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Savitz ST, Bailey SC, Dusetzina SB, Jones WS, Trogdon JG, Stearns SC. Treatment selection and medication adherence for stable angina: The role of area-based health literacy. J Eval Clin Pract 2020; 26:1711-1721. [PMID: 31994280 PMCID: PMC7552995 DOI: 10.1111/jep.13341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/28/2019] [Accepted: 11/29/2019] [Indexed: 01/09/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. Our objective is to evaluate whether community-level health literacy is associated with treatment selection and medication adherence patterns. METHOD The sample included Medicare fee-for-service beneficiaries (20% random sample) with stable angina in 2007-2013. We used an area-level health literacy variable because of the lack of an individual measure in claims. We measured the association between (a) area-based health literacy with treatment selection (medication only, percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) surgery) and (b) area-based health literacy with medication adherence. We controlled for other factors including demographics, co-morbidity burden, dual eligibility, and area deprivation index. RESULTS We identified 8300 patients of whom 8.7% lived in a low health literacy area. Overall, 56% of patients received medication only, 28% received PCI, and 15% received CABG. Patients in low health literacy areas were less likely to receive CABG (-3.5 percentage points; 95% CI, -6.8 to -0.3) than were patients in high health literacy areas, but the significance was sensitive to specification. Overall, 81.5% and 71.5% of patients were adherent to antianginals and statins, respectively. Living in low health literacy areas was associated with lower adherence to antianginals (-3.3 percentage points; 95% CI, -6.1 to -0.6) but not statins. CONCLUSIONS Low area-based health literacy was associated with being less likely to receive CABG and lower adherence, but the differences between low and high health literacy areas were small and sensitive to model specification. Individual factors such as dual eligibility status and race/ethnicity had stronger associations with outcomes than had area-based health literacy, suggesting that this area-based measure was inadequate to account for social determinants in this study.
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Affiliation(s)
- Samuel T Savitz
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stacy Cooper Bailey
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - W Schuyler Jones
- Department of Medicine, Duke Heart Center, Duke University Medical Center, Durham, North Carolina
| | - Justin G Trogdon
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Podder V, Price A, Sivapuram MS, Biswas R. Middle-aged man who could not afford an angioplasty. BMJ Case Rep 2019; 12:12/3/e227118. [PMID: 30936331 DOI: 10.1136/bcr-2018-227118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Coronary artery disease managed by percutaneous coronary intervention (PCI) has been noted for profit-driven overuse medicine. Concerns mount over inappropriate use of PCI for patients in India. We describe the case of a 55-year-old Indian man who presented for a second opinion following an urgent recommendation for PCI by two cardiologists following a recent acute myocardial infarction even though the patient was symptom-free and out of the window period for primary PCI. The proposed intervention placed the patient at financial risk for insolvency. This case report highlights the challenges and consequences of inappropriate overuse of PCI. Also, we outline the current lack of shared decision-making among patients and physicians for the PCI procedure. The challenges, inherent in the assumptions that overuse of PCI is evidence-based, are discussed including recommendations for the practice of evidence based medicine for this intervention.
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Affiliation(s)
- Vivek Podder
- Department of Medicine, Tairunnessa Memorial Medical College and Hospital, Gazipur, Bangladesh
| | - Amy Price
- Department of Continuing Education, University of Oxford, Oxford, UK.,Stanford MedicineX, University of Stanford, School of Medicine, Stanford, USA
| | - Madhava Sai Sivapuram
- Department of Medicine, Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinoutapalli, Andhra Pradesh, India
| | - Rakesh Biswas
- Department of Medicine, Kamineni Institute of Medical Sciences, Narketpally, Telangana, India
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Podder V, Dhakal B, Shaik GUS, Sundar K, Sivapuram MS, Chattu VK, Biswas R. Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment. Healthcare (Basel) 2018; 6:E78. [PMID: 29996517 PMCID: PMC6163835 DOI: 10.3390/healthcare6030078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/03/2018] [Accepted: 07/06/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Precision medicine aims to focus on meeting patient requirements accurately, optimizing patient outcomes, and reducing under-/overdiagnosis and therapy. We aim to offer a fresh perspective on accuracy driven “age-old precision medicine” and illustrate how newer case-based blended learning ecosystems (CBBLE) can strengthen the bridge between age-old precision approaches with modern technology and omics-driven approaches. METHODOLOGY We present a series of cases and examine the role of precision medicine within a “case-based blended learning ecosystem” (CBBLE) as a practicable tool to reduce overdiagnosis and overtreatment. We illustrated the workflow of our CBBLE through case-based narratives from global students of CBBLE in high and low resource settings as is reflected in global health. RESULTS Four micro-narratives based on collective past experiences were generated to explain concepts of age-old patient-centered scientific accuracy and precision and four macro-narratives were collected from individual learners in our CBBLE. Insights gathered from a critical appraisal and thematic analysis of the narratives were discussed. DISCUSSION AND CONCLUSION Case-based narratives from the individual learners in our CBBLE amply illustrate their journeys beginning with “age-old precision thinking” in low-resource settings and progressing to “omics-driven” high-resource precision medicine setups to demonstrate how the approaches, used judiciously, might reduce the current pandemic of over-/underdiagnosis and over-/undertreatment.
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Affiliation(s)
- Vivek Podder
- Department of Internal Medicine, Tairunnessa Memorial Medical College, Gazipur 1704, Bangladesh.
| | - Binod Dhakal
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
| | - Gousia Ummae Salma Shaik
- Department of Internal Medicine, Kamineni Institute of Medical Sciences, Narketpally 508254, India.
| | - Kaushik Sundar
- Department of Neurology, Rajagiri Hospital, Chunanangamvely, Aluva 683112, India.
| | - Madhava Sai Sivapuram
- Department of Internal Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinaoutapalli 521101, India.
| | - Vijay Kumar Chattu
- Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St. Augustine 0000, Trinidad and Tobago.
| | - Rakesh Biswas
- Department of Internal Medicine, Kamineni Institute of Medical Sciences, Narketpally 508254, India.
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Walters MA. Management of Chronic Stable Angina. Crit Care Nurs Clin North Am 2017; 29:487-493. [PMID: 29107310 DOI: 10.1016/j.cnc.2017.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chronic stable angina (CSA) is a symptomatic problem that is precipitated by ischemic heart disease. CSA is diagnosed when symptoms are present for at least 2 months without changes in severity, character, or triggering circumstances. This article is a summary of current treatment strategies aimed to prevent progression of atherosclerosis, and medication therapies to control angina symptoms and improve quality of life for the individual.
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Affiliation(s)
- Michele Ann Walters
- Department of Nursing, Morehead State University, St. Claire Regional Family Medicine, 316 West Second Street, CHER 201F, Morehead, KY 40351, USA.
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Abstract
BACKGROUND Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment. METHODS 2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment. FINDINGS The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs. CONCLUSION From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.
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Lyu H, Xu T, Brotman D, Mayer-Blackwell B, Cooper M, Daniel M, Wick EC, Saini V, Brownlee S, Makary MA. Overtreatment in the United States. PLoS One 2017; 12:e0181970. [PMID: 28877170 PMCID: PMC5587107 DOI: 10.1371/journal.pone.0181970] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/10/2017] [Indexed: 01/13/2023] Open
Abstract
Background Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment. Methods 2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment. Findings The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs. Conclusion From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.
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Affiliation(s)
- Heather Lyu
- Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Tim Xu
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel Brotman
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Brandan Mayer-Blackwell
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michol Cooper
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michael Daniel
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Elizabeth C. Wick
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Vikas Saini
- The Lown Institute, Boston, Massachusetts, United States of America
| | - Shannon Brownlee
- The Lown Institute, Boston, Massachusetts, United States of America
| | - Martin A. Makary
- Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Hensher M, Tisdell J, Zimitat C. “Too much medicine”: Insights and explanations from economic theory and research. Soc Sci Med 2017; 176:77-84. [DOI: 10.1016/j.socscimed.2017.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 01/10/2017] [Accepted: 01/16/2017] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Surgery-related mortality depends on a number of factors including the type of surgical procedure, quality of healthcare, co-morbidities, and age of patient. The objective of the study was to assess the in-hospital mortality in the elderly undergoing surgical treatment. METHODS This was a national data-based retrospective cohort study. Data were extracted from the National Health Fund, a public organization financing medical procedures in Poland. Adult citizens who underwent 9,344,384 surgical interventions (including 3,093,254 cases in seniors who were above 65 years old) between 2009 and 2012 were included in this study. Overall, surgery type-dependent, age-stratified in-hospital mortality related to surgery was assessed. RESULTS Overall in-hospital surgery-related mortality rate in seniors was stable (approximately 2 % annually, P for trend = 0.104). It doubled with each successive decade of life (1.2, 2.3, 5.6, and 13 % in 65-74, 75-84, 85-94 and ≥ 95 years old groups, respectively, in 2012). In ≥ 75-year-old mortality exceeded 10 % only after neurological surgeries, in ≥ 85-year-old after neurological, vascular, gastrointestinal, and endocrinological surgeries, and in ≥ 95-year-old also after heart and circulation, bones and muscles, liver, pancreas, and spleen operations. However, even in the oldest individuals it was low after genitourinary, female genital tract, head and neck, and eye surgeries. CONCLUSIONS The overall rate of in-hospital mortality after surgery, although increasing with age, is rather low up to the ninth decade of life. Whereas some surgeries pose a significant risk, others may be relatively safe even in the oldest subjects.
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Kosloff TM, Elton D, Shulman SA, Clarke JL, Skoufalos A, Solis A. Conservative spine care: opportunities to improve the quality and value of care. Popul Health Manag 2013; 16:390-6. [PMID: 23965043 PMCID: PMC3870576 DOI: 10.1089/pop.2012.0096] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Low back pain (LBP) has received considerable attention from researchers and health care systems because of its substantial personal, social, work-related, and economic consequences. A narrative review was conducted summarizing data about the epidemiology, care seeking, and utilization patterns for LBP in the adult US population. Recommendations from a consensus of clinical practice guidelines were compared to findings about the current state of clinical practice for LBP. The impact of the first provider consulted on the quality and value of care was analyzed longitudinally across the continuum of episodes of care. The review concludes with a description of recently published evidence that has demonstrated that favorable health and economic outcomes can be achieved by incorporating evidence-informed decision criteria and guidance about entry into conservative low back care pathways.
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Affiliation(s)
| | - David Elton
- Clinical Programs at UnitedHealth Group, Optum Health, Golden Valley, Minnesota
| | - Stephanie A. Shulman
- Innovative Health and Technology Solutions, Optum Health Care Solutions, Golden Valley, Minnesota
| | - Janice L. Clarke
- Jefferson School of Population Health, Philadelphia, Pennsylvania
| | - Alexis Skoufalos
- Jefferson School of Population Health, Philadelphia, Pennsylvania
| | - Amanda Solis
- Jefferson School of Population Health, Philadelphia, Pennsylvania
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