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Yagi R, Mori Y, Goto S, Iwami T, Inoue K. Routine Electrocardiogram Screening and Cardiovascular Disease Events in Adults. JAMA Intern Med 2024; 184:1035-1044. [PMID: 38949831 PMCID: PMC11217891 DOI: 10.1001/jamainternmed.2024.2270] [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] [Received: 12/26/2023] [Accepted: 04/16/2024] [Indexed: 07/02/2024]
Abstract
Importance The resting electrocardiogram (ECG) is commonly performed for cardiovascular disease (CVD) screening purposes in Japan. However, evidence is limited regarding the prognostic significance of ECG in clinical practice settings. Objective To investigate the association between ECG abnormalities and CVD outcomes in a working-age population. Design, Setting, and Participants This nationwide cohort study included individuals aged 35 to 65 years from the Japan Health Insurance Association database, which covers approximately 40% (30 million) of the working-age population in Japan. Data from April 1, 2015, to March 31, 2022, were included, and analysis was conducted from October 1, 2022, to April 11, 2024. Exposures Baseline ECG status (normal, 1 minor abnormality, ≥2 minor abnormalities, or major abnormality). Main Outcomes and Measures The primary outcome was a composite of overall death and CVD hospital admission due to myocardial infarction, stroke, or heart failure. The secondary outcome was developing a new major ECG abnormality over the years of screening. Results Of 3 698 429 individuals enrolled in the nationwide annual health check program (mean [SD] age, 47.1 [8.5] years; 66.6% male), 623 073 (16.8%) had 1 minor ECG abnormality, 144 535 (3.9%) had 2 or more minor ECG abnormalities, and 56 921 (1.5%) had a major ECG abnormality. During a median follow-up of 5.5 (IQR, 3.4-5.7) years, baseline ECG abnormality was independently associated with an increased incidence of the composite end points of overall death and CVD admission compared with normal ECG (incidence rates per 10 000 person-years: 92.7 [95% CI, 92.2-93.2] for normal ECG, 128.5 [95% CI, 127.2-129.9] for 1 minor ECG abnormality, 159.7 [95% CI, 156.6-162.9] for ≥2 minor ECG abnormalities, and 266.3 [95% CI, 259.9-272.3] for a major ECG abnormality; adjusted hazard ratios: 1.19 [95% CI, 1.18-1.20] for 1 minor ECG abnormality, 1.37 [95% CI, 1.34-1.39] for ≥2 minor ECG abnormalities, and 1.96 [95% CI, 1.92-2.02] for a major ECG abnormality). Furthermore, the presence and number of minor ECG abnormalities were associated with an increased incidence of developing new major ECG abnormalities (incidence rates per 10 000 person-years: 85.1 [95% CI, 84.5-85.5] for normal ECG, 217.2 [95% CI, 215.5-219.0] for 1 minor ECG abnormality, and 306.4 [95% CI, 302.1-310.7] for ≥2 minor ECG abnormalities; and adjusted hazard ratios: 2.52 [95% CI, 2.49-2.55] for 1 minor ECG abnormality and 3.61 [95% CI, 3.55-3.67] for ≥2 minor ECG abnormalities). Associations were noted regardless of baseline CVD risk. Conclusions and Relevance The findings of this study suggest that the potential role of routine ECG screening for early prevention of CVD events, along with the optimal follow-up strategy, should be examined in future studies.
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Affiliation(s)
- Ryuichiro Yagi
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Yuichiro Mori
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Goto
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of General Internal Medicine & Family Medicine, Department of General and Acute Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Taku Iwami
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Kosuke Inoue
- Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
- Hakubi Center for Advanced Research, Kyoto University, Kyoto, Japan
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Ambasta A, Holroyd-Leduc JM, Pokharel S, Mathura P, Shih AWY, Stelfox HT, Ma I, Harrison M, Manns B, Faris P, Williamson T, Shukalek C, Santana M, Omodon O, McCaughey D, Kassam N, Naugler C. Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization. Implement Sci 2024; 19:45. [PMID: 38956637 PMCID: PMC11221016 DOI: 10.1186/s13012-024-01376-6] [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: 04/29/2024] [Accepted: 06/23/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada. METHODS We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes. DISCUSSION The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work. TRIAL REGISTRATION This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic. CLINICALTRIALS gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.
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Affiliation(s)
- Anshula Ambasta
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- Department of Anesthesia, Pharmacology and Therapeutics, Therapeutics Initiative, University of British Columbia, Vancouver, V6T 1Z4, Canada.
| | - Jayna M Holroyd-Leduc
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Surakshya Pokharel
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Pamela Mathura
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Andrew Wei-Yeh Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Henry T Stelfox
- Faculty of Medicine and Dentistry, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Irene Ma
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Braden Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Caley Shukalek
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Maria Santana
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Onyebuchi Omodon
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Deirdre McCaughey
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Narmin Kassam
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Chris Naugler
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
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Kuo YC, Lin KC, Tan ECH. Discrepancies Among Hospitals and Regions in the Provision of Low-Value Care. Int J Health Policy Manag 2024; 13:7876. [PMID: 38618842 PMCID: PMC11270608 DOI: 10.34172/ijhpm.2024.7876] [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: 12/10/2022] [Accepted: 03/16/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Low-value care (LVC) is a critical issue in terms of patient safety and fiscal policy; however, little has been known in Asia. For the purpose of better understanding the extent of LVC on a national level, the utilization, costs, and associated characteristics of selected international recommendations were assessed in this study. METHODS This retrospective cohort study used the National Health Insurance (NHI) claims data during 2013-2017 to evaluate the LVC utilization. Adult beneficiaries who enrolled in the NHI program and received at least one of the low-value services in hospitals were included. We measured seven procedures derived from the international recommendations at the hospital level, and a composite measure was created by summing the total utilization of selected services to determine the overall prevalence and corresponding cost. The generalized estimating equation (GEE) model was adopted to estimate the association. RESULTS A total of 1 970 496 episodes of LVC was identified among 1 218 146 beneficiary-year observations and 2054 hospital-year observations. Overall, the utilization rate of the composite measure increased from 150.70 to 186.23 episodes per 10 000 beneficiaries with the growth in cost from US$ 5.40 to US$ 6.90 million. LVC utilization was proportional to the volume of outpatient visits and length of stay. Also, hospitals with a large volume of outpatient visits (adjusted odds ratio [aOR]: 95% CI, 2.10: 1.26 to 3.49 for Q2-Q3, 2.88: 1.45 to 5.75 for ≥Q3) and a higher proportion of older patients (aOR: 95% CI, 1.06: 1.02 to 1.11) were more likely to have high costs. CONCLUSION The utilization and corresponding cost of LVC appeared to increase annually despite the relatively lower prevalence compared to other countries. Multicomponent interventions such as recommendations, de-implementation policies and payment reforms are considered effective ways to reduce LVC. Repeated measurements would be needed to evaluate the effectiveness of interventions.
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Affiliation(s)
- Yu-Chen Kuo
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuan-Chia Lin
- Community Medicine Research Center, Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Elise Chia-Hui Tan
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung, Taiwan
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Kamel MA, Abbas MT, Kanaan CN, Awad KA, Baba Ali N, Scalia IG, Farina JM, Pereyra M, Mahmoud AK, Steidley DE, Rosenthal JL, Ayoub C, Arsanjani R. How Artificial Intelligence Can Enhance the Diagnosis of Cardiac Amyloidosis: A Review of Recent Advances and Challenges. J Cardiovasc Dev Dis 2024; 11:118. [PMID: 38667736 PMCID: PMC11050851 DOI: 10.3390/jcdd11040118] [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: 02/29/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed form of infiltrative cardiomyopathy caused by abnormal amyloid fibrils deposited extracellularly in the myocardium and cardiac structures. There can be high variability in its clinical manifestations, and diagnosing CA requires expertise and often thorough evaluation; as such, the diagnosis of CA can be challenging and is often delayed. The application of artificial intelligence (AI) to different diagnostic modalities is rapidly expanding and transforming cardiovascular medicine. Advanced AI methods such as deep-learning convolutional neural networks (CNNs) may enhance the diagnostic process for CA by identifying patients at higher risk and potentially expediting the diagnosis of CA. In this review, we summarize the current state of AI applications to different diagnostic modalities used for the evaluation of CA, including their diagnostic and prognostic potential, and current challenges and limitations.
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Affiliation(s)
- Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | | | - Kamal A. Awad
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Nima Baba Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - D. Eric Steidley
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Julie L. Rosenthal
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
- Division of Cardiovascular Imaging, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
- Division of Cardiovascular Imaging, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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5
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Pappas MA, Auerbach AD, Kattan MW, Blackstone EH, Rothberg MB, Sessler DI. Consequences of preoperative cardiac stress testing-A cohort study. J Clin Anesth 2023; 90:111158. [PMID: 37418830 PMCID: PMC10530324 DOI: 10.1016/j.jclinane.2023.111158] [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: 01/31/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery. DESIGN A retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018. SETTING A large integrated health system. PATIENTS Patients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery. MEASUREMENTS To assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality. MAIN RESULTS In causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1-12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8-9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9-9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75-0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1-33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses. CONCLUSIONS Preoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced.
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Affiliation(s)
- Matthew A Pappas
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America.
| | - Andrew D Auerbach
- Department of Hospital Medicine, University of California, San Francisco, CA, United States of America
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Eugene H Blackstone
- Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, United States of America; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Segar MW, Keshvani N, Pandey A. From prediction to prevention: The role of heart failure risk models: Heart to Heart: The Promise and Pitfalls of Heart Failure Risk Prediction Models. Eur J Heart Fail 2023; 25:1739-1741. [PMID: 37702311 DOI: 10.1002/ejhf.3034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Affiliation(s)
- Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Ambasta A, Omodon O, Herring A, Ferrie L, Pokharel S, Mehta A, Liu L, Hews-Girard J, Tam C, Taylor S, Lonergan K, Faris P, Duncan D, Woodhouse D. Repurposing the Ordering of Routine Laboratory Tests in Hospitalised Medical Patients (RePORT): results of a cluster randomised stepped-wedge quality improvement study. BMJ Qual Saf 2023; 32:517-525. [PMID: 37164639 DOI: 10.1136/bmjqs-2022-015611] [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: 10/05/2022] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Low-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients. METHODS We used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020-June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat. RESULTS We included a total of 125 854 patient-days. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=-0.14, 95% CI -0.07 to -0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention. CONCLUSIONS A multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results.
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Affiliation(s)
- Anshula Ambasta
- Medicine, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Onyebuchi Omodon
- Ward of the 21st Century, University of Calgary Cumming School of Medicine, Calgary, Canada
| | | | - Leah Ferrie
- Physician Learning Program, University of Calgary, Calgary, Canada
| | | | - Ashi Mehta
- Health Quality Council of Alberta, Calgary, Canada
| | | | | | - Cheuk Tam
- Medicine, University of Calgary Faculty of Medicine, Calgary, Canada
| | - Simon Taylor
- Medicine, University of Calgary, Calgary, Canada
| | | | - Peter Faris
- Measurement and Analysis; Research Excellence Support Team, Alberta Bone and Joint Health Institute; Alberta Health Services, Calgary, Canada
| | - Diane Duncan
- Physician Learning Program, University of Calgary, Calgary, Canada
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Aras MA, Abreau S, Mills H, Radhakrishnan L, Klein L, Mantri N, Rubin B, Barrios J, Chehoud C, Kogan E, Gitton X, Nnewihe A, Quinn D, Bridges C, Butte AJ, Olgin JE, Tison GH. Electrocardiogram Detection of Pulmonary Hypertension Using Deep Learning. J Card Fail 2023; 29:1017-1028. [PMID: 36706977 PMCID: PMC10363571 DOI: 10.1016/j.cardfail.2022.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/23/2022] [Accepted: 12/25/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is life-threatening, and often diagnosed late in its course. We aimed to evaluate if a deep learning approach using electrocardiogram (ECG) data alone can detect PH and clinically important subtypes. We asked: does an automated deep learning approach to ECG interpretation detect PH and its clinically important subtypes? METHODS AND RESULTS Adults with right heart catheterization or an echocardiogram within 90 days of an ECG at the University of California, San Francisco (2012-2019) were retrospectively identified as PH or non-PH. A deep convolutional neural network was trained on patients' 12-lead ECG voltage data. Patients were divided into training, development, and test sets in a ratio of 7:1:2. Overall, 5016 PH and 19,454 patients without PH were used in the study. The mean age at the time of ECG was 62.29 ± 17.58 years and 49.88% were female. The mean interval between ECG and right heart catheterization or echocardiogram was 3.66 and 2.23 days for patients with PH and patients without PH, respectively. In the test dataset, the model achieved an area under the receiver operating characteristic curve, sensitivity, and specificity, respectively of 0.89, 0.79, and 0.84 to detect PH; 0.91, 0.83, and 0.84 to detect precapillary PH; 0.88, 0.81, and 0.81 to detect pulmonary arterial hypertension, and 0.80, 0.73, and 0.76 to detect group 3 PH. We additionally applied the trained model on ECGs from participants in the test dataset that were obtained from up to 2 years before diagnosis of PH; the area under the receiver operating characteristic curve was 0.79 or greater. CONCLUSIONS A deep learning ECG algorithm can detect PH and PH subtypes around the time of diagnosis and can detect PH using ECGs that were done up to 2 years before right heart catheterization/echocardiogram diagnosis. This approach has the potential to decrease diagnostic delays in PH.
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Affiliation(s)
- Mandar A Aras
- UCSF Department of Medicine, Division of Cardiology, San Francisco, California
| | - Sean Abreau
- UCSF Department of Medicine, Division of Cardiology, San Francisco, California
| | - Hunter Mills
- Bakar Computation Health Sciences Institute, University of California, San Francisco, San Francisco, California
| | - Lakshmi Radhakrishnan
- Bakar Computation Health Sciences Institute, University of California, San Francisco, San Francisco, California
| | - Liviu Klein
- UCSF Department of Medicine, Division of Cardiology, San Francisco, California
| | - Neha Mantri
- UCSF Department of Medicine, Division of Cardiology, San Francisco, California
| | - Benjamin Rubin
- Bakar Computation Health Sciences Institute, University of California, San Francisco, San Francisco, California
| | - Joshua Barrios
- UCSF Department of Medicine, Division of Cardiology, San Francisco, California
| | | | - Emily Kogan
- Janssen Pharmaceuticals, Inc, Raritan, New Jersey
| | - Xavier Gitton
- Actelion Pharmaceuticals Ltd., Allschwil, Switzerland
| | | | | | | | - Atul J Butte
- Bakar Computation Health Sciences Institute, University of California, San Francisco, San Francisco, California
| | - Jeffrey E Olgin
- UCSF Department of Medicine, Division of Cardiology, San Francisco, California
| | - Geoffrey H Tison
- UCSF Department of Medicine, Division of Cardiology, San Francisco, California; Bakar Computation Health Sciences Institute, University of California, San Francisco, San Francisco, California; Division of Cardiology, Department of Medicine and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California.
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9
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Udell JA, Brickman AR, Chu A, Ferreira-Legere LE, Sheth MS, Ko DT, Austin PC, Abdel-Qadir H, Ivers NM, Bhatia RS, Farkouh ME, Stukel TA, Tu JV. Primary Care Clinical Volumes, Cholesterol Testing, and Cardiovascular Outcomes. Can J Cardiol 2023; 39:340-349. [PMID: 36574928 DOI: 10.1016/j.cjca.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 12/07/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND It is unknown whether the annual number of primary care physician (PCP) unique outpatient assessments, which we refer to as clinical volume, translates into better cardiovascular preventive care. We examined the relationship between PCP outpatient clinical volumes and cholesterol testing and major adverse cardiovascular event rates among guideline-recommended eligible patients. METHODS This was a retrospective cohort study conducted as part of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, a population-based cohort of almost all adult residents of Ontario, Canada, followed from 2008 to 2012. For each clinical volume quintile, we compared cholesterol testing and major adverse cardiovascular events, defined as time to first event of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. RESULTS The 10,037 PCPs evaluated had an annualized median volume of 2303 clinical encounters (IQR 1292-3680). Among 4,740,380 patients, 84% underwent guideline-concordant cholesterol testing at least once over 5 years, ranging from 73% with the lowest clinical volume quintile physicians to 86% with the highest. After multivariable adjustment, there was a 10.5% relative increase in the probability of cholesterol testing for every doubling of clinical volumes (95% CI 9.7-11.4; P < 0.001). Patients treated by the lowest volume quintile physicians had the highest rate of major adverse cardiovascular outcomes (compared with the highest volume quintile physicians: adjusted HR 1.15, 95% CI 1.10-1.21; P < 0.001). CONCLUSIONS Patients of physicians with the lowest clinical volumes received less frequent cholesterol testing and had the highest rate of incident cardiovascular events. Further research investigating the drivers of this relationship is warranted.
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Affiliation(s)
- Jacob A Udell
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Arielle R Brickman
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | | | | | - Maya S Sheth
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Family Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Thérèse A Stukel
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jack V Tu
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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10
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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Oakes AH, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within the Veterans Health Administration. J Gen Intern Med 2023; 38:285-293. [PMID: 35445352 PMCID: PMC9905526 DOI: 10.1007/s11606-022-07561-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/31/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Low-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA). OBJECTIVE To examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery. DESIGN Retrospective cohort study using VHA administrative data from fiscal years 2017-2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not. PARTICIPANTS National cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery. MAIN MEASURES Difference in rate of receipt and attributed cost of potential cascade services in Veterans who underwent low-value preoperative testing compared to those who did not KEY RESULTS: Among 635,824 Veterans undergoing low-risk procedures, 7.8% underwent preoperative EKG. Veterans who underwent a preoperative EKG experienced an additional 52.4 (95% CI 47.7-57.2) cascade services per 100 Veterans, resulting in $138.28 (95% CI 126.19-150.37) per Veteran in excess costs. Among 739,005 Veterans undergoing low- or intermediate-risk surgery, 3.9% underwent preoperative CXR. These Veterans experienced an additional 61.9 (95% CI 57.8-66.1) cascade services per 100 Veterans, resulting in $152.08 (95% CI $146.66-157.51) per Veteran in excess costs. For both cohorts, care cascades consisted largely of repeat tests, follow-up imaging, and follow-up visits, with low rates invasive services. CONCLUSIONS Among a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service. These findings may guide de-implementation policies within VHA and other integrated healthcare systems that target those services whose downstream effects are most prevalent and costly.
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Affiliation(s)
- Aimee N Pickering
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center (HERC), VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Aaron L Schwartz
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy and Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Allison H Oakes
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Enterprise Health Services Research, Enterprise Analytics Hub, Anthem Inc., Wilmington, DE, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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11
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Tsai DJ, Lou YS, Lin CS, Fang WH, Lee CC, Ho CL, Wang CH, Lin C. Mortality risk prediction of the electrocardiogram as an informative indicator of cardiovascular diseases. Digit Health 2023; 9:20552076231187247. [PMID: 37448781 PMCID: PMC10336769 DOI: 10.1177/20552076231187247] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Background The electrocardiogram (ECG) may be the most popular test in the management of cardiovascular disease (CVD). Although wide applications of artificial intelligence (AI)-enabled ECG have been developed, an integrating indicator for CVD risk stratification was not investigated. Since mortality may be the most important global outcome, this study aimed to develop a survival deep learning model (DLM) to establish a critical ECG value and explore the associations with various CVD events. Methods We trained a DLM with 451,950 12-lead resting ECGs obtained from 210,552 patients, for whom 23,592 events occurred. The internal validation set included 27,808 patients with one ECG for each patient. The external validations were performed in a community hospital with 33,047 patients and two transnational data sets with 233,647 and 1631 ECGs. We distinguished the cause of mortality and additionally investigated CVD-related outcomes, including new-onset acute myocardial infarction (AMI), stroke (STK), and heart failure (HF). Results The DLM achieved C-indices of 0.858/0.836 in internal/external validation sets by using ECG over a 10-year period. The high-mortality-risk group identified by the proposed DLM presented a hazard ratio (HR) of 14.16 (95% confidence interval (CI): 11.33-17.70) compared to the low-risk group in the internal validation and presented a higher risk of cardiovascular (CV) mortality (HR: 18.50, 95% CI: 9.82-34.84), non-CV mortality (HR: 13.68, 95% CI: 10.76-17.38), AMI (HR: 4.01, 95% CI: 2.24-7.17), STK (HR: 2.15, 95% CI: 1.70-2.72), and HF (HR: 6.66, 95% CI: 4.54-9.77), which was consistent in an independent community hospital. The transnational validation also revealed HRs of 4.91 (95% CI: 2.63-9.16) and 2.29 (95% CI: 2.15-2.44) for all-cause mortality in the SaMi-Trop and Clinical Outcomes in Digital Electrocardiography 15% (CODE15) cohorts. Conclusions The mortality risk by AI-enabled ECG may be applied in passive electronic-health-record-based CVD risk screening, which may identify more asymptomatic and unaware high-risk patients.
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Affiliation(s)
- Dung-Jang Tsai
- Department of Statistics and Information Science, Fu Jen Catholic University, New Taipei City
- Artificial Intelligence of Things Center, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Graduate Institutes of Life Sciences, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei
| | - Yu-Sheng Lou
- Artificial Intelligence of Things Center, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Graduate Institutes of Life Sciences, Tri-Service General Hospital, National Defense Medical Center, Taipei
- School of Public Health, National Defense Medical Center, Taipei
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Wen-Hui Fang
- Department of Family and Community Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chia-Cheng Lee
- Medical Informatics Office, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Ching-Liang Ho
- Division of Hematology and Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chih-Hung Wang
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei
| | - Chin Lin
- Artificial Intelligence of Things Center, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Graduate Institutes of Life Sciences, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei
- School of Public Health, National Defense Medical Center, Taipei
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12
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Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. METHOD: A scoping review was conducted according to recommendations outlined by Arksey and O'Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. RESULTS The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. CONCLUSIONS Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J. Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO USA
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
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13
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Welch JM, Zhuang T, Shapiro LM, Harris AHS, Baker LC, Kamal RN. Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clin Orthop Relat Res 2022; 480:1851-1862. [PMID: 35608508 PMCID: PMC9473771 DOI: 10.1097/corr.0000000000002255] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use. QUESTIONS/PURPOSES (1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not? METHODS In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use. RESULTS When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually. CONCLUSION Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Jessica M. Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | | | - Alex H. S. Harris
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Laurence C. Baker
- Department of Health Research Policy, Stanford University, Stanford, CA, USA
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
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14
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Roberts DJ, Sypes EE, Nagpal SK, Niven D, Mamas M, McIsaac DI, van Walraven C, Shorr R, Graham ID, Stelfox HT, Grimshaw J. Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e053920. [PMID: 35393307 PMCID: PMC8991042 DOI: 10.1136/bmjopen-2021-053920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Overuse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system inefficiencies and costs. We seek to systematically review the evidence for overuse of different cardiovascular healthcare services in high-income countries. METHODS AND ANALYSIS We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2010 onwards. Two investigators will independently review titles and abstracts and full-text studies. We will include published English-language studies conducted in high-income countries that enrolled adults (mean/median age ≥18 years) and reported the incidence or prevalence of overuse of cardiovascular tests, medications or procedures; adjusted risk factors for overuse; or adjusted associations between overuse and outcomes (reported estimates of morbidity, mortality, costs or lengths of hospital stay). Acceptable methods of defining low-value care will include literature review and multidisciplinary iterative panel processes, healthcare services with reproducible evidence of a lack of benefit or harm, or clinical practice guideline or Choosing Wisely recommendations. Two investigators will independently extract data and evaluate study risk of bias in duplicate. We will calculate summary estimates of the incidence and prevalence of overuse of different cardiovascular healthcare services across studies unstratified and stratified by country; method of defining low-value care; the percentage of included females, different races, and those with low and high socioeconomic status or cardiovascular risk; and study risks of bias using random-effects models. We will also calculate pooled estimates of adjusted risk factors for overuse and adjusted associations between overuse and outcomes overall and stratified by country using random-effects models. We will use the Grading of Recommendations, Assessment, Development and Evaluation to determine certainty in estimates. ETHICS AND DISSEMINATION No ethics approval is required for this study as it deals with published data. Results will be presented at meetings and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021257490.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Daniel I McIsaac
- Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carl van Walraven
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeremy Grimshaw
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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15
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Piessens V, Delvaux N, Heytens S, Aertgeerts B, De Sutter A. Downstream activities after laboratory testing in primary care: an exploratory outcome of the ELMO cluster randomised trial (Electronic Laboratory Medicine Ordering with evidence-based order sets in primary care). BMJ Open 2022; 12:e059261. [PMID: 35379642 PMCID: PMC8981323 DOI: 10.1136/bmjopen-2021-059261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To estimate the rate and type of downstream activities (DAs) after laboratory testing in primary care, with a specific focus on check-up laboratory panels, and to explore the effect of a clinical decision support system (CDSS) for laboratory ordering on these DAs. DESIGN Cluster randomised clinical trial. SETTING 72 primary care practices in Belgium, with 272 general practitioners (GPs), randomly assigned to the intervention arm or the control arm. PARTICIPANTS The study included 10 270 lab panels from 9683 primary care patients (women 55.1%, mean age 56.5). All adult patients who consulted one of the participating GPs during the trial period and needed a laboratory exam were eligible for participation. INTERVENTIONS GPs in the intervention group used a CDSS integrated into their online laboratory ordering system, while GPs in the control arm used their lab ordering system as usual. The trial duration was 6 months, with another 6 months follow-up. MAIN OUTCOME MEASURES This publication reports on the exploratory outcome of DAs after an initial laboratory exam and the effect of the CDSS on these DAs. RESULTS 19.7% of all laboratory panels resulted in further diagnostic procedures (95% CI 18.9% to 20.5%) and 19% (95% CI 18.2% to 19.7%) in treatment changes. Check-up laboratory exams showed similar rates of DAs, with 17.5% (95% CI 13.8% to 21.2%) diagnostic DAs and 18.9% (95% CI 13.9% to 23.9%) treatment changes. Using the CDSS resulted in a significant reduction in downstream referrals (-2.4%; 95% CI -4.2% to -0.6%; p=0008), imaging and endoscopies (-0.9%; 95% CI -1.6% to -0.1%; p=0026) and treatment changes (-5.4%; 95% CI -9.5% to -1.2%; p=0.01). CONCLUSION This is the largest study so far to examine DAs after laboratory testing. It shows that almost one in three laboratory exams leads to further DAs, even in check-up panels. Using a CDSS for laboratory orders may reduce the rate of some DAs. TRIAL REGISTRATION NUMBER NCT02950142.
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Affiliation(s)
- Veerle Piessens
- Public Health and Primary Care, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
| | | | - Stefan Heytens
- Public Health and Primary Care, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
| | | | - An De Sutter
- Public Health and Primary Care, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
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Bandovas JP, Leal B, Reis-de-Carvalho C, Sousa DC, Araújo JC, Peixoto P, Henriques SO, Vaz Carneiro A. Broadening risk factor or disease definition as a driver for overdiagnosis: A narrative review. J Intern Med 2022; 291:426-437. [PMID: 35253285 PMCID: PMC9314822 DOI: 10.1111/joim.13465] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).
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Affiliation(s)
- João Pedro Bandovas
- Department of General Surgery, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Beatriz Leal
- Department of Anesthestics, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
| | - Catarina Reis-de-Carvalho
- Department of Obstetrics, Gynecology and Reproductive Medicine, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - David Cordeiro Sousa
- Vision Sciences Study Center, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Vitreoretinal Unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - João Cruz Araújo
- Family Medicine Department, Unidade de Saúde Familiar Gualtar, Braga, Portugal
| | - Pedro Peixoto
- Department of Family Medicine, Unidade de Saúde Familiar do Mar, Póvoa de Varzim, Portugal
| | | | - António Vaz Carneiro
- Institute for Evidence Based Healthcare, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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17
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Zipursky JS, Thiruchelvam D, Redelmeier DA. Prenatal electrocardiogram testing and postpartum depression: A population-based cohort study. Obstet Med 2022; 15:31-39. [PMID: 35444726 PMCID: PMC9014547 DOI: 10.1177/1753495x211012502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/12/2021] [Accepted: 03/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background Cardiovascular symptoms in pregnancy may be a clue to psychological distress. We examined whether electrocardiogram testing in pregnant women is associated with an increased risk of subsequent postpartum depression. Methods We conducted a population-based cohort study of pregnant women who delivered in Ontario, Canada comparing women who received a prenatal ECG to women who did not. Results In total, 3,238,218 women gave birth during the 25-year study period of whom 157,352 (5%) received an electrocardiogram during prenatal care. Receiving an electrocardiogram test was associated with a one-third relative increase in the odds of postpartum depression (odds ratio 1.34; 95% confidence interval 1.29-1.39, p < 0.001). Conclusion The association between prenatal electrocardiogram testing and postpartum depression suggests a possible link of organic disease with mental illness, and emphasizes that cardiovascular symptoms may be a clinical clue to the presence of an underlying mood disorder.
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Affiliation(s)
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences Program, Sunnybrook Research
Institute, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto,
Canada
| | - Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto,
Canada
- Evaluative Clinical Sciences Program, Sunnybrook Research
Institute, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto,
Canada
- Division of General Internal Medicine, Sunnybrook Health
Sciences Centre, Toronto, Canada
- Center for Leading Injury Prevention Practice Education &
Research, Toronto, Canada
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18
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Squires JE, Cho-Young D, Aloisio LD, Bell R, Bornstein S, Brien SE, Decary S, Varin MD, Dobrow M, Estabrooks CA, Graham ID, Greenough M, Grinspun D, Hillmer M, Horsley T, Hu J, Katz A, Krause C, Lavis J, Levinson W, Levy A, Mancuso M, Morgan S, Nadalin-Penno L, Neuner A, Rader T, Santos WJ, Teare G, Tepper J, Vandyk A, Wilson M, Grimshaw JM. Inappropriate use of clinical practices in Canada: a systematic review. CMAJ 2022; 194:E279-E296. [PMID: 35228321 PMCID: PMC9053971 DOI: 10.1503/cmaj.211416] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. Methods: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. Results: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9). Interpretation: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.
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Affiliation(s)
- Janet E Squires
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta.
| | - Danielle Cho-Young
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Laura D Aloisio
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Robert Bell
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Stephen Bornstein
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Susan E Brien
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Simon Decary
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Melissa Demery Varin
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Mark Dobrow
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Carole A Estabrooks
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Ian D Graham
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Megan Greenough
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Doris Grinspun
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michael Hillmer
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Tanya Horsley
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Jiale Hu
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Alan Katz
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Christina Krause
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - John Lavis
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Wendy Levinson
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Adrian Levy
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michelina Mancuso
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Steve Morgan
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Letitia Nadalin-Penno
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Andrew Neuner
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Tamara Rader
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Wilmer J Santos
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Gary Teare
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Joshua Tepper
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Amanda Vandyk
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Michael Wilson
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute (Squires, Cho-Young, Aloisio, Graham, Santos, Grimshaw); School of Epidemiology and Public Health (Graham), School of Nursing (Squires, Demery Varin, Greenough, Nadalin-Penno, Vandyk) and Department of Medicine (Grimshaw), University of Ottawa, University of Ottawa, Ottawa, Ont.; Department of Surgery (Bell), Dalla Lana School of Public Health (Dobrow), Department of Medicine (Levinson), and Department of Family and Community Medicine (Tepper), University of Toronto, Toronto, Ont.; Division of Community Health and Humanities (Bornstein), Memorial University of Newfoundland, St. John's, Nfld.; Public Reports (Brien), Health Quality Ontario, Toronto, Ont.; Faculty of Medicine (Decary), University of Montreal, Montréal, Que.; Faculty of Nursing (Estabrooks), University of Alberta, Edmonton, Alta.; Registered Nurses Association of Ontario (Grinspun); Ontario Ministry of Health and Long-Term Care (Hillmer), Toronto, Ont.; Royal College of Physicians and Surgeons of Canada (Horsley), Ottawa, Ont.; Virginia Commonwealth University (Hu), Richmond, Va.; Family Medicine (Katz), University of Manitoba, Winnipeg, Man.; BC Patient Safety and Quality Council (Krause), Vancouver, BC; Clinical Epidemiology and Biostatistics (Lavis) and McMaster Health Forum (Wilson), McMaster University, Hamilton, Ont.; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; New Brunswick Health Council (Mancuso), Moncton, NB; Faculty of Medicine (Morgan), The University of British Columbia, Vancouver, BC; Health Quality Council of Alberta (Neuner), Calgary, Alta.; Canadian Agency for Drugs and Technologies in Health (Rader), Ottawa, Ont.; Alberta Health Services (Teare), Edmonton, Alta
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Rockwell MS, Michaels KC, Epling JW. Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study. BMC Health Serv Res 2022; 22:37. [PMID: 34991573 PMCID: PMC8733793 DOI: 10.1186/s12913-021-07345-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods
Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). Conclusions In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07345-9.
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Affiliation(s)
- Michelle S Rockwell
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA.
| | - Kenan C Michaels
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, VA, 24016, Roanoke, USA
| | - John W Epling
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA
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20
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Appold B, Soniega-Sherwood J, Persaud R, Moss R, Ramnarine M, LaVine SP, Bhansali R, Ahn S, Richman M. Reining in Unnecessary Admission EKGs: A Successful Interdepartmental High-Value Care Initiative. Cureus 2021; 13:e18351. [PMID: 34722095 PMCID: PMC8552818 DOI: 10.7759/cureus.18351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Unnecessary "admission electrocardiograms (EKGs)" on admitted patients waiting ("boarding") in the emergency department (ED) are often ordered. We introduced evidence-based EKG ordering guidelines and determined changes in the percent of patients with "preadmission" and "admission" EKGs ordered before vs. after guideline introduction and which patient characteristics predicted EKG ordering. Methods In 2016, our ED, cardiology, and hospitalist services implemented EKG ordering guidelines to reduce unnecessary ED EKGs ordered after disposition. We compared pre- vs. post-guideline EKG ordering to determine whether guidelines were associated with changes in "preadmission" or "admission EKG" ordering. Patients with an admission diagnosis unrelated to cardiac or pulmonary systems were included. An EKG was "admission" if the order time was after disposition time. The numerator was the number of "admission EKGs" ordered; the denominator was the total number of such admissions; those with "preadmission EKGs" were excluded from this analysis. Variables that might influence EKG ordering were explored. The chi-square test with Bonferroni adjustment was used to compare 2015 vs. 2016 percentages of patients with an "admission EKG." Results There was a decrease in unwarranted "admission EKGs" among ED boarding patients (44.1% pre-implementation to 27.5% by two years post-implementation) and an increase in unwarranted "preadmission EKGs" (66.1% pre-implementation to 72.8% post-implementation). Age ≥40 and past medical history independently predicted EKG ordering. Discussion The decrease in the ordering of "admission EKGs" but "preadmission EKGs" suggests the decline reflects a true change in ordering and not a general environmental/ecologic decline in ordering. This highlights the importance of careful guideline development and implementation.
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Affiliation(s)
- Brendan Appold
- Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, USA
| | | | - Riaad Persaud
- Emergency Medicine, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | - Rachel Moss
- Emergency Medicine, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | | | - Sean P LaVine
- Internal Medicine, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | - Rohan Bhansali
- Cardiology, Northwell Health Long Island Jewish Medical Center, New Hyde Park, USA
| | - Seungjun Ahn
- Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, USA
- Department of Biostatistics, University of Florida, Gainesville, USA
| | - Mark Richman
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City, USA
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21
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Ganguli I, Cui J, Thakore N, Orav EJ, Januzzi JL, Baugh CW, Sequist TD, Wasfy JH. Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation. J Am Coll Cardiol 2021; 77:3171-3179. [PMID: 34167642 DOI: 10.1016/j.jacc.2021.04.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value. OBJECTIVES This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events. METHODS Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services. RESULTS Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending. CONCLUSIONS Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Jinghan Cui
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - James L Januzzi
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher W Baugh
- Harvard Medical School, Boston, Massachusetts, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. https://twitter.com/DrChrisBaugh
| | - Thomas D Sequist
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Mass General Brigham, Boston, Massachusetts, USA. https://twitter.com/TomSequist
| | - Jason H Wasfy
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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22
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Schorrlepp M, Burchert D. [Less is more… in the general practitioner's internistic surgery : Subclinical hypothyroidism, hyperuricemia, routine ECG and NT-proBNP as selected examples]. Internist (Berl) 2021; 62:354-362. [PMID: 33599783 DOI: 10.1007/s00108-021-00956-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
Exceeding the need for care in general practitioner (GP) practices is a known problem that affects the work of approximately 16,000 specialists for internal medicine in the family practice context every day in Germany. In order to spare patients unnecessary treatment and measures, these must be critically questioned on a regular basis. Subclinical hypothyroidism (SH) and hyperuricemia (HU) are frequent laboratory constellations. The selected articles by Stott et al., de Montmollin et al. and Mooijaart et al. could show that treatment of SH in older patients is not effective. Furthermore, according to the studies of Li et al. and Badve et al. treatment of HU is only beneficial in the treatment of gout and nephrolithiasis and has no influence on the development of chronic kidney disease. The Canadian group of Bhatia demonstrated that the ECG for low-risk patients that is often part of health check-ups in Canada, usually results in more follow-up examinations without the groups with and without ECG differing with respect to major adverse cardiac events (MACE). Laboratory chemical analysis of N‑terminal prohormone of brain natriuretic peptide (NT-proBNP) for managing the treatment of heart failure is also not more effective than traditional treatment methods according to Felker et al., therefore, it can be discarded. "Choosing wisely", "Less is more" and the "Klug entscheiden (Smart decisions)" recommendations by the German Society for Internal Medicine are initiatives that make the process of avoiding overprovision of care accessible for all practitioners in a short and concise form.
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Affiliation(s)
- M Schorrlepp
- Gesundheitszentrum am Juxplatz, Kapellenstr. 7, 55124, Mainz, Deutschland.
| | - D Burchert
- Diabetologische Schwerpunktpraxis, Mainz, Deutschland
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23
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An Association Between Cardiologist Billing Patterns, Health Care Use, and Outcomes in Cardiac Patients. CJC Open 2021; 3:758-768. [PMID: 34169255 PMCID: PMC8209405 DOI: 10.1016/j.cjco.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/01/2021] [Indexed: 12/04/2022] Open
Abstract
Background Whether individual cardiologist billings are associated with differences in ambulatory care management and clinical outcomes in patients with coronary artery disease (CAD) and heart failure (HF) remains poorly understood. Methods We conducted a population-based, retrospective cohort study of cardiologists who treat patients with CAD or HF using administrative claims data in Ontario, Canada. The primary exposure was cardiologist billing quintile. We then stratified median billing amounts into quintiles, from lowest (quintile 1) to highest billing physicians (quintile 5). Results The main outcomes of interest were cardiac diagnostic and therapeutic procedures that occurred within 365 days of the index visit. Our 2 cohorts respectively consisted of 170,959 patients with CAD seen by 1 of 423 cardiologists and 56,262 HF patients seen by 1 of 413 cardiologists. CAD patients of higher-billing cardiologists had higher rates of echocardiograms (adjusted odds ratio [aOR], 1.65; 95% confidence interval [CI], 1.39 to 1.94 for quintile 5 vs quintile 2) and stress tests (aOR, 1.50; 95% CI, 1.28-1.75) at 1 year, with a similar pattern for HF patients of echocardiogram (aOR, 1.40; 95% CI, 1.23-1.59; P < 0.001) and stress test (aOR, 1.32; 95% CI, 1.15-1.51) use. CAD patients of cardiologists in quintile 1 had a higher mortality rate (aOR, 1.16; 95% CI, 1.03-1.31), and HF patients of cardiologists in billing quintile 4 had a lower hospitalization rate at 1 year (OR, 0.94; 95% CI, 0.89-0.99; P = 0.02). Conclusions Cardiac patients seen by the highest-billing cardiologists received more noninvasive cardiac testing compared with lower-billing cardiologists.
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24
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Augustsson H, Ingvarsson S, Nilsen P, von Thiele Schwarz U, Muli I, Dervish J, Hasson H. Determinants for the use and de-implementation of low-value care in health care: a scoping review. Implement Sci Commun 2021; 2:13. [PMID: 33541443 PMCID: PMC7860215 DOI: 10.1186/s43058-021-00110-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. AIM The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. METHODS A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. RESULTS In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. CONCLUSION The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. REGISTRATION The review has not been registered.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
| | - Irene Muli
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Jessica Dervish
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE 171 77 Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, SE 171 29 Stockholm, Sweden
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25
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Calder LA, Neilson HK, Whyte EM, Ji J, Bhatia RS. Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse. CJC Open 2020; 3:434-441. [PMID: 34027346 PMCID: PMC8129482 DOI: 10.1016/j.cjco.2020.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/24/2020] [Indexed: 11/19/2022] Open
Abstract
Background Evidence-based campaigns are available to support appropriate diagnostic testing in cardiology, but medico-legal concerns can impede implementation. Methods We conducted a retrospective descriptive analysis of medico-legal cases (civil legal, regulatory authority, hospital matters) involving cardiologists in Canada. For eligibility, cases must have closed at the Canadian Medical Protective Association between January 1, 2009 and December 31, 2018. We defined test underuse and overuse using criticisms in the medico-legal record from peer experts, regulatory authorities, or hospitals. We used a contributing factors framework and descriptive statistics for analysis. Results From 2009 to 2018, the Canadian Medical Protective Association closed 60,598 cases with 368 (0.6%) involving a cardiologist. Within those cases, there was no criticism of cardiac diagnostic test overuse and 15 cases (4.1%) with criticism of underuse (tests not ordered, not expedited, delayed). In 12 of 15 cases of underuse (80.0%), the patient experienced severe harm or death. Of 8 civil legal cases, 6 were decided in favour of the plaintiff (75.0%) and 2 were dismissed by consent before proceeding to trial (25.0%). Decisions on regulatory authority matters did not favour the cardiologist (7 of 7 cases). In all cases of underuse, there was need for focused testing to investigate new or worsening symptoms. The most common contributing factors included clinical decision-making, situational awareness, and communication with teams and patients. Conclusions Medico-legal cases involving cardiologists and the overuse or underuse of cardiac diagnostic tests were extremely rare in Canada, despite the potential for harm. The criticisms of cardiac diagnostic test underuse related to issues with diagnosing symptomatic patients.
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Affiliation(s)
- Lisa A. Calder
- Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Corresponding author: Dr Lisa A. Calder, Canadian Medical Protective Association, 875 Carling Avenue, Ottawa, Ontario K1S 5P1, Canada. Tel.: +1-613-725-2000; fax: +1-613-725-1300.
| | - Heather K. Neilson
- Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Eileen M. Whyte
- Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Jun Ji
- Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - R. Sacha Bhatia
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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26
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Ganguli I, Lupo C, Mainor AJ, Wang Q, Orav EJ, Rosenthal MB, Sequist TD, Colla CH. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit. JAMA Netw Open 2020; 3:e2029891. [PMID: 33306120 PMCID: PMC7733154 DOI: 10.1001/jamanetworkopen.2020.29891] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. OBJECTIVE To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. EXPOSURE Receipt of a given test within 1 week before or after the AWV. MAIN OUTCOMES AND MEASURES Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. RESULTS Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. CONCLUSIONS AND RELEVANCE In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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27
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Bouck Z, Calzavara AJ, Ivers NM, Kerr EA, Chu C, Ferguson J, Martin D, Tepper J, Austin PC, Cram P, Levinson W, Bhatia RS. Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA Intern Med 2020; 180:973-983. [PMID: 32511668 PMCID: PMC7281357 DOI: 10.1001/jamainternmed.2020.1611] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE The association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date. OBJECTIVE To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE). DESIGN, SETTING, AND PARTICIPANTS This population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019. EXPOSURES Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE. MAIN OUTCOMES AND MEASURES Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested). RESULTS Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score-matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age, 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively. CONCLUSIONS AND RELEVANCE Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.
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Affiliation(s)
- Zachary Bouck
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Noah M Ivers
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eve A Kerr
- VA Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Michigan Program on Value Enhancement, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - Cherry Chu
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Jacob Ferguson
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Joshua Tepper
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine and Geriatrics at Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Henderson J, Bouck Z, Holleman R, Chu C, Klamerus ML, Santiago R, Bhatia RS, Kerr EA. Comparison of Payment Changes and Choosing Wisely Recommendations for Use of Low-Value Laboratory Tests in the United States and Canada. JAMA Intern Med 2020; 180:524-531. [PMID: 32040158 PMCID: PMC7042826 DOI: 10.1001/jamainternmed.2019.7143] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/10/2019] [Indexed: 02/05/2023]
Abstract
Importance Evidence comparing the consequences of Choosing Wisely recommendations across health systems or with the consequences of recommendations plus policy change is lacking. Objectives To compare changes in the use of 2 low-value laboratory tests after the release of Choosing Wisely recommendations across 3 health care jurisdictions and changes associated with a related policy change. Design, Setting, and Participants This cross-sectional study was a population-based interrupted time series of adult patients (aged 18-64 years) who had primary care visits between January 1, 2010, and June 30, 2015, or established hypothyroidism between January 1, 2012, and June 30, 2015, across 3 health care delivery jurisdictions: Ontario, Canada; the US Veterans Health Administration; and the US employer-sponsored insurance market. Data analysis was performed from March 21, 2018, to October 31, 2019. Exposures A December 2010 payment policy change that eliminated reimbursement of vitamin D screening in Ontario, Canada, and the subsequent release of Choosing Wisely recommendations against low-value use of vitamin D tests in February 2013 and triiodothyronine tests in October 2013 in the United States and both tests in October 2014 in Canada. Main Outcomes and Measures Relative marginal effects (RMEs) comparing low-value testing rates after the release of Choosing Wisely recommendations with rates expected based on prerelease trends and the associated change in low-value vitamin D testing after the 2010 payment policy change in Ontario, Canada. Results Of 54 223 448 total persons, 28 504 576 (52.6%) were female, with 17 895 458 persons (33.0%) aged 18 to 34 years, 11 101 985 (20.5%) aged 35 to 44 years, and 25 226 005 (46.5%) aged 45 to 64 years. The December 2010 policy eliminating reimbursement for low-value vitamin D screening in Ontario, Canada, was associated with a 92.7% (95% CI, 92.4%-93.0%) relative reduction in such screening. Corresponding Choosing Wisely recommendations were associated with smaller reductions: 4.5% (95% CI, 2.6%-6.3%) in Ontario, 13.8% (95% CI, 11.8%-15.9%) for US Veterans Health Administration, and 14.0% (95% CI, 12.8%-15.2%) for US employer-sponsored insurance. In contrast, low-value use of triiodothyronine testing did not change significantly in Ontario, Canada (RME, 0.3%; 95% CI, -1.4% to 2.0%) or the US Veterans Health Administration (RME, 0.7%; 95% CI, -4.7% to 6.4%) and increased (RME, 3.0%; 95% CI, 1.6%-4.4%) for US employer-sponsored insurance. Conclusions and Relevance In this study, marginal reductions in the use of 2 low-value laboratory tests were associated with the release of related Choosing Wisely recommendations but a greater reduction in low-value vitamin D screening was associated with a previous payment policy change implemented in Ontario, Canada. These findings suggest that recommendations alone may be insufficient to significantly reduce use of low-value services and that pairing recommendations with policy changes may be more effective.
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Affiliation(s)
- James Henderson
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Rob Holleman
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Cherry Chu
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Mandi L. Klamerus
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Robin Santiago
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Michigan Program on Value Enhancement, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Armario P, Freixa-Pamias R. Utilidad pronóstica de la electrocardiograma basal en pacientes hipertensos mayores de 65 años. Es solo la hipertrofia ventricular izquierda lo que importa? Rev Clin Esp 2020; 220:123-125. [DOI: 10.1016/j.rce.2019.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
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30
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Prognostic utility of baseline electrocardiography for patients older than 65 years with hypertension. Is left ventricular hypertrophy the only thing that matters? Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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31
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Segar MW, Vaduganathan M, McGuire DK, Basit M, Pandey A. Response to Comment on Segar et al. Machine Learning to Predict the Risk of Incident Heart Failure Hospitalization Among Patients With Diabetes: The WATCH-DM Risk Score. Diabetes Care 2019;42:2298-2306. Diabetes Care 2020; 43:e26-e27. [PMID: 31959648 PMCID: PMC7411282 DOI: 10.2337/dci19-0059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Matthew W Segar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mujeeb Basit
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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Tharmaratnam T, Bouck Z, Sivaswamy A, Wijeysundera HC, Chu C, Yin CX, Nesbitt GC, Edwards J, Yared K, Wong B, Weinerman A, Thavendiranathan P, Rakowski H, Dorian P, Anderson G, Austin PC, Dudzinski DM, Ko DT, Weiner RB, Bhatia RS. Association Between Physicians' Appropriate Use of Echocardiography and Subsequent Healthcare Use and Outcomes in Patients With Heart Failure. J Am Heart Assoc 2020; 9:e013360. [PMID: 31870231 PMCID: PMC6988149 DOI: 10.1161/jaha.119.013360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background There is little understanding of whether a physician's tendency to order an inappropriate cardiac service is associated with the use of other cardiac services and clinical outcomes in their patients with heart failure (HF). Methods and Results We conducted a secondary analysis of 35 Ontario‐based cardiologists who participated in the control arm of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial. Transthoracic echocardiograms, ordered during the trial, were classified as rarely appropriate (rA), appropriate, or maybe appropriate on the basis of the 2011 appropriate use criteria. Cardiologists were grouped into tertiles of rA transthoracic echocardiogram ordering frequency: low ordering (bottom tertile), n=11; moderate ordering, n=12; or high ordering (top tertile), n=12. The main outcomes were measures of cardiac service use, including cardiology‐related physician visits, tests, and medications. Among 1677 patients with heart failure and an outpatient visit to 1 of 35 cardiologists, we found no significant association between rA transthoracic echocardiogram ordering frequency (by tertile) and cardiac testing use, although patients of cardiologists in the high ordering group had fewer physician visits, on average, than patients seen by low ordering cardiologists. In addition, patients of cardiologists in the highest rA ordering tertile had significantly lower odds of receiving potentially effective interventions, such as β blockers (odds ratio, 0.62; 95% CI, 0.43–0.89), than the low ordering group. Conclusions Although patients of cardiologists who frequently order rA transthoracic echocardiograms do not appear more (or less) likely to have subsequent cardiac tests, these patients have fewer follow‐up visits and lower odds of receiving evidence‐based medications. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02038101.
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Affiliation(s)
- Tharmegan Tharmaratnam
- School of Medicine Royal College of Surgeons Ireland Dublin Ireland.,Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,Dalla Lana School of Public Health University of Toronto Ontario Canada
| | | | - Harindra C Wijeysundera
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Cherry Chu
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Cindy X Yin
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | | | - Jeremy Edwards
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Kibar Yared
- The Scarborough Hospital Toronto Ontario Canada
| | - Brian Wong
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Adina Weinerman
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | | | - Harry Rakowski
- Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
| | - Paul Dorian
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Geoff Anderson
- Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - Peter C Austin
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - David M Dudzinski
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - Dennis T Ko
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Rory B Weiner
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
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33
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Tharmaratnam T, Bouck Z, Sivaswamy A, Wijeysundera HC, Chu C, Yin CX, Nesbitt GC, Edwards J, Yared K, Wong B, Weinerman A, Thavendiranathan P, Rakowski H, Dorian P, Anderson G, Austin PC, Dudzinski DM, Ko DT, Weiner RB, Bhatia RS. Low-Value Transthoracic Echocardiography, Healthcare Utilization, and Clinical Outcomes in Patients With Coronary Artery Disease. Circ Cardiovasc Qual Outcomes 2019; 12:e006123. [PMID: 31707824 DOI: 10.1161/circoutcomes.119.006123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes. METHODS AND RESULTS A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65-0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66-0.94]); β-blocker prescription (OR, 0.70 [95% CI, 0.55-0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22-0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04-2.28]), although all other outcomes were similar. CONCLUSIONS Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02038101.
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Affiliation(s)
- Tharmegan Tharmaratnam
- School of Medicine, Royal College of Surgeons in Ireland, Dublin (T.T.).,Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.)
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.).,Dalla Lana School of Public Health (Z.B.), University of Toronto, ON, Canada
| | - Atul Sivaswamy
- Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.)
| | - Harindra C Wijeysundera
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre (H.C.W., D.T.K.), University of Toronto, ON, Canada.,Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.).,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | - Cherry Chu
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.)
| | - Cindy X Yin
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.)
| | - Gillian C Nesbitt
- Cardiology Division, Mount Sinai Hospital, Toronto, ON, Canada (G.C.N.)
| | - Jeremy Edwards
- Division of Cardiology, St. Michael's Hospital, Toronto, ON, Canada (J.E., P.D.)
| | - Kibar Yared
- Department of Cardiology, The Scarborough Hospital, Toronto, ON, Canada (K.Y.)
| | - Brian Wong
- Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | - Adina Weinerman
- Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | | | - Harry Rakowski
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (P.T., H.R., R.S.B.)
| | - Paul Dorian
- Division of Cardiology, St. Michael's Hospital, Toronto, ON, Canada (J.E., P.D.)
| | - Geoff Anderson
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada
| | - Peter C Austin
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.)
| | - David M Dudzinski
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States (D.M.D, R.B.W.)
| | - Dennis T Ko
- Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre (H.C.W., D.T.K.), University of Toronto, ON, Canada.,Department of Medicine (H.C.W., B.W., A.W., D.T.K.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.).,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (H.C.W., B.W., A.W., D.T.K.)
| | - Rory B Weiner
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States (D.M.D, R.B.W.)
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada (T.T., Z.B., C.C., C.X.Y., R.S.B.).,Institute for Health Policy, Management, and Evaluation (H.C.W., G.A., P.C.A., D.T.K., R.S.B.), University of Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada (A.S., H.C.W., P.C.A., D.T.K., R.S.B.).,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada (P.T., H.R., R.S.B.)
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Gérvas J, Oliver LL, Pérez-Fernandez M. Family and Community Medicine and its role in preventing health overuse (preventive, diagnostic, therapeutic and rehabilitative). CIENCIA & SAUDE COLETIVA 2019; 25:1233-1240. [PMID: 32267426 DOI: 10.1590/1413-81232020254.30082019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/23/2019] [Indexed: 11/22/2022] Open
Abstract
In Medicine, it is critical "to offer 100% of what is needed and avoid 100% of what is not needed." Unfortunately, this primary issue is challenging, and generally, more than required is offered, and everything that is unnecessary is not avoided. This is a nonsystematic review with a teaching objective that reviews the general issue in primary care and suggests ways to avoid overuse and shortcomings concerning preventive, diagnostic, therapeutic, and rehabilitative interventions. Knowing not to do is science and art that is hardly taught and practiced less. The overuse that harm are an almost daily part of clinical practice in prevention, diagnosis, treatment, and rehabilitation. It is essential to promote "the art and science of not doing".
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Affiliation(s)
- Juan Gérvas
- Equipo CESCA. Pradillo 68.28002 Madrid España.
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35
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Ganguli I, Simpkin AL, Lupo C, Weissman A, Mainor AJ, Orav EJ, Rosenthal MB, Colla CH, Sequist TD. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open 2019; 2:e1913325. [PMID: 31617925 PMCID: PMC6806665 DOI: 10.1001/jamanetworkopen.2019.13325] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. OBJECTIVE To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. DESIGN, SETTING, AND PARTICIPANTS Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. MAIN OUTCOMES AND MEASURES Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. RESULTS This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. CONCLUSIONS AND RELEVANCE The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Arabella L. Simpkin
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Ganguli I, Lupo C, Mainor AJ, Raymond S, Wang Q, Orav EJ, Chang CH, Morden NE, Rosenthal MB, Colla CH, Sequist TD. Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Intern Med 2019; 179:1211-1219. [PMID: 31158270 PMCID: PMC6547245 DOI: 10.1001/jamainternmed.2019.1739] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care. OBJECTIVE To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019. EXPOSURES Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG. MAIN OUTCOMES AND MEASURES Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade. RESULTS Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade. CONCLUSIONS AND RELEVANCE Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
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Affiliation(s)
- Ishani Ganguli
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Partners HealthCare, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alexander J Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephanie Raymond
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Chiang-Hua Chang
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Meredith B Rosenthal
- Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Thomas D Sequist
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Partners HealthCare, Boston, Massachusetts
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Walsh B, Macfarlane PW, Prutkin JM, Smith SW. Distinctive ECG patterns in healthy black adults. J Electrocardiol 2019; 56:15-23. [DOI: 10.1016/j.jelectrocard.2019.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 01/26/2023]
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Tison GH, Zhang J, Delling FN, Deo RC. Automated and Interpretable Patient ECG Profiles for Disease Detection, Tracking, and Discovery. Circ Cardiovasc Qual Outcomes 2019; 12:e005289. [PMID: 31525078 PMCID: PMC6951431 DOI: 10.1161/circoutcomes.118.005289] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 07/15/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND The ECG remains the most widely used diagnostic test for characterization of cardiac structure and electrical activity. We hypothesized that parallel advances in computing power, machine learning algorithms, and availability of large-scale data could substantially expand the clinical inferences derived from the ECG while at the same time preserving interpretability for medical decision-making. METHODS AND RESULTS We identified 36 186 ECGs from the University of California, San Francisco database that would enable training of models for estimation of cardiac structure or function or detection of disease. We segmented the ECG into standard component waveforms and intervals using a novel combination of convolutional neural networks and hidden Markov models and evaluated this segmentation by comparing resulting electrical intervals against 141 864 measurements produced during the clinical workflow. We then built a patient-level ECG profile, a 725-element feature vector and used this profile to train and interpret machine learning models for examples of cardiac structure (left ventricular mass, left atrial volume, and mitral annulus e-prime) and disease (pulmonary arterial hypertension, hypertrophic cardiomyopathy, cardiac amyloid, and mitral valve prolapse). ECG measurements derived from the convolutional neural network-hidden Markov model segmentation agreed with clinical estimates, with median absolute deviations as a fraction of observed value of 0.6% for heart rate and 4% for QT interval. Models trained using patient-level ECG profiles enabled surprising quantitative estimates of left ventricular mass and mitral annulus e' velocity (median absolute deviation of 16% and 19%, respectively) with good discrimination for left ventricular hypertrophy and diastolic dysfunction as binary traits. Model performance using our approach for disease detection demonstrated areas under the receiver operating characteristic curve of 0.94 for pulmonary arterial hypertension, 0.91 for hypertrophic cardiomyopathy, 0.86 for cardiac amyloid, and 0.77 for mitral valve prolapse. CONCLUSIONS Modern machine learning methods can extend the 12-lead ECG to quantitative applications well beyond its current uses while preserving the transparency that is so fundamental to clinical care.
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Affiliation(s)
- Geoffrey H. Tison
- Division of Cardiology, Department of Medicine (G.H.T., F.N.D., R.C.D.), University of California, San Francisco
- Bakar Institute for Computational Health Sciences (G.H.T., R.C.D.), University of California, San Francisco
- Center for Digital Health Innovation (G.H.T., R.C.D.), University of California, San Francisco
| | - Jeffrey Zhang
- Cardiovascular Research Institute (J.Z.), University of California, San Francisco
- Department of Electrical Engineering and Computer Science, University of California at Berkeley, CA (J.Z., R.C.D.)
| | - Francesca N. Delling
- Division of Cardiology, Department of Medicine (G.H.T., F.N.D., R.C.D.), University of California, San Francisco
| | - Rahul C. Deo
- Division of Cardiology, Department of Medicine (G.H.T., F.N.D., R.C.D.), University of California, San Francisco
- Bakar Institute for Computational Health Sciences (G.H.T., R.C.D.), University of California, San Francisco
- Center for Digital Health Innovation (G.H.T., R.C.D.), University of California, San Francisco
- Institute for Human Genetics (R.C.D.), University of California, San Francisco
- Department of Electrical Engineering and Computer Science, University of California at Berkeley, CA (J.Z., R.C.D.)
- California Institute for Quantitative Biosciences, San Francisco, CA (R.C.D.)
- One Brave Idea and Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (R.C.D.)
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Bouck Z, Pendrith C, Chen XK, Frood J, Reason B, Khan T, Costante A, Kirkham K, Born K, Levinson W, Bhatia RS. Measuring the frequency and variation of unnecessary care across Canada. BMC Health Serv Res 2019; 19:446. [PMID: 31269933 PMCID: PMC6610789 DOI: 10.1186/s12913-019-4277-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 06/18/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions. METHODS Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years. RESULTS Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. CONCLUSIONS The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.
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Affiliation(s)
- Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville Street, 6th Floor, Toronto, Ontario M5S 1B2 Canada
| | - Ciara Pendrith
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
| | - Xi-Kuan Chen
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Jennifer Frood
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Ben Reason
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Tanya Khan
- Canadian Institute for Health Information, 1010 Sherbrooke Street West, Suite 602, Montreal, Quebec H3A 2R7 Canada
| | - Alicia Costante
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Kyle Kirkham
- Department of Anesthesia, Women’s College Hospital, 76 Grenville Street, Toronto, Ontario M5S 1B2 Canada
| | - Karen Born
- Choosing Wisely Canada, 250 Yonge Street, Room 648, Toronto, Ontario M5G 1B1 Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto – St Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada
| | - R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville Street, 6th Floor, Toronto, Ontario M5S 1B2 Canada
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Harskamp RE. Electrocardiographic screening in primary care for cardiovascular disease risk and atrial fibrillation. Prim Health Care Res Dev 2019; 20:e101. [PMID: 32800007 PMCID: PMC8060828 DOI: 10.1017/s1463423619000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 04/16/2019] [Indexed: 11/28/2022] Open
Abstract
Electrocardiograms (ECGs) are frequently recorded in primary care for screening purposes. An ECG is essential in diagnosing atrial fibrillation, and ECG abnormalities are associated with cardiovascular events. While recent studies show that ECGs adequately reclassify a proportion of patients based on the clinical risk score calculations, there are no data to support that this also results in improved health outcomes. When applied for screening for atrial fibrillation, more cases are found with routine care, but this would be undone when physicians would perform systematic pulse palpation. In most studies, the harms of routine ECG use (such as unnecessary diagnostic testing, emotional distress, increased health expenses) were poorly documented. As such, the routine performing of ECGs in asymptomatic primary care patients, whether it is for cardiovascular disease risk assessment or atrial fibrillation, cannot be recommended.
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Affiliation(s)
- Ralf E. Harskamp
- Department of General Practice, Amsterdam University Medical Centers – Location Academic Medical Center, Amsterdam, The Netherlands
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Badgery-Parker T, Pearson SA, Dunn S, Elshaug AG. Measuring Hospital-Acquired Complications Associated With Low-Value Care. JAMA Intern Med 2019; 179:499-505. [PMID: 30801628 PMCID: PMC6450303 DOI: 10.1001/jamainternmed.2018.7464] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Studies of low-value care have focused on the prevalence of low-value care interventions but have rarely quantified downstream consequences of these interventions for patients or the health care system. OBJECTIVE To measure immediate in-hospital harm associated with 7 low-value procedures. DESIGN, SETTING, AND PARTICIPANTS A cohort study with a descriptive analysis using hospital admission data from 225 public hospitals in New South Wales, Australia, was conducted from July 1, 2014, to June 30, 2017. All 9330 episodes involving 1 of 7 low-value procedures were evaluated, including endoscopy for dyspepsia in people younger than 55 years (3689 episodes); knee arthroscopy for osteoarthritis or meniscal tears (3963 episodes); colonoscopy for constipation in people younger than 50 years (665 episodes); endovascular repair of abdominal aortic aneurysm in asymptomatic, high-risk patients (508 episodes); carotid endarterectomy in asymptomatic, high-risk patients (273 episodes); renal artery angioplasty (176 episodes); and spinal fusion for uncomplicated low back pain (56 episodes). Sixteen hospital-acquired complications (HACs) were used as a measure of harm associated with low-value care. MAIN OUTCOMES AND MEASURES For each low-value procedure, the percentage associated with any HAC and the difference in mean length of stay for patients receiving low-value care with and without HACs were calculated. RESULTS Across the 225 hospitals and 9330 episodes of low-value care, rates of HACs were low for low-value endoscopy (4 [0.1%] episodes; 95% CI, 0.02%-0.2%), knee arthroscopy (18 [0.5%] episodes; 95% CI, 0.2%-0.7%), and colonoscopy (2 [0.3%] episodes; 95% CI, 0.0%-0.9%) but higher for low-value spinal fusion (4 [7.1%] episodes; 95% CI, 2.2%-11.5%), endovascular repair of abdominal aortic aneurysm (76 [15.0%] episodes; 95% CI, 11.1%-19.7%), carotid endarterectomy (21 [7.7%] episodes; 95% CI, 5.2%-10.1%), and renal artery angioplasty (15 [8.5%] episodes; 95% CI, 5.8%-11.5%). For most procedures, the most common HAC was health care-associated infection, which accounted for 83 (26.3%) (95% CI, 21.8%-31.5%) of all HACs observed. The highest rate of health care-associated infection was 8.4% (95% CI, 5.2%-11.4%) for renal artery angioplasty. For all 7 low-value procedures, median length of stay for patients with an HAC was 2 times or more the median length of stay for patients without a complication. For example, median length of stay was 1 (interquartile range [IQR], 1-1) day for knee arthroscopy with no HACs but increased to 10.5 (IQR, 1.0-21.3) days for patients with an HAC. CONCLUSIONS AND RELEVANCE These findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate. Although only some immediate consequences of just 7 low-value services were examined, harm related to all low-value procedures was noted, including high rates of harm for certain higher-risk procedures. The full burden of low-value care for patients and the health system is yet to be quantified.
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Affiliation(s)
- Tim Badgery-Parker
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia.,Capital Markets Cooperative Research Centre, Health Market Quality Program, Sydney, Australia
| | - Sallie-Anne Pearson
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia.,Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Susan Dunn
- Activity Based Management, New South Wales Ministry of Health, Sydney, Australia
| | - Adam G Elshaug
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia
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Abstract
IMPORTANCE Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse. OBSERVATIONS A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits). CONCLUSIONS AND RELEVANCE Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore.,Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore
| | - Sanket S Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut.,Department of Veterans Affairs West Haven, West Haven, Connecticut
| | - Eric R Coon
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Scott M Wright
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah Korenstein
- Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
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Bouck Z, Mecredy GC, Ivers NM, Barua M, Martin D, Austin PC, Tepper J, Bhatia RS. Frequency and Associations of Prescription Nonsteroidal Anti-inflammatory Drug Use Among Patients With a Musculoskeletal Disorder and Hypertension, Heart Failure, or Chronic Kidney Disease. JAMA Intern Med 2018; 178:1516-1525. [PMID: 30304456 PMCID: PMC6248204 DOI: 10.1001/jamainternmed.2018.4273] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE International nephrology societies advise against nonsteroidal anti-inflammatory drug (NSAID) use in patients with hypertension, heart failure, or chronic kidney disease (CKD); however, recent studies have not investigated the frequency or associations of use in these patients. OBJECTIVES To estimate the frequency of and variation in prescription NSAID use among high-risk patients, to identify characteristics associated with prescription NSAID use, and to investigate whether use is associated with short-term, safety-related outcomes. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, administrative claims databases were linked to create a cohort of primary care visits for a musculoskeletal disorder involving patients 65 years and older with a history of hypertension, heart failure, or CKD between April 1, 2012, and March 31, 2016, in Ontario, Canada. EXPOSURE Prescription NSAID use was defined as at least 1 patient-level Ontario Drug Benefit claim for a prescription NSAID dispensing within 7 days after a visit. MAIN OUTCOMES AND MEASURES Multiple cardiovascular and renal safety-related outcomes were observed between 8 and 37 days after each visit, including cardiac complications (any emergency department visit or hospitalization for cardiovascular disease), renal complications (any hospitalization for hyperkalemia, acute kidney injury, or dialysis), and death. RESULTS The study identified 2 415 291 musculoskeletal-related primary care visits by 814 049 older adults (mean [SD] age, 75.3 [4.0] years; 61.1% female) with hypertension, heart failure, or CKD, of which 224 825 (9.3%) were followed by prescription NSAID use. The median physician-level prescribing rate was 11.0% (interquartile range, 6.7%-16.7%) among 7365 primary care physicians. Within a sample of 35 552 matched patient pairs, each consisting of an exposed and nonexposed patient matched on the logit of their propensity score for prescription NSAID use (exposure), the study found similar rates of cardiac complications (288 [0.8%] vs 279 [0.8%]), renal complications (34 [0.1%] vs 33 [0.1%]), and death (27 [0.1%] vs 30 [0.1%]). For cardiovascular and renal-safety related outcomes, there was no difference between exposed patients (308 [0.9%]) and nonexposed patients (300 [0.8%]) (absolute risk reduction, 0.0003; 95% CI, -0.001 to 0.002; P = .74). CONCLUSIONS AND RELEVANCE While prescription NSAID use in primary care was frequent among high-risk patients, with widespread physician-level variation, use was not associated with increased risk of short-term, safety-related outcomes.
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Affiliation(s)
- Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Graham C Mecredy
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Noah M Ivers
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Moumita Barua
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Research Institute, Toronto General Hospital, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Joshua Tepper
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Health Quality Ontario, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Bouck Z, Ferguson J, Ivers NM, Kerr EA, Shojania KG, Kim M, Cram P, Pendrith C, Mecredy GC, Glazier RH, Tepper J, Austin PC, Martin D, Levinson W, Bhatia RS. Physician Characteristics Associated With Ordering 4 Low-Value Screening Tests in Primary Care. JAMA Netw Open 2018; 1:e183506. [PMID: 30646242 PMCID: PMC6324437 DOI: 10.1001/jamanetworkopen.2018.3506] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently. OBJECTIVES To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians. EXPOSURES Physician sex, years since medical school graduation, and primary care model. MAIN OUTCOMES AND MEASURES This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2). RESULTS The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users. CONCLUSIONS AND RELEVANCE This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.
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Affiliation(s)
- Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Jacob Ferguson
- currently a student at Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Noah M. Ivers
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eve A. Kerr
- Center for Clinical Management, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Kaveh G. Shojania
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Min Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System and Health Network, Toronto, Ontario, Canada
| | - Ciara Pendrith
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Graham C. Mecredy
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Richard H. Glazier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joshua Tepper
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- R Sacha Bhatia
- Women's College Hospital, Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
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Mahajan S, Krumholz HM. Screening ECGs in low-risk patients are associated with increased risk of downstream cardiac testing. BMJ Evid Based Med 2018; 23:150-151. [PMID: 29674521 DOI: 10.1136/bmjebm-2018-110943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Shiwani Mahajan
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
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Bouck Z, Mecredy G, Ivers NM, Pendrith C, Fine B, Martin D, Glazier RH, Tepper J, Levinson W, Bhatia RS. Routine use of chest x-ray for low-risk patients undergoing a periodic health examination: a retrospective cohort study. CMAJ Open 2018; 6:E322-E329. [PMID: 30104416 PMCID: PMC6182124 DOI: 10.9778/cmajo.20170138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Many evidence-based recommendations advocate against the use of routine chest x-rays for asymptomatic, low-risk outpatients; however, it is unclear how regularly chest x-rays are ordered in primary care. Our study aims to describe the frequency of, and variation in, routine chest x-ray use in low-risk outpatients among primary care physicians. METHODS In this retrospective cohort study, Ontario residents aged 18 years and older with a periodic health examination (PHE) between Apr. 1, 2010, and Mar. 31, 2015, were identified via administrative claims data. Patients with a recent history (last 3 years) of any of the following were excluded: cardiac or pulmonary disease, high-risk comorbidity (e.g., diabetes), consultations/visits or procedures involving cardiac or pulmonary specialists, cancer and severe chest trauma. The primary outcome, a routine chest x-ray, was defined as at least 1 chest x-ray claim within 7 days after a PHE. RESULTS While a routine chest x-ray followed only 2.42% of 2 847 508 PHEs, one-quarter of family physicians (499/2031) ordered chest x-rays for more than 5.0% of their PHEs (interquartile range 1.5%-5.0%) and accounted for 62.9% of all tests observed. Routine chest x-ray use declined by 2.0% per quarter (adjusted rate ratio 0.98, 95% confidence interval [CI] 0.97-0.98). Older age (45-64 yr v. 18-44 yr, adjusted odds ratio [OR] 1.82, 95% CI 1.78-1.86; ≥ 65 yr v. 18-44 yr, adjusted OR 2.48, 95% CI 2.39-2.58) and male sex of the patient (OR 2.19, 95% CI 2.14-2.24) and male sex of the provider (OR 1.55, 95% CI 1.51-1.59) were significantly associated with increased odds of a routine chest x-ray being ordered. INTERPRETATION It is relatively uncommon for a chest x-ray to be ordered as part of a PHE in Ontario; however, the substantial variation observed among physicians suggests potential for interventions targeted at the most frequent users.
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Affiliation(s)
- Zachary Bouck
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Graham Mecredy
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Noah M Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Ciara Pendrith
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Ben Fine
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Danielle Martin
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Richard H Glazier
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Joshua Tepper
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - Wendy Levinson
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bouck, Ivers, Bhatia) and Department of Family and Community Medicine (Martin), Women's College Hospital; Choosing Wisely Canada (Bouck, Levinson, Bhatia); Institute for Clinical Evaluative Sciences (ICES) (Mecredy, Ivers, Glazier, Bhatia), Toronto, Ont.; Cumming School of Medicine (Pendrith), University of Calgary, Calgary, Alta.; Trillium Health Partners (Fine), Mississauga, Ont.; Institute for Health Care Policy Management and Evaluation (Martin, Tepper), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital; Departments of Diagnostic Imaging (Fine), Family and Community Medicine (Glazier, Tepper) and Medicine (Levinson), University of Toronto, Toronto Ont.
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Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Cardiovascular Disease Risk With Electrocardiography: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 319:2308-2314. [PMID: 29896632 DOI: 10.1001/jama.2018.6848] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Cardiovascular disease (CVD), which encompasses atherosclerotic conditions such as coronary heart disease, cerebrovascular disease, and peripheral arterial disease, is the most common cause of death among adults in the United States. Treatment to prevent CVD events by modifying risk factors is currently informed by CVD risk assessment with tools such as the Framingham Risk Score or the Pooled Cohort Equations, which stratify individual risk to inform treatment decisions. OBJECTIVE To update the 2012 US Preventive Services Task Force (USPSTF) recommendation on screening for coronary heart disease with electrocardiography (ECG). EVIDENCE REVIEW The USPSTF reviewed the evidence on whether screening with resting or exercise ECG improves health outcomes compared with the use of traditional CVD risk assessment alone in asymptomatic adults. FINDINGS For asymptomatic adults at low risk of CVD events (individuals with a 10-year CVD event risk less than 10%), it is very unlikely that the information from resting or exercise ECG (beyond that obtained with conventional CVD risk factors) will result in a change in the patient's risk category as assessed by the Framingham Risk Score or Pooled Cohort Equations that would lead to a change in treatment and ultimately improve health outcomes. Possible harms are associated with screening with resting or exercise ECG, specifically the potential adverse effects of subsequent invasive testing. For asymptomatic adults at intermediate or high risk of CVD events, there is insufficient evidence to determine the extent to which information from resting or exercise ECG adds to current CVD risk assessment models and whether information from the ECG results in a change in risk management and ultimately reduces CVD events. As with low-risk adults, possible harms are associated with screening with resting or exercise ECG in asymptomatic adults at intermediate or high risk of CVD events. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends against screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at low risk of CVD events. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events. (I statement).
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Affiliation(s)
| | | | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | | | | | | | | | | | | | | | | | | | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
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Wintemute K, Wilson L, Levinson W. Choosing Wisely in primary care: Moving from recommendations to implementation. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2018; 64:336-338. [PMID: 29760252 PMCID: PMC5951647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Kimberly Wintemute
- Assistant Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario and Primary Care Co-Lead for Choosing Wisely Canada.
| | - Lynn Wilson
- Vice Dean of Partnerships for the Faculty of Medicine and Professor in the Department of Family and Community Medicine at the University of Toronto and Primary Care Co-Lead for Choosing Wisely Canada
| | - Wendy Levinson
- Professor of Medicine at the University of Toronto and Chair of Choosing Wisely Canada
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