Wilding KM, Adkins L, Bourque M, Miller JM. How Will a Shift to Value-Based Financial Models Affect Care for Hospitalized Children? Hosp Pediatr 2024; 14:e177-e180. [PMID: 38351892 DOI: 10.1542/hpeds.2023-007400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- David I Rappaport
- Division of General Academic Pediatrics
- Utilization Management, Nemours Children's Hospital, Wilmington, Delaware
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karen Marie Wilding
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
| | - Lisa Adkins
- Utilization Management, Nemours Children's Hospital, Wilmington, Delaware
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
| | - Maryanne Bourque
- Utilization Management, Nemours Children's Hospital, Wilmington, Delaware
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
| | - Jonathan M Miller
- Division of General Academic Pediatrics
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
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13
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Albanowski K, Brent C, Landrigan CP, Benjamin Wolk C, Schondelmeyer AC, Brady PW, Beidas RS, Schisterman EF, Bonafide CP. Getting Started With Multi-site Research: Lessons From the Eliminating Monitor Overuse (EMO) Study. Hosp Pediatr 2024; 14:e181-e188. [PMID: 38410860 PMCID: PMC10896739 DOI: 10.1542/hpeds.2023-007550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Research in Pediatric Hospital Medicine is growing and expanding rapidly, and with this comes the need to expand single-site research projects into multisite research studies within practice-based research networks. This expansion is crucial to ensure generalizable findings in diverse populations; however, expanding Pediatric Hospital Medicine research projects from single to multisite can be daunting. We provide an overview of major logistical steps and challenges in project management, regulatory approvals, data use agreements, training, communication, and financial management that are germane to hospitalist researchers launching their first multisite project by sharing processes and lessons learned from running multisite research projects in the Pediatric Research in Inpatient Settings Network within the Eliminating Monitor Overuse study portfolio. This description is relevant to hospitalist researchers transitioning from single-site to multisite research or those considering serving as site lead for a multisite project.
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Affiliation(s)
- Kimberly Albanowski
- Section of Hospital Medicine
- Clinical Futures Children’s Hospital of Philadelphia, Philadelphia
| | - Canita Brent
- Section of Hospital Medicine
- Clinical Futures Children’s Hospital of Philadelphia, Philadelphia
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Massachusetts
- Department of Pediatrics and Medicine, and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Courtney Benjamin Wolk
- Psychiatry
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Amanda C. Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Rinad S. Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Evanston, Illinois
| | | | - Christopher P. Bonafide
- Section of Hospital Medicine
- Clinical Futures Children’s Hospital of Philadelphia, Philadelphia
- Departments of Pediatrics
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
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14
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Lu P, Mian M, Yii M, McArdle DJT, Rhodes A, Sreedharan S. Rising use of diagnostic imaging in Australia: An analysis of Medicare-funded radiology services between 2000 and 2021. J Med Imaging Radiat Oncol 2024; 68:50-56. [PMID: 37797195 DOI: 10.1111/1754-9485.13591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION The use of diagnostic imaging services is increasing worldwide. This has important impacts on healthcare resource allocation and potential risks to the population. This study aimed to quantify trends in medical imaging in Australia over the past two decades. METHODS Data were extracted from the Australian Medicare Benefits Schedule (MBS) between 2000 and 2021. Simple linear regression analyses were performed to assess changes in absolute utilisation and utilisation rate per 100,000 population of total imaging services as well as by each imaging modality. Logistic regression analysis was performed to assess changes in total imaging services as a proportion of total Medicare services over time. Chi-squared test was used to assess for change in modality composition of imaging services. RESULTS There were 436,255,500 imaging studies performed between 2000 and 2021. The absolute utilisation of total imaging services increased annually by an average of 864,404 (95% CI: 808,235-920,573, p < 0.001). For each consecutive year, the proportion of total Medicare services attributed to total imaging services increased by 0.01% (95% CI: 0.01-0.01, p < 0.01). There was also a statistically significant increase in the utilisation rates of imaging services per 100,000 population for each imaging modality. The number of imaging services per radiologist increased on average by 74 (95% CI: 26-122, p < 0.05) annually. CONCLUSION The utilisation of diagnostic imaging services has increased in Australia between 2000 and 2021, outpacing the population growth, total healthcare services, and the radiologist workforce.
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Affiliation(s)
- Patrick Lu
- Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mustafa Mian
- Department of Oral and Maxillofacial Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Matthew Yii
- Department of Ear, Nose and Throat Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Alexander Rhodes
- Department of Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Radiology, University of Melbourne, Parkville, Victoria, Australia
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15
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Warshawsky I, Lemerman H, Gunkelman S, Mandalapu R, Uli NK, Patterson A, Gannon D, Engler L, Love AM, Davidson JR, Baccon J, Bigham MT. Promoting Choosing Wisely Thyroid Function Test Guidelines in a Large Pediatric Hospital System. Hosp Pediatr 2024; 14:116-125. [PMID: 38263871 DOI: 10.1542/hpeds.2023-007371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND Free thyroxine (fT4) is often ordered when not indicated. The goal of the current study was to use quality improvement tools to identify and implement an optimal approach to reduce inappropriate fT4 testing throughout a large pediatric hospital system. METHODS After reviewing evidence-based guidelines and best practices, a thyroid-stimulating hormone with reflex to fT4 test and an outpatient thyroid order panel with clinical decision support at order entry, along with several rounds of provider education and feedback, were implemented. Outpatient and inpatient order sets and system preference lists were reviewed with subject matter experts and revised when appropriate. Tracking metrics were identified. Automated monthly run charts and statistical process control charts were created using data retrieved from the electronic health record. Charts established baseline data, balancing measure data, monitored the impact of interventions, and identified future interventions. RESULTS Over a 44-month period, among nonendocrinology providers, a reduction in fT4 and thyroid-stimulating hormone co-orders from 67% to 15% and an increase in reflex fT4 tests from 0% to 77% was obtained in inpatient and outpatient settings. Direct cost savings as a result of performing 5179 fewer fT4 tests over 3 years was determined to be $45 800. CONCLUSIONS After implementation of a reflex fT4 test, a novel order panel with clinical decision support, provider education, and changes to ordering modes, a large and sustainable reduction in fT4 tests that was associated with significant cost savings was achieved among nonendocrinology providers.
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Affiliation(s)
| | | | - Samantha Gunkelman
- Department of Pediatrics
- Division of Pediatric Hospital Medicine
- Department of Quality Services
| | | | - Naveen K Uli
- Department of Pediatrics
- Division of Pediatric Endocrinology
| | | | | | | | | | | | | | - Michael T Bigham
- Department of Pediatrics
- Department of Quality Services
- Division of Critical Care Services, Akron Children's Hospital, Akron, Ohio
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16
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Bessat C, Bingisser R, Schwendinger M, Bulaty T, Fournier Y, Della Santa V, Pfeil M, Schwab D, Leuppi JD, Geigy N, Steuer S, Roos F, Christ M, Sirova A, Espejo T, Riedel H, Atzl A, Napieralski F, Marti J, Cisco G, Foley RA, Schindler M, Hartley MA, Fayet A, Garcia E, Locatelli I, Albrich WC, Hugli O, Boillat-Blanco N. PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial. Trials 2024; 25:86. [PMID: 38273319 PMCID: PMC10809691 DOI: 10.1186/s13063-023-07795-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/09/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). METHODS The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. DISCUSSION The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. TRIAL REGISTRATION This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. TRIAL STATUS Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.
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Affiliation(s)
- Cécile Bessat
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.
| | - Roland Bingisser
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | | | - Tim Bulaty
- Emergency Department, Cantonal Hospital of Baden, Baden, Switzerland
| | - Yvan Fournier
- Emergency Department, Intercantonal Hospital of Broye, Payerne, Switzerland
| | | | - Magali Pfeil
- Emergency Department, Hospital Riviera-Chablais, Rennaz, Switzerland
| | - Dominique Schwab
- Emergency Department, Hospital Riviera-Chablais, Rennaz, Switzerland
| | - Jörg D Leuppi
- Emergency Department and University Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department and University Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Stephan Steuer
- Emergency Department, St Claraspital, Basel, Switzerland
| | | | - Michael Christ
- Emergency Department, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Adriana Sirova
- Emergency Department, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Tanguy Espejo
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | - Henk Riedel
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | - Alexandra Atzl
- Emergency Department, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Fabian Napieralski
- Emergency Department, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Joachim Marti
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Giulio Cisco
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Rose-Anna Foley
- Qualitative research platform, social sciences sector, Department of Epidemiology and Health Services, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- School of Health Sciences HESAV, University of Applied sciences of Western Switzerland, HES-SO, Lausanne, Switzerland
| | - Melinée Schindler
- Qualitative research platform, social sciences sector, Department of Epidemiology and Health Services, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Mary-Anne Hartley
- Intelligent Global Health Research Group, Machine Learning and Optimization Laboratory, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Aurélie Fayet
- Clinical Research Center (CRC), University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Elena Garcia
- Emergency Department, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Isabella Locatelli
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases & Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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Álvaro de la Parra JA, Del Olmo Rodríguez M, Caramés Sánchez C, Blanco Á, Pfang B, Mayoralas-Alises S, Fernandez-Ferro J, Calvo E, Gómez Martín Ó, Fernández Tabera J, Plaza Nohales C, Nieto C, Short Apellaniz J. Effect of an algorithm for automatic placing of standardised test order sets on low-value appointments and attendance rates at four Spanish teaching hospitals: an interrupted time series analysis. BMJ Open 2024; 14:e081158. [PMID: 38267242 PMCID: PMC10824031 DOI: 10.1136/bmjopen-2023-081158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024] Open
Abstract
OBJECTIVE Reducing backlogs for elective care is a priority for healthcare systems. We conducted an interrupted time series analysis demonstrating the effect of an algorithm for placing automatic test order sets prior to first specialist appointment on avoidable follow-up appointments and attendance rates. DESIGN Interrupted time series analysis. SETTING 4 academic hospitals from Madrid, Spain. PARTICIPANTS Patients referred from primary care attending 10 033 470 outpatient appointments from 16 clinical specialties during a 6-year period (1 January 2018 to 30 June 2023). INTERVENTION An algorithm using natural language processing was launched in May 2021. Test order sets developed for 257 presenting complaints from 16 clinical specialties were placed automatically before first specialist appointments to increase rates of diagnosis and initiation of treatment with discharge back to primary care. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes included rate of diagnosis and discharge to primary care and follow-up to first appointment index. The secondary outcome was trend in 'did not attend' rates. RESULTS Since May 2021, a total of 1 175 814 automatic test orders have been placed. Significant changes in trend of diagnosis and discharge to primary care at first appointment (p=0.005, 95% CI 0.5 to 2.9) and 'did not attend' rates (p=0.006, 95% CI -0.1 to -0.8) and an estimated attributable reduction of 11 306 avoidable follow-up appointments per month were observed. CONCLUSION An algorithm for placing automatic standardised test order sets can reduce low-value follow-up appointments by allowing specialists to confirm diagnoses and initiate treatment at first appointment, also leading to early discharge to primary care and a reduction in 'did not attend' rates. This initiative points to an improved process for outpatient diagnosis and treatment, delivering healthcare more effectively and efficiently.
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Affiliation(s)
| | - Marta Del Olmo Rodríguez
- Quirónsalud, Madrid, Spain
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
| | - Cristina Caramés Sánchez
- Quirónsalud, Madrid, Spain
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
| | | | - Bernadette Pfang
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | - Jose Fernandez-Ferro
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
- Neurology Department, Hospital Universitario Rey Juan Carlos, Mostoles, Spain
| | - Emilio Calvo
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
- Orthopaedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Óscar Gómez Martín
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Jesús Fernández Tabera
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
- Villalba General University Hospital, Collado Villalba, Spain
| | - Carmen Plaza Nohales
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
- Hospital Universitario Rey Juan Carlos, Mostoles, Spain
| | - Carlota Nieto
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Jorge Short Apellaniz
- Instituto de Investigacion Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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18
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Ellen M, Correia L, Levinson W. Choosing wisely 10 years later: reflection and looking ahead. BMJ Evid Based Med 2024; 29:10-13. [PMID: 37479242 DOI: 10.1136/bmjebm-2023-112266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Luis Correia
- Department of Internal Medicine, Center for Evidence-Based Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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19
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Zapf MAC, Fabbri DV, Andrews J, Li G, Freundlich RE, Al-Droubi S, Wanderer JP. Development of a machine learning model to predict intraoperative transfusion and guide type and screen ordering. J Clin Anesth 2023; 91:111272. [PMID: 37774648 PMCID: PMC10623374 DOI: 10.1016/j.jclinane.2023.111272] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/12/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023]
Abstract
STUDY OBJECTIVE To develop an algorithm to predict intraoperative Red Blood Cell (RBC) transfusion from preoperative variables contained in the electronic medical record of our institution, with the goal of guiding type and screen ordering. DESIGN Machine Learning model development on retrospective single-center hospital data. SETTING Preoperative period and operating room. PATIENTS The study included patients ≥18 years old who underwent surgery during 2019-2022 and excluded those who refused transfusion, underwent emergency surgery, or surgery for organ donation after cardiac or brain death. INTERVENTION Prediction of intraoperative transfusion vs. no intraoperative transfusion. MEASUREMENTS The outcome variable was intraoperative transfusion of RBCs. Predictive variables were surgery, surgeon, anesthesiologist, age, sex, body mass index, race or ethnicity, preoperative hemoglobin (g/dL), partial thromboplastin time (s), platelet count x 109 per liter, and prothrombin time. We compared the performances of seven machine learning algorithms. After training and optimization on the 2019-2021 dataset, model thresholds were set to the current institutional performance level of sensitivity (93%). To qualify for comparison, models had to maintain clinically relevant sensitivity (>90%) when predicting on 2022 data; overall accuracy was the comparative metric. MAIN RESULTS Out of 100,813 cases that met study criteria from 2019 to 2021, intraoperative transfusion occurred in 5488 (5.4%) of cases. The LightGBM model was the highest performing algorithm in external temporal validity experiments, with overall accuracy of (76.1%) [95% confidence interval (CI), 75.6-76.5], while maintaining clinically relevant sensitivity of (91.2%) [95% CI, 89.8-92.5]. If type and screens were ordered based upon the LightGBM model, the predicted type and screen to transfusion ratio would improve from 8.4 to 5.1. CONCLUSIONS Machine learning approaches are feasible in predicting intraoperative transfusion from preoperative variables and may improve preoperative type and screen ordering practices when incorporated into the electronic health record.
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Affiliation(s)
- Matthew A C Zapf
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Daniel V Fabbri
- Department of Biomedical Informatics and Department of Computer Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Andrews
- Department of Pathology, Microbiology and Immunology and Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E Freundlich
- Department of Anesthesiology and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Samer Al-Droubi
- HealthIT Department, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Briedé S, Brandwijk ON, van Charldorp TC, Kaasjager HAH. A patient's perspective on care decisions: a qualitative interview study. BMC Health Serv Res 2023; 23:1335. [PMID: 38041103 PMCID: PMC10693144 DOI: 10.1186/s12913-023-10342-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/17/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Discussing treatment wishes and limitations during medical consultations aims to enable patients to define goals and preferences for future care. Patients and physicians, however, face multiple barriers, resulting in postponing or avoiding the conversation. The aim of this study was to explore an internal medicine outpatient clinic population's perception on (discussing) treatment wishes and limitations. METHODS Semi-structured interviews were conducted in two rounds with 44 internal medicine outpatient clinic patients at the University Medical Centre Utrecht, a tertiary care teaching medical centre in the Netherlands. Interviews were transcribed verbatim and thematically analysed with a phenomenological approach and inductive, data-driven coding. RESULTS Four themes were identified, two (1-2) represent a deep conviction, two (3-4) are practically oriented: (1) patients associate treatment wishes and limitations with the end-of-life, making it sensitive and currently irrelevant, (2) patients assume this process leads to fixed choices, whilst their wishes might be situation dependent, (3) treatment wishes and limitations are about balancing whether a treatment 'is worth it', in which several subthemes carry weight, (4) the physician is assigned a key role. CONCLUSION AND PRACTICE IMPLICATIONS The themes provide starting points for future interventions. It should be emphasized that care decisions are a continuous, dynamic process, relevant at any time in any circumstance and the physician should be aware of his/her key role.
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Affiliation(s)
- S Briedé
- Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Postbus 85500, Utrecht, GA, 3508, the Netherlands.
| | - O N Brandwijk
- Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Postbus 85500, Utrecht, GA, 3508, the Netherlands
| | - T C van Charldorp
- Department of Languages, Literature and Communication, Faculty of Humanities, Utrecht University, Utrecht, the Netherlands
| | - H A H Kaasjager
- Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Postbus 85500, Utrecht, GA, 3508, the Netherlands
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Paz-Martin D, Arnal-Velasco D. Can we nudge to reduce the perioperative low value care? Decision making factors influencing safe practice implementation. Curr Opin Anaesthesiol 2023; 36:698-705. [PMID: 37767927 DOI: 10.1097/aco.0000000000001315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
PURPOSE OF THE REVIEW Highlight sources of low-value care (LVC) during the perioperative period help understanding the decision making behind its persistence, the barriers for change, and the potential implementation strategies to reduce it. RECENT FINDINGS The behavioural economics science spread of use through aligned strategies or nudge units offer an opportunity to improve success in the LVC reduction. SUMMARY LVC, such as unneeded surgeries, or preanaesthesia tests for low-risk surgeries in low-risk patients, is a relevant source of waste and preventable harm, most especially in the perioperative period. Despite the international focus on it, initial efforts to reduce it in the last decade have not clearly shown a sustainable improvement. Understanding the shared decision-making process and the barriers to be expected when tackling LVC is the first step to build the change. Applying a structured strategy based on the behavioural science principles may be the path to increasing high value care in an effective an efficient way. It is time to foster nudge units at different healthcare system levels.
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Affiliation(s)
| | - Daniel Arnal-Velasco
- Unit of Anesthesiology and Reanimation, Hospital Universitario Fundacion Alcorcon, Alcorcon, Spain
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22
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Tamblyn R, Moraga T, Girard N, Chan FKI, Habib B, Boulet J. Clinical competence, communication ability and adherence to choosing wisely recommendations for lipid reducing drug use in older adults. BMC Geriatr 2023; 23:761. [PMID: 37986045 PMCID: PMC10662284 DOI: 10.1186/s12877-023-04429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Although lipid-lowering drugs are not recommended for primary prevention in patients 75+, prevalence of use is high and there is unexplained variation in prescribing between physicians. The objective of this study was to determine if physician communication ability and clinical competence are associated with prescribing lipid-lowering drugs for primary and secondary prevention. METHODS We used a cohort of 4,501 international medical graduates, 161,214 U.S. Medicare patients with hyperlipidemia (primary prevention) and 49,780 patients with a history of cardiovascular disease (secondary prevention) not treated with lipid-lowering therapy who were seen by study physicians in ambulatory care. Clinical competence and communication ability were measured by the ECFMG clinical assessment examination. Physician citizenship, age, gender, specialty and patient characteristics were also measured. The outcome was an incident prescription of lipid-lowering drug, evaluated using multivariable GEE logistic regression models for primary and secondary prevention for patients 75+ and 65-74. RESULTS Patients 75+ were less likely than those 65-74 to receive lipid-lowering drugs for primary (OR 0.62, 95% CI 0.59-0.66) and secondary (OR 0.70, 95% CI 0.63-0.78) prevention. For every 20% increase in clinical competence score, the odds of prescribing therapy for primary prevention to patients 75+ increased by 24% (95% CI 1.02-1.5). Communication ability had the opposite effect, reducing the odds of prescribing for primary prevention by 11% per 20% score increase (95% CI 0.8-0.99) for both age groups. Physicians who were citizens of countries with higher proportions of Hispanic (South/Central America) or Asian (Asia/Oceania) people were more likely to prescribe treatment for primary prevention, and internal medicine specialists were more likely to treat for secondary prevention than primary care physicians. CONCLUSION Clinical competence, communication ability and physician citizenship are associated with lipid-lowering drug prescribing for primary prevention in patients aged 75+.
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Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue., Montreal, QC, H3A 1G1, Canada.
- Department of Medicine, McGill University Health Center, Montreal, QC, Canada.
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada.
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Fiona K I Chan
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue., Montreal, QC, H3A 1G1, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - John Boulet
- Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, PA, USA
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23
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Djulbegovic B, Greenberg CS. Hematology referral madness syndrome. Blood Adv 2023; 7:6702-6704. [PMID: 37729619 PMCID: PMC10641470 DOI: 10.1182/bloodadvances.2023011434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 09/22/2023] Open
Affiliation(s)
- Benjamin Djulbegovic
- Division of Medical Hematology and Oncology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Charles S. Greenberg
- Division of Medical Hematology and Oncology, Department of Medicine, Medical University of South Carolina, Charleston, SC
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Atlibenkin S, Dwolatzky T, Porat O, Karban A, Zalts R. Hospital Care Efficiency - Measuring Lipid Profile During Hospitalization. Int J Gen Med 2023; 16:5193-5197. [PMID: 37964945 PMCID: PMC10642567 DOI: 10.2147/ijgm.s441401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/02/2023] [Indexed: 11/16/2023] Open
Abstract
Background Lipid profile measurement in order to identify patients with elevated low-density lipoprotein cholesterol (LDL-C) is clearly recommended for all age groups. However, the value of screening patients for elevated LDL-C during hospitalization has not been determined. The aim of this study was to investigate the value of lipid screening tests in patients admitted to internal medicine wards, and as part of our efforts to promote a more intelligent and efficient use of laboratory and imaging tests during hospital care. Methods We conducted this retrospective, observational study, in which medical charts of patients for whom at least one lipid profile measurement was performed during hospitalization were reviewed. The patients were categorized into 5 groups according to admission diagnosis, and for each patient, we looked if the lipid profile was mentioned or referred to, based on guidelines, in the discharge summary. Results Lipid profile taken during hospitalization was referred to in the discharge letter in only 38.7% of patients, and even in the case of a need to consider according to guidelines, only a 45.7% consideration rate was found. Conclusion This study highlights the need for a more efficient and focused approach to the use of lipid profile measurement during hospitalization.
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Affiliation(s)
- Smadar Atlibenkin
- Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, 3109601, Israel
| | - Tzvi Dwolatzky
- Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, 3109601, Israel
- Geriatrics Unit, Rambam Health Care Campus, Haifa, Israel
| | - Or Porat
- Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, 3109601, Israel
| | - Amir Karban
- Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, 3109601, Israel
- Department of Internal Medicine C, Rambam Health Care Campus, Haifa, Israel
| | - Ronen Zalts
- Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, 3109601, Israel
- Department of Internal Medicine C, Rambam Health Care Campus, Haifa, Israel
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25
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Terashima M, Kaneda H. Be Open-Minded - Recognize an Invisible Gorilla and Let Go of Linus' Security Blanket. Circ J 2023; 87:1703-1704. [PMID: 37197940 DOI: 10.1253/circj.cj-23-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
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26
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Mukherjee S, Dong W, Schiltz NK, Stange KC, Cullen J, Gerds AT, Carraway HE, Singh A, Advani AS, Sekeres MA, Koroukian SM. Patterns of Diagnostic Evaluation and Determinants of Treatment in Older Patients With Non-transfusion Dependent Myelodysplastic Syndromes. Oncologist 2023; 28:901-910. [PMID: 37120291 PMCID: PMC10546824 DOI: 10.1093/oncolo/oyad114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/20/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Older patients with myelodysplastic syndromes (MDS), particularly those with no or one cytopenia and no transfusion dependence, typically have an indolent course. Approximately, half of these receive the recommended diagnostic evaluation (DE) for MDS. We explored factors determining DE in these patients and its impact on subsequent treatment and outcomes. PATIENTS AND METHODS We used 2011-2014 Medicare data to identify patients ≥66 years of age diagnosed with MDS. We used Classification and Regression Tree (CART) analysis to identify combinations of factors associated with DE and its impact on subsequent treatment. Variables examined included demographics, comorbidities, nursing home status, and investigative procedures performed. We conducted a logistic regression analysis to identify correlates associated with receipt of DE and treatment. RESULTS Of 16 851 patients with MDS, 51% underwent DE. patients with MDS with no cytopenia (n = 3908) had the lowest uptake of DE (34.7%). Compared to patients with no cytopenia, those with any cytopenia had nearly 3 times higher odds of receiving DE [adjusted odds ratio (AOR), 2.81: 95% CI, 2.60-3.04] and the odds were higher for men than for women [AOR, 1.39: 95%CI, 1.30-1.48] and for Non-Hispanic Whites [vs. everyone else (AOR, 1.17: 95% CI, 1.06-1.29)]. The CART showed DE as the principal discriminating node, followed by the presence of any cytopenia for receiving MDS treatment. The lowest percentage of treatment was observed in patients without DE, at 14.6%. CONCLUSION In this select older patients with MDS, we identified disparities in accurate diagnosis by demographic and clinical factors. Receipt of DE influenced subsequent treatment but not survival.
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Affiliation(s)
- Sudipto Mukherjee
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Weichuan Dong
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Nicholas K Schiltz
- Frances P. Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Kurt C Stange
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jennifer Cullen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Aaron T Gerds
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hetty E Carraway
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhay Singh
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anjali S Advani
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mikkael A Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Florida, Miami, FL, USA
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, OH, USA
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Friedman NR, Watkins L, Barnard-Brak L, Barber A, White SW. De-implementation of Low-Value Practices for Autism Spectrum Disorder. Clin Child Fam Psychol Rev 2023; 26:690-705. [PMID: 37452164 DOI: 10.1007/s10567-023-00447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
Due to a variety of factors, Autism Spectrum Disorder (ASD) has long been tethered to use of low-value practice (LVP), arguably moreso than any other psychiatric or neurodevelopmental condition. Although dissemination of empirically supported treatments (EST) for autistic individuals has expanded markedly over the past decade, there has not been concomitant reduction in the use of LVP. It is critical that clinicians and scientists not only promote the implementation of EST, but also facilitate the de-implementation (abandonment and/or divestment) of ineffective or harmful practices. In this review, we describe a data-driven approach that can be used to identify LVP, drawing from established criteria for identification of evidence-based treatments (e.g., APA Division 12, National Clearinghouse on Autism Evidence and Practice; SAMHSA), as well as broader considerations such as social validity, cost, and parsimony. Herein, a data-based approach to LVP identification is proposed with a goal of improving quality of service access. Within an implementation science framework, we identify specific facilitators that sustain LVP use, and recommendations for subsequent de-implementation strategies are offered.
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Affiliation(s)
- Nicole R Friedman
- Center for Youth Development and Intervention, University of Alabama, 101 McMillan Bldg, Box 870348, Tuscaloosa, AL, 35487, USA
- Department of Psychology, University of Alabama, Tuscaloosa, AL, USA
| | - Laci Watkins
- Department of Special Education, University of Alabama, Tuscaloosa, AL, USA
- Department of Educational Psychology, Texas A&M University, College Station, TX, USA
| | - Lucy Barnard-Brak
- Department of Special Education, University of Alabama, Tuscaloosa, AL, USA
| | - Angela Barber
- Department of Communication Sciences and Disorders, Samford University, Birmingham, AL, USA
| | - Susan W White
- Center for Youth Development and Intervention, University of Alabama, 101 McMillan Bldg, Box 870348, Tuscaloosa, AL, 35487, USA.
- Department of Psychology, University of Alabama, Tuscaloosa, AL, USA.
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28
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Schuttner L, Richardson C, Parikh T, Wong ES. "Low-value" glycemic outcomes among older adults with diabetes cared for by primary care nurse practitioners or physicians: A retrospective cohort study. Int J Nurs Stud 2023; 145:104532. [PMID: 37315453 PMCID: PMC10760981 DOI: 10.1016/j.ijnurstu.2023.104532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND "Low-value" healthcare is care without benefit to patients. Overly intensive glycemic control (i.e., HgbA1C < 7 %) can cause harm to patients at high risk of hypoglycemia, particularly among older adults with co-morbidities. It is unknown whether overly intensive glycemic control differs among patients with diabetes and at high-risk of hypoglycemia cared for by primary care nurse practitioners versus physicians. OBJECTIVE This study examined patients with diabetes at high risk of hypoglycemia receiving primary care between Jan 2010 and Jan 2012, comparing patients reassigned to nurse practitioners to those reassigned to physicians after their previous physician separated from practice in an integrated United States health system. DESIGN This was a retrospective cohort study. Study outcomes were collected at two years after reassignment to a new primary care provider. Outcomes were predicted probabilities of HgbA1C < 7 % using two-stage residual inclusion instrumental variable models, controlling for baseline confounders. SETTING Primary care clinics within the United States Veterans Health Administration. PARTICIPANTS 38,543 patients with diabetes at increased risk for hypoglycemia (age ≥ 65 years with renal disease, dementia, or cognitive impairment), who had their primary care physician leave the Veterans Health Administration and who were reassigned to a new primary care provider in the following year. RESULTS Cohort patients were on average 76 years and 99 % men. Of these, 33,700 were reassigned to physicians and 4843 to nurse practitioners. After two years with their new provider, in adjusted models, patients reassigned to nurse practitioners had a -20.4 percentage-point [95 % CI -37.9 to -2.8] lower probability of two-year HgbA1C < 7 %. CONCLUSIONS Aligned with prior studies on care quality, rates of overly intensive glycemic control may be appropriately lower among older patients with diabetes at high-risk of hypoglycemia, cared for by nurse practitioners than physicians. TWEETABLE ABSTRACT Primary care nurse practitioners deliver equivalent or better rates of low-value diabetes care for older patients, compared to physicians.
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Affiliation(s)
- Linnaea Schuttner
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Claire Richardson
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Toral Parikh
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Edwin S Wong
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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29
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Guan Y, Haardörfer R, McBride CM, Escoffery C, Lipscomb J. Testing Theory-Based Messages to Encourage Women at Average Risk for Breast Cancer to Consider Biennial Mammography Screening. Ann Behav Med 2023; 57:696-707. [PMID: 37155576 DOI: 10.1093/abm/kaad018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND The US Preventive Services Task Force does not recommend routine annual mammography screening for women aged 40-49 at average risk. Little research has been done to develop theory-based communication interventions to facilitate informed decision-making about reducing potentially low-value mammography screening. PURPOSE Evaluate the effects of theory-based persuasive messages on women's willingness to consider delaying screening mammography until age 50 or have mammograms biennially. METHODS We conducted a randomized controlled communication experiment online with a population-based sample of U.S. women aged 40-49 (N = 383) who screened to be at average risk for breast cancer. Women were randomly assigned to the following messaging summaries: annual mammography risks in 40s (Arm 1, n = 124), mammography risks plus family history-based genetic risk (Arm 2, n = 120), and mammography risks, genetic risk, and behavioral alternatives (Arm 3, n = 139). Willingness to delay screening or reduce screening frequency was assessed post-experiment by a set of 5-point Likert scale items. RESULTS Women in Arm 3 reported significantly greater willingness to delay screening mammography until age 50 (mean = 0.23, SD = 1.26) compared with those in Arm 1 (mean = -0.17, SD = 1.20; p = .04). There were no significant arm differences in willingness to reduce screening frequency. Exposure to the communication messages significantly shifted women's breast cancer-related risk perceptions without increasing unwarranted cancer worry across all three arms. CONCLUSIONS Providing women with screening information and options may help initiate challenging discussions with providers about potentially low-value screening.
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Affiliation(s)
- Yue Guan
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Regine Haardörfer
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Colleen M McBride
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Martella M, Lenzi J, Gianino MM. Diagnostic Technology: Trends of Use and Availability in a 10-Year Period (2011-2020) among Sixteen OECD Countries. Healthcare (Basel) 2023; 11:2078. [PMID: 37510518 PMCID: PMC10378781 DOI: 10.3390/healthcare11142078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Overuse of imaging results in cost increases, with little to no benefit to patients. The purpose of this study is to evaluate imaging tests and radiology equipment over a ten-year period in 16 Organisation for Economic Co-operation and Development (OECD) countries. METHODS Twelve countries were included in a time-trend analysis based on OECD indicators on diagnostic imaging (computer tomography [CT], magnetic resonance imaging [MRI], and positron emission tomography [PET]). These annual indicators included the number of exams per 1000 population, the number of devices per million population, and the number of exams per device. Average annual percent change was used to measure country-specific trends. RESULTS Most countries saw a rise in the exam-to-scanner ratio for CT, MRI, and PET, demonstrating a faster increase in exam volume than device volume. Italy exhibited an increase in CT, MRI, and PET equipment units during the same period, but not in exams, most likely due to a reduction in medical procedures during the pandemic. Only in Luxemburg, CT and PET examinations increased despite a reduction in scanners. CONCLUSIONS Considering the expected increasing demand for diagnostics due to the evolving needs of the population, proper governance and resource allocation are necessary requirements for cost-efficient health systems.
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Affiliation(s)
- Manuela Martella
- Department of Public Health Science and Pediatrics, University of Turin, 10126 Torino, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy
| | - Maria Michela Gianino
- Department of Public Health Science and Pediatrics, University of Turin, 10126 Torino, Italy
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Venezia L, Buonocore MR, Barbuscio I, Bortoluzzi F, Monica F, Manfredi G, Anderloni A, Stasi E. Choosing Wisely in Gastroenterology: five new recommendations from the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Eur J Gastroenterol Hepatol 2023; 35:728-733. [PMID: 37272504 DOI: 10.1097/meg.0000000000002573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND 'Choosing Wisely' is an international campaign against inappropriateness in medical practices that aims to promote a rational and evidence-based use of resources. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) joined the Campaign in 2017 releasing five recommendations. AIMS To identify five new recommendations for a correct, evidence-based approach to the management of gastrointestinal diseases. METHODS All AIGO members were asked to identify practices or interventions that, even though diffuse in clinical practice, do not provide benefit for patients. The proposed items were then revised, divided by topic and ranked. After a systematic review of the literature for each item, five new recommendations were identified. RESULTS The five recommendations are: do not request surveillance investigations for patients with pancreatic cysts who are poor surgical candidates, irrespective of cysts nature and characteristics; do not request esophagogastroduodenoscopy in patients with recent onset of upper gastrointestinal symptoms younger than 50 years, without alarm features; do not request surveillance colonoscopy for asymptomatic colonic diverticular disease without changes in symptoms; do not perform food intolerance tests except for those scientifically validated; do not prescribe proton pump inhibitors to patients with liver cirrhosis, outside of established indications. CONCLUSION The Choosing Wisely recommendations will reduce unnecessary testing and treatments, increasing patient safety and overall healthcare quality.
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Affiliation(s)
- Ludovica Venezia
- Gastroenterology Unit, Department of Oncological and Specialty Medicine, Azienda Ospedaliero-Universitaria 'Maggiore della Carità', Novara
| | | | | | | | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste
| | - Guido Manfredi
- Gastroenterology and Endoscopy Department, ASST Crema 'Maggiore' Hospital, Crema
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Matteo, Pavia
| | - Elisa Stasi
- Gastroenterology, Digestive Endoscopy, 'Vito Fazzi' Hospital, Lecce, Italy
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Allen CJ, Johnson FM, In H, Katz MHG, Snyder RA. Shifting the Focus: Value-Based Care in Surgical Oncology. Ann Surg Oncol 2023; 30:3871-3874. [PMID: 37014556 DOI: 10.1245/s10434-023-13369-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/01/2023] [Indexed: 04/05/2023]
Affiliation(s)
- Casey J Allen
- Division of Surgical Oncology, Institute of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.
| | - Fabian M Johnson
- Division of Surgical Oncology, The Johns Hopkins University, Baltimore, MD, USA
| | - Haejin In
- Division of Surgical Oncology, The Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Weinerman AS, Guo Y, Saha S, Yip PM, Lapointe-Shaw L, Fralick M, Kwan JL, MacMillan TE, Liu J, Rawal S, Sheehan KA, Simons J, Tang T, Bhatia S, Razak F, Verma AA. Data-driven approach to identifying potential laboratory overuse in general internal medicine (GIM) inpatients. BMJ Open Qual 2023; 12:e002261. [PMID: 37495257 PMCID: PMC10373691 DOI: 10.1136/bmjoq-2023-002261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge. OBJECTIVE To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests. DESIGN, SETTING AND PARTICIPANTS A multicentre, retrospective study at three academic hospitals in Toronto, Canada. All general internal medicine (GIM) hospitalisations between 1 April 2010 and 31 October 2017. RESULTS There were 106 813 GIM hospitalisations during the study period, with median hospital length-of-stay of 4.6 days (IQR: 2.33-9.19). There were 21 tests which had a cumulative cost >US$15 400 at all three sites. The costliest test was plasma electrolytes (US$4 907 775), the test with the lowest proportion of abnormal results was red cell folate (0.2%) and the test with the greatest physician-level variation in use was antiphospholipid antibodies (coefficient of variation 3.08). The five tests with the highest cumulative rank based on greatest cost, lowest proportion of abnormal results and highest physician-level variation were: (1) lactate, (2) antiphospholipid antibodies, (3) magnesium, (4) troponin and (5) partial thromboplastin time. In addition, this method identified unique tests that may be a potential source of laboratory overuse at each hospital. CONCLUSIONS A simple multidimensional, data-driven approach combining cost, proportion of abnormal results and physician-level variation can inform interventions to reduce laboratory test overuse. Reducing low value laboratory testing is important to promote high value, patient-centred care.
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Affiliation(s)
- Adina S Weinerman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yishan Guo
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sudipta Saha
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Paul M Yip
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
| | - Michael Fralick
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Janice L Kwan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Thomas E MacMillan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jessica Liu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Shail Rawal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kathleen A Sheehan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Janet Simons
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, Ontario, Canada
| | - Terence Tang
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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Gleadhill C, Dooley K, Kamper SJ, Manvell N, Corrigan M, Cashin A, Birchill N, Donald B, Leyland M, Delbridge A, Barnett C, Renfrew D, Lamond S, Boettcher CE, Chambers L, Maude T, Davis J, Hodgson S, Makaroff A, Wallace JB, Kotrick K, Mullen N, Gallagher R, Zelinski S, Watson T, Davidson S, Viana Da Silva P, Mahon B, Delore C, Manvell J, Gibbs B, Hook C, Stoddard C, Meers E, Byrne M, Schneider T, Bolsewicz K, Williams CM. What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia. BMJ Open 2023; 13:e071489. [PMID: 37328182 PMCID: PMC10277099 DOI: 10.1136/bmjopen-2022-071489] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVES To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions. DESIGN We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting. SETTING Australian primary care. PARTICIPANTS Registered physiotherapists who are members of a practice-based research network (n=31). RESULTS The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application. CONCLUSION High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.
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Affiliation(s)
- Connor Gleadhill
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- New South Wales Regional Health Partners, Newcastle, New South Wales, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Katherine Dooley
- School of Health Sciences, Charles Sturt University, Albury, New South Wales, Australia
| | - Steven J Kamper
- School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- Allied Health Department, Nepean Blue Mountains Local Health District, Kingswood, New South Wales, Australia
| | - Nicole Manvell
- NUmoves Physiotherapy, Callaghan, New South Wales, Australia
| | | | - Aidan Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Noah Birchill
- Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Bruce Donald
- John Hunter Hospital Physiotherapy, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Murray Leyland
- Thornton Physiotherapy, Maitland, New South Wales, Australia
| | - Andrew Delbridge
- Regent Street Physiotherapy, New Lambton, New South Wales, Australia
| | | | - David Renfrew
- Newcastle Performance Physiotherapy, Newcastle, New South Wales, Australia
| | - Steven Lamond
- Newcastle Knights, Newcastle, New South Wales, Australia
| | - Craig Edward Boettcher
- Regent Street Physiotherapy, New Lambton, New South Wales, Australia
- Faculty of Medicine, The University of Sydney, Newcastle, New South Wales, Australia
| | - Lucia Chambers
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Travis Maude
- Advanced Physiotherapy, Warners Bay, New South Wales, Australia
| | - Jon Davis
- PhysioStudio, Maitland, New South Wales, Australia
| | - Stephanie Hodgson
- Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Andrew Makaroff
- Employers Mutual Limited, Newcastle, New South Wales, Australia
| | | | - Kelly Kotrick
- Newcastle Performance Physiotherapy, Newcastle, New South Wales, Australia
| | | | - Ryan Gallagher
- Honeysuckle Health, Newcastle, New South Wales, Australia
| | - Samuel Zelinski
- NUmoves Physiotherapy, Callaghan, New South Wales, Australia
| | - Toby Watson
- The Good Physio, Newcastle, New South Wales, Australia
| | - Simon Davidson
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Priscilla Viana Da Silva
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | | | - Caitlin Delore
- Regent Street Physiotherapy, New Lambton, New South Wales, Australia
| | - Joshua Manvell
- Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | | | - Chris Hook
- Advanced Physiotherapy, Warners Bay, New South Wales, Australia
| | - Chris Stoddard
- Terrace Physio Plus, Raymond Terrace, New South Wales, Australia
| | - Elliot Meers
- Kinetic Sports Physiotherapy, Newcastle, New South Wales, Australia
| | - Michael Byrne
- Recovery Partners, Newcastle, New South Wales, Australia
| | | | - Katarzyna Bolsewicz
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- National Centre for Immunisation Research and Surveillance, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Christopher Michael Williams
- School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- Mid North Coast Local Health District, Port Macquarie, New South Wales, Australia
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Poole MK, Lee RM, Kinderknecht KL, Kenney EL. De-implementing public health policies: a qualitative study of the process of implementing and then removing body mass index (BMI) report cards in Massachusetts public schools. Implement Sci Commun 2023; 4:63. [PMID: 37296487 DOI: 10.1186/s43058-023-00443-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND This study explored reasons for the adoption of a policy to distribute report cards to parents about children's weight status ("BMI report cards") in Massachusetts (MA) public schools in 2009 and the contextual factors influencing the policy removal in 2013. METHODS We conducted semi-structured, qualitative interviews with 15 key decision-makers and practitioners involved with implementing and de-implementing the MA BMI report card policy. We analyzed interview data using a thematic analytic approach guided by the Consolidated Framework for Implementation Research (CFIR) 2.0. RESULTS Primary themes were that (1) factors other than scientific evidence mattered more for policy adoption, (2) societal pressure spurred policy adoption, (3) problems with the policy design contributed to inconsistent implementation and dissatisfaction, and (4) media coverage, societal pressure, and organizational politics and pressure largely prompted de-implementation. CONCLUSIONS Numerous factors contributed to the de-implementation of the policy. An orderly process for the de-implementation of a policy in public health practice that manages drivers of de-implementation may not yet exist. Public health research should further focus on how to de-implement policy interventions when evidence is lacking or there is potential for harm.
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Affiliation(s)
- Mary Kathryn Poole
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
| | - Rebekka M Lee
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Kelsey L Kinderknecht
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Erica L Kenney
- Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
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Esposito S, Amirthalingam G, Bassetti M, Blasi F, De Rosa FG, Halasa NB, Hung I, Osterhaus A, Tan T, Torres JP, Vena A, Principi N. Monoclonal antibodies for prophylaxis and therapy of respiratory syncytial virus, SARS-CoV-2, human immunodeficiency virus, rabies and bacterial infections: an update from the World Association of Infectious Diseases and Immunological Disorders and the Italian Society of Antinfective Therapy. Front Immunol 2023; 14:1162342. [PMID: 37256125 PMCID: PMC10226646 DOI: 10.3389/fimmu.2023.1162342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/26/2023] [Indexed: 06/01/2023] Open
Abstract
Monoclonal antibodies (mABs) are safe and effective proteins produced in laboratory that may be used to target a single epitope of a highly conserved protein of a virus or a bacterial pathogen. For this purpose, the epitope is selected among those that play the major role as targets for prevention of infection or tissue damage. In this paper, characteristics of the most important mABs that have been licensed and used or are in advanced stages of development for use in prophylaxis and therapy of infectious diseases are discussed. We showed that a great number of mABs effective against virus or bacterial infections have been developed, although only in a small number of cases these are licensed for use in clinical practice and have reached the market. Although some examples of therapeutic efficacy have been shown, not unlike more traditional antiviral or antibacterial treatments, their efficacy is significantly greater in prophylaxis or early post-exposure treatment. Although in many cases the use of vaccines is more effective and cost-effective than that of mABs, for many infectious diseases no vaccines have yet been developed and licensed. Furthermore, in emergency situations, like in epidemics or pandemics, the availability of mABs can be an attractive adjunct to our armament to reduce the impact. Finally, the availability of mABs against bacteria can be an important alternative, when multidrug-resistant strains are involved.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Gayatri Amirthalingam
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
| | - Matteo Bassetti
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | | | - Natasha B. Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ivan Hung
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Albert Osterhaus
- Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Foundation, Hannover, Germany
| | - Tina Tan
- Division of Infectious Diseases, Feinberg School of Medicine of Northwestern University, Chicago, IL, United States
| | - Juan Pablo Torres
- Department of Pediatrics and Pediatric Surgery, Facultad de Medicina, University of Chile, Santiago, Chile
- Instituto Sistemas Complejos de Ingeniería (ISCI), Santiago, Chile
| | - Antonio Vena
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Cho HJ, Tsega S, Krouss M, Goetz C, Dunn AS, Di Capua J, Lee I, Linker AS, Makhni S, Korenstein D. Student High Value Care Initiative: a Longitudinal Model for Student-Led Implementation and Scholarship. J Gen Intern Med 2023; 38:1541-1546. [PMID: 36829048 PMCID: PMC10160281 DOI: 10.1007/s11606-023-08100-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/09/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Educating medical trainees to practice high value care is a critical component to improving quality of care and should be introduced at the beginning of medical education. AIM To create a successful educational model that provides medical students and junior faculty with experiential learning in quality improvement and mentorship opportunities, and produce effective quality initiatives. SETTING A tertiary medical center affiliated with a medical school in New York City. PARTICIPANTS First year medical students, junior faculty in hospital medicine, and a senior faculty course director. PROGRAM DESCRIPTION The Student High Value Care initiative is a longitudinal initiative comprised of six core elements: (1) project development, (2) value improvement curriculum, (3) mentorship, (4), Institutional support, (5) scholarship, and (6) student leadership. PROGRAM EVALUATION During the first 3 years, 68 medical students and ten junior faculty participated in 10 quality improvement projects. Nine projects were successful in their measured outcomes, with statistically significant improvements. Nine had an abstract accepted to a regional or national meeting, and seven produced publications in peer-reviewed literature. DISCUSSION In the first 3 years of the initiative, we successfully engaged medical students and junior faculty to create and support the implementation of successful quality improvement initiatives. Since that time, the program continues to offer meaningful mentorship and scholarship opportunities.
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Affiliation(s)
- Hyung J Cho
- New York City Health + Hospitals Corporation, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Surafel Tsega
- New York City Health + Hospitals Corporation, New York, NY, USA.
| | - Mona Krouss
- New York City Health + Hospitals Corporation, New York, NY, USA
- Division of Hospital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Celine Goetz
- Division of Hospital Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Di Capua
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Irene Lee
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anne S Linker
- Division of Hospital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sonya Makhni
- Division of Hospital Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Domenghino A, Walbert C, Birrer DL, Puhan MA, Clavien PA. Consensus recommendations on how to assess the quality of surgical interventions. Nat Med 2023; 29:811-822. [PMID: 37069361 DOI: 10.1038/s41591-023-02237-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/26/2023] [Indexed: 04/19/2023]
Abstract
Postoperative complications represent a major public health burden worldwide. Without standardized, clinically relevant and universally applied endpoints, the evaluation of surgical interventions remains ill-defined and inconsistent, opening the door for biased interpretations and hampering patient-centered health care delivery. We conducted a Jury-based consensus conference incorporating the perspectives of different stakeholders, who based their recommendations on the work of nine panels of experts. The recommendations cover the selection of postoperative outcomes from the perspective of patients and other stakeholders, comparison and interpretation of outcomes, consideration of cultural and demographic factors, and strategies to deal with unwarranted outcomes. With the recommendations developed exclusively by the Jury, we provide a framework for surgical outcome assessment and quality improvement after medical interventions, that integrates the main stakeholders' perspectives.
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Affiliation(s)
- Anja Domenghino
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | | | - Dominique Lisa Birrer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland.
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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Hanaki N, Miyata J, Yamada Y, Shiga T. Choosing Wisely® in Japanese Emergency Medicine: Nine Recommendations to Improve The Value of Health Care. J Emerg Med 2023; 64:371-379. [PMID: 37019499 DOI: 10.1016/j.jemermed.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/09/2022] [Accepted: 01/06/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND The overuse of diagnostic and therapeutic modalities has become an issue in the field of emergency medicine. The health care system of Japan aims to provide the most appropriate quality and quantity of care at the right price, while focusing on patient value. The Choosing Wisely® campaign was launched in Japan and other countries. OBJECTIVE In this article, recommendations were discussed to improve the field of emergency medicine based on the state of the Japanese health care system. METHODS The modified Delphi method, a consensus-building method, was used in this study. The final recommendations were developed by a working group of 20 medical professionals, students, and patients, consisting of members of the emergency physician electronic mailing list. RESULTS From the 80 candidates recommended and excessive actions gathered, nine recommendations were formulated after two Delphi rounds. The recommendations included the suppression of excessive behavior and the implementation of appropriate medical treatment, like rapid pain relief and the application of ultrasonography during central venous catheter placement. CONCLUSIONS This study formulated recommendations to improve the field of Japanese emergency medicine, based on the feedback of patients and health care professionals. The nine recommendations will be helpful for all people involved in emergency care in Japan because they have the potential to prevent the overuse of diagnostic and therapeutic modalities, while maintaining the appropriate quality of patient care.
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Affiliation(s)
- Nao Hanaki
- Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Jun Miyata
- Department of Island and Community Medicine, Nagasaki University Graduate School of Biomedical Sciences, Goto-shi, Nagasaki, Japan
| | - Yoshie Yamada
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Shiga
- Department of Emergency Medicine, International University of Health and Welfare, Tokyo, Otawara, Japan
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Nguyen HT, De Allegri M, Heil J, Hennigs A. Population-Level Impact of Omitting Axillary Lymph Node Dissection in Early Breast Cancer Women: Evidence from an Economic Evaluation in Germany. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:275-287. [PMID: 36409454 PMCID: PMC9676848 DOI: 10.1007/s40258-022-00771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The American College of Surgeons Oncology Group Z0011 trial showed that complete axillary lymph node dissection (cALND) did not improve survival benefits in patients with one or two tumour-involved sentinel lymph nodes and undergoing breast conservation. Still, a considerable number of the Z0011-eligible patients continue to be treated with cALND in various countries. Given the potential economic gain from implementation of the Z0011 recommendations, we quantified population-level impacts of omitting cALND among Z0011-eligible patients in clinical practice. METHODS This 2-year economic analysis adopted both the perspective of patients under statutory insurance and the societal perspective, using data collected prospectively from 179 German breast cancer units between 2008 and 2015. The estimation of cost savings and health gain relied on a single decision tree, which considered three scenarios: clinical practice at the baseline; actual implementation in routine care; and hypothetical full implementation in all eligible patients. RESULTS Data for 188,909 patients with primary breast cancer were available, 13,741 (7.3%) of whom met the Z0011 inclusion criteria. The use of cALND decreased from 94.3% in 2010 to 46.9% in 2015, resulting in a gain of 335 quality-adjusted life-years and a saving of EUR50,334,756 for the society. Had cALND been omitted in all eligible patients, the total gain would have been more than double. CONCLUSIONS The implementation of the Z0011 recommendations resulted in substantial savings and health gain in Germany. Our findings suggest that it is beneficial to introduce additional policy measures to promote further uptake of the Z0011 recommendations in clinical practice.
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Affiliation(s)
- Hoa Thi Nguyen
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany.
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg, Germany
| | - Jörg Heil
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
| | - André Hennigs
- Breast Unit, University Hospital, Heidelberg University, Heidelberg, Germany
- Breast Unit, Klinik St. Elisabeth, Heidelberg, Germany
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Di Lena É, Antoun A, Hopkins B, Barone N, Do U, Meterissian S. Sentinel lymph node biopsy in women over 70: Evaluation of rates of axillary staging and impact on adjuvant therapy in elderly women. Surgery 2023; 173:603-611. [PMID: 36372577 DOI: 10.1016/j.surg.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 09/04/2022] [Accepted: 09/10/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The 2016 Society of Surgical Oncology Choosing Wisely guidelines recommended against routine sentinel lymph node biopsy in women ≥70 years old with favorable, early-stage breast cancer, as sentinel lymph node biopsy does not decrease recurrence or mortality in these patients. This study's objective was to evaluate the use of sentinel lymph node biopsy and its effect on management in elderly patients. METHODS A retrospective analysis of female patients ≥70 years old with stage I-II, clinically node-negative, hormone-receptor positive, HER2-negative disease undergoing upfront breast cancer surgery between 2017 and 2019. Primary outcome was rate of sentinel lymph node biopsy. Secondary outcome was effect of sentinel lymph node biopsy on adjuvant therapy. RESULTS In total, 142 patients were included. Median age was 76 (interquartile range 73-81), and 71.8% underwent lumpectomy. On final pathology, 57.7% had invasive ductal carcinoma, and median tumor size was 15 mm (interquartile range 10-24.3). A total of 118 patients (83.1%) underwent sentinel lymph node biopsy; of these, 27 (22.9%) were positive for N1mi (7 patients) or N1a disease (20 patients). On multivariate regression analysis, patients undergoing sentinel lymph node biopsy were more likely to be younger (odds ratio 0.87, 95% confidence interval 0.78-0.95). The major risk factor for sentinel lymph node biopsy positivity was lymphovascular invasion (odds ratio 13.4, 95% confidence interval 4.57-40.1). Patients with sentinel lymph node biopsy positivity were more likely to receive local adjuvant radiation therapy (odds ratio 4.66, 95% confidence interval 1.49-16.8) and tended to receive more adjuvant regional radiation therapy (75.0% if sentinel lymph node biopsy positive compared with 15.3% if sentinel lymph node biopsy negative, P < .001). CONCLUSION Despite the 2016 Choosing Wisely guidelines, more than 80% of patients ≥70 years old underwent sentinel lymph node biopsy at our institution. If sentinel lymph node biopsy was positive, this is associated with over 4-fold higher rates of adjuvant radiation therapy.
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Affiliation(s)
- Élise Di Lena
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Canada; Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, Canada
| | - Alen Antoun
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Canada
| | - Brent Hopkins
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Uyen Do
- Division of Experimental Surgery, Department of Surgery, McGill University, Montreal, Canada
| | - Sarkis Meterissian
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Canada; Breast Center, McGill University Health Center, Montreal, Canada.
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Marcarian T, Obreja V, Murray K, Meltzer JS, Miller PS. Success in Supporting Early Mobility and Exercise in a Cardiothoracic Intensive Care Unit. J Nurs Adm 2023; 53:161-167. [PMID: 36821500 DOI: 10.1097/nna.0000000000001262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Early mobility contributes to improved patient outcomes and reduced hospital length of stay during acute and intensive care hospitalization. The Bedside Mobility Assessment Tool was implemented in a cardiothoracic intensive care unit during participation in a nationwide evidence-based quality improvement initiative. One outcome included a high level of mobility that was sustained over time. Using the Dynamic Sustainability Framework model, this article describes the key components that contributed to this sustained mobility performance over 4 years.
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Affiliation(s)
- Taline Marcarian
- Author Affiliations: Clinical Nurse (Drs Marcarian and Obreja), Unit Director (Murray), and Intensivist and Medical Director (Dr Meltzer), Cardiothoracic Intensive Care Unit, Ronald Reagan UCLA Medical Center; and Senior Nurse Scientist (Dr Miller), Center for Nursing Excellence, UCLA Health
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Dent J. Risk and reward in the resource deplete setting: Lessons from rural, regional and remote emergency medicine. Emerg Med Australas 2023; 35:155-156. [PMID: 36543324 DOI: 10.1111/1742-6723.14161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- James Dent
- Emergency Department, The Tweed Hospital, Tweed Heads, New South Wales, Australia
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Mavragani A, Ali I, Heisler M, Levy H, Fagerlin A, Kullgren JT. Helping Patients With Chronic Conditions Overcome Challenges of High-Deductible Health Plans: Mixed Methods Study. JMIR Form Res 2023; 7:e37596. [PMID: 36719718 PMCID: PMC9929725 DOI: 10.2196/37596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND A growing number of Americans are enrolled in high-deductible health plans (HDHPs). Enrollees in HDHPs, particularly those with chronic conditions, face high out-of-pocket costs and often delay or forgo needed care owing to cost. These challenges could be mitigated by the use of cost-conscious strategies when seeking health care, such as discussing costs with providers, saving for medical expenses, and using web-based tools to compare prices, but few HDHP enrollees engage in such cost-conscious strategies. A novel behavioral intervention could enable HDHP enrollees with chronic conditions to adopt these strategies, but it is unknown which intervention features would be most valued and used by this patient population. OBJECTIVE This study aimed to assess preferences among HDHP enrollees with chronic conditions for a novel behavioral intervention that supports the use of cost-conscious strategies when planning for and seeking health care. METHODS In an exploratory sequential mixed methods study among HDHP enrollees with chronic conditions, we conducted 20 semistructured telephone interviews and then surveyed 432 participants using a national internet survey panel. Participants were adult HDHP enrollees with diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, or asthma. The interviews and survey assessed participants' health care experiences when using HDHPs and their preferences for the content, modality, and frequency of use of a novel intervention that would support their use of cost-conscious strategies when seeking health care. RESULTS Approximately half (11/20, 55%) of the interview participants reported barriers to using cost-conscious strategies. These included not knowing where to find information and worrying that the use of cost-conscious strategies would be very time consuming. Most (18/20, 90%) interviewees who had discussed costs with providers, saved for medical expenses, or used web-based price comparison tools found these strategies to be helpful for managing their health care costs. Most (17/20, 85%) interviewees expressed interest in an intervention delivered through a website or phone app that would help them compare prices for services at different locations. Survey participants were most interested in learning to compare prices and quality, followed by discussing costs with their providers and putting aside money for care, through a website-based or email-based intervention that they would use a few times a year. CONCLUSIONS Regular use of cost-conscious strategies could mitigate financial barriers faced by HDHP enrollees with chronic conditions. Interventions to encourage the use of cost-conscious strategies should be delivered through a web-based modality and focus on helping these patients in navigating their HDHPs to better manage their out-of-pocket spending.
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Affiliation(s)
| | - Iman Ali
- University of Michigan, Ann Arbor, MI, United States
| | - Michele Heisler
- University of Michigan, Ann Arbor, MI, United States.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Helen Levy
- University of Michigan, Ann Arbor, MI, United States
| | - Angela Fagerlin
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT, United States.,University of Utah, Salt Lake City, UT, United States
| | - Jeffrey T Kullgren
- University of Michigan, Ann Arbor, MI, United States.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, United States
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Villela-Nogueira CA, Ferraz MLG, Pessoa MG, Souto FJD, Nabuco LC, Coelho HSM, Ridruejo E, Silva M, Bittencourt PL, Brandão-Mello CE. Choosing wisely recommendations regarding the top five list of procedures to avoid in the treatment of viral hepatitis: A position statement from the Brazilian Society of Hepatology endorsed by the Latin American Association for the Study of the liver. Ann Hepatol 2023; 28:100764. [PMID: 36182033 DOI: 10.1016/j.aohep.2022.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/25/2022] [Accepted: 09/09/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES The Choosing Wisely (CW) initiative aims to improve daily practice supported by evidence concerning unnecessary medical tests, procedures, and treatments. This philosophy is essential in managing viral hepatitis (VH), which primary care physicians increasingly carry out. It is also essential to achieving disease elimination. Thus, the aim of our study was to propose evidence-based CW recommendations in VH. MATERIALS AND METHODS The Brazilian Society of Hepatology (SBH) formed a panel of experts in VH who selected evidence-based CW recommendations, which were subsequently scrutinized and ranked by all members of SBH using a web-based approach. RESULTS Five recommendations were chosen in order of importance: 1) do not order anti-HCV testing after achieving sustained virological response; 2) do not request serial HCV viral load to evaluate HCV progression, 3) do not add ribavirin to direct-acting antivirals in non-cirrhotic, naïve HCV patients; 4) do not screen for hepatocellular carcinoma in HCV patients with none to moderate fibrosis (≤ F2); 5) do not request anti-HBs after HBV vaccination, except for children born to HBV-infected mothers, hemodialysis patients, healthcare professionals, people who have had sexual contact with chronic HBV carriers, HIV-positive persons and immunocompromised individuals (hematopoietic stem-cell transplant recipients or persons receiving chemotherapy). CONCLUSIONS CW recommendations may help general practitioners adopt a more rational and cost-effective approach in managing patients with VH in Brazil and Latin America, leading to lesser waste or harm to patients.
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Affiliation(s)
- Cristiane A Villela-Nogueira
- Faculdade de Medicina, Departamento de Clínica Médica e Serviço de Hepatologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brazil.
| | | | - Mário Guimarães Pessoa
- Divisão de Gastroenterologia e Hepatologia, Hospital das Clínicas da Universidade de São Paulo, Brazil
| | - Francisco José Dutra Souto
- Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Mato Grosso, Mato Grosso, Brazil
| | - Letícia Cancella Nabuco
- Serviço de Hepatologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - Henrique Sérgio Moraes Coelho
- Faculdade de Medicina, Departamento de Clínica Médica e Serviço de Hepatologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - Ezequiel Ridruejo
- Sección Hepatologia, Departamento de Medicina, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, "CEMIC", Ciudad Autónoma de Buenos Aires, Argentina
| | - Marcelo Silva
- Departamento de Desarollo Académico del Hospital Universitário Austral, Buenos Aires, Argentina
| | | | - Carlos Eduardo Brandão-Mello
- Hospital Universitário Gaffrée e Guinle, Escola de Medicina e Cirurgia da Universidade do Rio de Janeiro, Brazil
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Trapani S, Montemaggi A, Indolfi G. Choosing Wisely in pediatric healthcare: A narrative review. Front Pediatr 2023; 10:1071088. [PMID: 36704146 PMCID: PMC9871764 DOI: 10.3389/fped.2022.1071088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Background It has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment. Methods In this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare. Results To date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe. Discussion We reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.
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Affiliation(s)
- Sandra Trapani
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Giuseppe Indolfi
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department NEUROFARBA, University of Florence, Florence, Italy
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Wahidi MM, Haywood H, Bass GD, Nathanson I, Chowdhury A, Sangvai DG. Value-Based Care for Chest Physicians. Chest 2023; 163:1193-1200. [PMID: 36627080 DOI: 10.1016/j.chest.2022.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 01/08/2023] Open
Abstract
Value-based care aims to improve the health outcomes of patients, eliminate waste and unwarranted clinical variation, and reduce the total cost of care. Professional medical societies have put forward guidelines to raise awareness on unproven practice patterns (Choosing Wisely Campaign), and payers have sought to replace the traditional fee-for-service payment models with value-based contracts that share financial gains or losses based on achieving high-quality outcomes and lowering the cost of care. Regardless of whether their practices are engaged in value-based arrangements, chest physicians should seek understanding of these principles, participate in designing and implementing practical and impactful high-value initiatives in their practices, and have a national voice on the path forward.
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Affiliation(s)
| | | | - Geoffrey D Bass
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Zhuang T, Shapiro LM, Schultz EA, Truong NM, Harris AHS, Kamal RN. Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline? J Hand Surg Am 2023; 48:19-27. [PMID: 36460552 DOI: 10.1016/j.jhsa.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG. METHODS Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release. RESULTS Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to -0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by -23.57 per 1,000 patients (95% CI, -37.72 to -9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG. CONCLUSIONS The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS. CLINICAL RELEVANCE Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.
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Affiliation(s)
- Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Emily A Schultz
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Nicole M Truong
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Alex H S Harris
- Department of Surgery, Stanford University, Redwood City, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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Khan M, Thompson J, Kiiskila L, Oboh O, Truong T, Prentice A, Assifi MM, Chung M, Wright GP. Timing and necessity of staging imaging in clinical stage II cutaneous melanoma: Cost-effectiveness and clinical decision analysis. Am J Surg 2023; 225:93-98. [PMID: 36400601 DOI: 10.1016/j.amjsurg.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 10/02/2022] [Accepted: 10/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Preoperative imaging in clinical stage II melanoma is not indicated per National Comprehensive Cancer Network (NCCN) guidelines but remains common in clinical practice. METHODS Patients presenting with cutaneous clinical stage II melanoma from 2007 to 2019 were retrospectively reviewed. A clinical decision analysis with cost data was designed to understand ideal practice patterns in managing stage II melanoma, with pre-versus selective post-operative imaging as the initial decision node. RESULTS There were 277 subjects included, and 143 underwent preoperative imaging (49.5%). This changed management (i.e. no surgery) in one patient (0.4%). Overall, 16 patients had additional findings on imaging (5.8%). Upfront surgery with selective postoperative imaging was a more cost-effective strategy than routine performance of preoperative imaging, with savings of $1677 per patient. CONCLUSION Preoperative imaging is a low yield, costly approach for patients with clinical stage II melanoma with minimal impact on the decision to proceed with surgical management.
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Affiliation(s)
- Mariam Khan
- Spectrum Health General Surgery Residency Program, 100 Michigan St. NE, Grand Rapids, MI, USA, 49503.
| | - Jessica Thompson
- Spectrum Health General Surgery Residency Program, 100 Michigan St. NE, Grand Rapids, MI, USA, 49503.
| | - Lindsey Kiiskila
- Department of Surgery, Michigan State University College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, USA, 49503.
| | - Oselenonome Oboh
- Department of Surgery, Michigan State University College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, USA, 49503.
| | - Thao Truong
- Department of Surgery, Michigan State University College of Human Medicine, 15 Michigan St. NE, Grand Rapids, MI, USA, 49503.
| | - Anthony Prentice
- Spectrum Health Department of Nursing, Surgical Services, 100 Michigan St. NE, Grand Rapids, MI, USA, 49503.
| | - M Mura Assifi
- Division of Surgical Oncology, Spectrum Health Medical Group, 145 Michigan St. NE Suite 5500, Grand Rapids, MI, USA, 49503.
| | - Mathew Chung
- Division of Surgical Oncology, Spectrum Health Medical Group, 145 Michigan St. NE Suite 5500, Grand Rapids, MI, USA, 49503.
| | - G Paul Wright
- Division of Surgical Oncology, Spectrum Health Medical Group, 145 Michigan St. NE Suite 5500, Grand Rapids, MI, USA, 49503.
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The impact of performance feedback reports on physician ordering behavior in the use of computed tomography pulmonary angiography (CTPA). Emerg Radiol 2023; 30:63-69. [PMID: 36378395 PMCID: PMC9664050 DOI: 10.1007/s10140-022-02100-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The increased utilization, and potential overutilization, of computed tomography pulmonary angiography (CTPA) is a well-recognized issue within emergency departments (EDs). The objective of this study is to determine the impact of performance feedback reports on CTPA ordering behavior among ED physicians. METHODS We conducted a prospective study of the impact of individualized performance feedback reports on the ordering behavior of physicians working at two high-volume community EDs in Ontario, Canada. We generated individualized reports (or "Dashboards") for each ED physician containing detailed feedback and peer comparison for each physician's CTPA ordering. Our baseline pre-intervention period was January 1 to December 31, 2018, and our intervention period was January 1, 2019, to December 31, 2021. We tracked individual and group ordering behavior through the study period. Our primary outcomes are impact of feedback on (1) overall group ordering rate and (2) overall diagnostic yield. Secondary analysis was done to determine the impact of the intervention on those physicians with the highest CTPA utilization rate. RESULTS There was no statistically significant difference in the diagnostic yield of the included physicians in either of the years of the intervention period. There was a statically significant increase in the utilization rate for CTPA from 2018 to 2020 and 2021 from 5.9 to 7.9 and 11.4 CTPAs per 1000 ED visits respectively (p < 0.5). CONCLUSION Our study found no consistent significant impact of individualized feedback and peer comparison on physician ordering of CTPAs. This points to a potentially greater impact of environmental and institutional factors, as opposed to physician-targeted quality improvement measures, on physician ordering behavior.
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