1
|
Kjelle E, Brandsæter IØ, Andersen ER, Hofmann BM. Cost of Low-Value Imaging Worldwide: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024:10.1007/s40258-024-00876-2. [PMID: 38427217 DOI: 10.1007/s40258-024-00876-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide. METHODS This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive. RESULTS Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients. CONCLUSIONS This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.
Collapse
Affiliation(s)
- Elin Kjelle
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Ingrid Øfsti Brandsæter
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Bjørn Morten Hofmann
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics at the University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
| |
Collapse
|
2
|
Heidel JS, Miller J, Donovan E, Handa R, Van Haren R, Salfity H, Starnes SL. Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection. J Thorac Cardiovasc Surg 2024; 167:517-525.e2. [PMID: 37236600 DOI: 10.1016/j.jtcvs.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES The need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients. METHODS Patients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses. RESULTS A total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion. CONCLUSIONS Reserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.
Collapse
Affiliation(s)
- Justin S Heidel
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - James Miller
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Eileen Donovan
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Rahul Handa
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Robert Van Haren
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Hai Salfity
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Sandra L Starnes
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio.
| |
Collapse
|
3
|
Feldman ZM, Lella SK, Lee S, Bellomo T, Bocklett J, Dua A, LaMuraglia GM, Srivastava SD, Eagleton MJ, Zacharias N. Implementation of a Consensus-Driven Quality Improvement Protocol to Decrease Length of Stay after Elective Carotid Endarterectomy. Ann Vasc Surg 2023; 97:97-105. [PMID: 37355013 DOI: 10.1016/j.avsg.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/23/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND National guidelines stipulate that postoperative length-of-stay (LOS) after elective carotid endarterectomy (CEA) should not exceed 1 day on average, yet perioperative care coordination gaps may limit the ability for institutions to achieve this goal. Internal review determined that increased LOS after CEA at our institution was frequently attributable to urinary retention or postoperative hypertension. We designed and implemented a quality improvement (QI) protocol aiming to better our institutional performance in postoperative LOS after CEA, consisting of 2 Plan-Do-Study-Act (PDSA) cycles. METHODS In the first PDSA cycle, a division-wide standardized protocol was developed by which antihypertensive medications were managed preoperatively and through postoperative day (POD) 1. This protocol included dedicated patient outreach with instructions for at-home antihypertensive management through the morning of POD 0. Second, alpha-1-blockade was administered to all male patients preoperatively. All patients receiving an elective CEA performed at our institution by vascular surgeons were included in the protocol. The primary outcome measure was defined percent failure of the LOS >1 day metric, with raw LOS as a secondary outcome measure. Process measures included adherence to the antihypertensive medication protocol and adherence to preoperative alpha-1 blockade. Balance measures included documented intraoperative hypotension and 30-day readmission. Fisher's exact test was used to evaluate relationships between preintervention and postintervention cohorts and the outcome measure. Wilcoxon rank-sum tests were used to evaluate relationships between cohorts and total LOS. RESULTS Baseline performance on the LOS >1 day metric after elective CEA was 58.3% in the 8 months prior to intervention, across 48 patients. Both PDSA interventions were implemented simultaneously. In the 12 months after intervention, 64 patients met protocol inclusion criteria, including 19 symptomatic patients (29.7%). Process measure success for preoperative antihypertensive regimen adherence was 89.8%. For males not chronically prescribed alpha-1 blockade preoperatively, process measure success for adherence to preoperative alpha-1 blockade was 78.8%. The intraoperative hypotension balance measure occurred in 1 patient (1.6%). Performance on the LOS >1 day outcome measure was improved to 32.8% (P = 0.01). Performance on the raw LOS outcome measure was similar between the preintervention cohort (median 2 days, interquartile range [IQR] 1-2) and postintervention cohort (median 1 day, IQR 1-2, P = 0.07). Performance on the 30-day readmission balance measure was similar between preintervention (6.3%) and postintervention cohorts (9.4%, P = 0.73). CONCLUSIONS The consensus-driven development and implementation of a QI protocol to reduce postoperative LOS after CEA showed promising results in our institution, with approximately 40% improvement in the primary outcome measure. Wider efforts to improve LOS after CEA should include a focus on minimization of postoperative hypertension and urinary retention.
Collapse
Affiliation(s)
- Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Srihari K Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sujin Lee
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Tiffany Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jennifer Bocklett
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Glenn M LaMuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
4
|
Finley DJ, Fay KA, Porter ED, Hasson RM, Millington TM, Phillips JD. Reducing Unnecessary Type and Screens Prior to Thoracic Surgery: A Quality Improvement Initiative. J Surg Res 2023; 283:743-750. [PMID: 36463813 DOI: 10.1016/j.jss.2022.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Previous work identified that routine preoperative type and screen (T&S) testing before elective thoracic surgery is overutilized. We hypothesized that instituting a quality improvement (QI) initiative to change practice would significantly reduce this unnecessary testing, reduce costs, and improve healthcare efficiency. MATERIALS AND METHODS A QI initiative was developed at a single, academic center to reduce empiric T&S ordering before elective anatomic lung resections. Two interventions were implemented: 1) education based on current institutional data and 2) an electronic medical record order set modification. Utilization of T&S testing, blood transfusion data, and perioperative outcomes were tracked and compared between a preintervention group (2015-2018) and a postintervention group (2020-2021). Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules. RESULTS Of the 553 patients included: 420 were in the preintervention group and 133 were in the postintervention group. The rate of routine T&Ss significantly dropped after implementing the QI initiative (97 versus 20%, P ≤ 0.001). Additionally, no difference in blood transfusion rate was observed (4.3 versus 2.3%, P = 0.29), and there were no differences noted in postoperative complications (P = 0.82), 30-day readmission (P = 0.29), or mortality (P = 0.96). Based on current volumes of ∼200 anatomic lung resections/year, estimated cost savings from reducing T&S testing from 97 to 20% would be at least $40,000 a year. CONCLUSIONS Our QI initiative significantly reduced the use of routine T&S testing. This practice change was achieved while maintaining excellent outcomes demonstrating routine preoperative T&S testing can be safely reduced in most elective thoracic surgery.
Collapse
Affiliation(s)
- David J Finley
- Dartmouth-Hitchcock Medical Center, Thoracic Surgery, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire.
| | - Kayla A Fay
- Dartmouth-Hitchcock Medical Center, Thoracic Surgery, Lebanon, New Hampshire
| | - Eleah D Porter
- Dartmouth-Hitchcock Medical Center, Thoracic Surgery, Lebanon, New Hampshire
| | - Rian M Hasson
- Dartmouth-Hitchcock Medical Center, Thoracic Surgery, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| | | | - Joseph D Phillips
- Dartmouth-Hitchcock Medical Center, Thoracic Surgery, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| |
Collapse
|
5
|
Allen RW, Shaw RD, Burney CP, Newton LE, Lee AY, Judd BG, Ivatury SJ. Deep sleep and beeps II: Sleep quality improvement project in general surgery patients. Surgery 2022; 172:1697-1703. [PMID: 38375787 DOI: 10.1016/j.surg.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/02/2022] [Accepted: 09/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Poor sleep leads to poor health outcomes. Phase I of our sleep quality improvement project showed severe sleep disturbance in the ward setting. We implemented a novel PostOp Pack to improve sleep quality. METHODS Patients underwent elective, general surgery procedures. Fitbit trackers measured total sleep time. Patients completed the inpatient Richards-Campbell Sleep Questionnaire, which combines 5 domains into a cumulative score (0-100). Patients completed the outpatient Pittsburgh Sleep Quality Index preoperatively and postoperatively. Patients received the PostOp Pack, which included physical items and a sleep-protective order set to reduce nighttime awakenings. Patients from phase I served as the historical control. The primary outcome was the percentage of patients with Richards-Campbell Sleep Questionnaire total sleep score ≥50. The secondary outcomes included the mean Richards-Campbell Sleep Questionnaire domain scores and Fitbit total sleep time. RESULTS A total of 49 patients were compared with 64 historical controls. The percentage of patients with a total sleep score ≥50 was significantly higher in patients receiving a PostOp Pack versus historical control (69% vs. 44%, difference 26%, 95% confidence interval 6.1-45%, P = .01). The mean Richards-Campbell Sleep Questionnaire Total Sleep Score was significantly higher in patients with a PostOp Pack (62 vs 49, mean difference 13, 95% confidence interval 6-21, P ≤ .01). The PostOp Pack Richards-Campbell Sleep Questionnaire domain scores were significantly higher in various areas: Sleep Latency (68 vs 49, P ≤ .01), Awakenings (56 vs 40, P = .01), Sleep Quality (61 vs 49, P = .02), and Noise Disturbance (70 vs 59, P = .04). Of all patients, 92% would use PostOp Pack again in a future hospitalization. No patients had a failure to rescue event with PostOp Pack. The mean total sleep time was significantly improved with PostOp Pack on night 1 (6.4 vs 4.7 hours, P = .03). CONCLUSION The PostOp Pack improves inpatient sleep quality and is safe.
Collapse
Affiliation(s)
- Robert W Allen
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Robert D Shaw
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Laura E Newton
- Geisel School of Medicine, Dartmouth College, Lebanon, NH
| | - Andrew Y Lee
- Geisel School of Medicine, Dartmouth College, Lebanon, NH
| | - Brooke G Judd
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine, Dartmouth College, Lebanon, NH; Sleep Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Srinivas Joga Ivatury
- Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin TX
| |
Collapse
|
6
|
Hsu DS, Banks KC, Jiang SF, Phillips JL, Ely S, Heinz BB, Maxim CL, Ashiku SK, Patel AR, Velotta JB. Routine Post-pull Chest Radiograph is Not Necessary After VATS Lobectomy. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
|
7
|
Chikwe J, Mitzman B. Editor's Choice: A Place for All Thoracic Surgeons. Ann Thorac Surg 2022; 114:1991-1994. [PMID: 36433624 DOI: 10.1016/j.athoracsur.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Brian Mitzman
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah
| |
Collapse
|
8
|
Zukowski M, Haas A, Schaefer EW, Shen C, Reed MF, Taylor MD, Go PH. Are Routine Chest Radiographs After Chest Tube Removal in Thoracic Surgery Patients Necessary? J Surg Res 2022; 276:160-167. [PMID: 35344742 DOI: 10.1016/j.jss.2022.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The routine use of chest x-ray (CXR) to evaluate the pleural space after chest tube removal is a common practice driven primarily by surgeon preference and institutional protocol. The results of these postpull CXRs frequently lead to additional interventions that serve only to increase health care costs and resource utilization. We investigated the utility of these postpull CXRs in thoracic surgery patients and assessed their effectiveness in predicting the need for tube replacement. METHODS Single-institution retrospective study comprising thoracic surgery patients requiring postoperative chest tube drainage over a 3-y period. Demographics and surgical characteristics, including surgical approach, procedure, and procedure type, were recorded. Outcomes included postpull CXR findings, interventions resulting from radiographic abnormalities, and the additional health resource utilization incurred by obtaining these studies on asymptomatic patients. RESULTS The study included 433 patients. Postpull CXRs were performed in 87.1% of patients, with 33.2% demonstrating an abnormality compared with the prior study. Among these, 65.7% resulted only in repeat imaging and 25.7% resulted in discharge delay. Overall, a total of 13 patients (3%) required chest tube replacement, three during the index hospitalization and the other 10 requiring readmission. Among those requiring chest tube replacement, 75% had normal postpull imaging, and all were symptomatic. CONCLUSIONS Recurrent pneumothorax after chest tube removal requiring immediate tube reinsertion is relatively rare and does not occur in the absence of symptoms. Our study suggests that routine postpull CXRs have limited clinical utility and can be safely omitted in asymptomatic patients with appropriate clinical observation.
Collapse
Affiliation(s)
- Monica Zukowski
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Alec Haas
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Eric W Schaefer
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Chan Shen
- Division of Outcomes, Research & Quality, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Division of Health Services and Behavioral Research, Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Michael F Reed
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Matthew D Taylor
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Pauline H Go
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
| |
Collapse
|
9
|
Phillips JD, Porter ED. Retraining Your Dogma. Ann Thorac Surg 2021; 113:2105-2106. [PMID: 34166640 DOI: 10.1016/j.athoracsur.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Joseph D Phillips
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, 1Medical Center Drive, Lebanon, NH 03766.
| | - Eleah D Porter
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, 1Medical Center Drive, Lebanon, NH 03766
| |
Collapse
|
10
|
Bostock IC, Antonoff MB. Challenging Dogmas to Enable Progress Forward. Ann Thorac Surg 2021; 113:2104-2105. [PMID: 34052221 DOI: 10.1016/j.athoracsur.2021.04.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/29/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Ian C Bostock
- Department of Thoracic Surgery The University of Texas, MD Anderson Cancer Center
| | - Mara B Antonoff
- Department of Thoracic Surgery The University of Texas, MD Anderson Cancer Center
| |
Collapse
|