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Doshmangir L, Jabbari H, Arab-Zozani M, Naghavi-Behzad M, Abedi Z, Mostafavi H. Factors affecting hospital services overutilization and reductive strategies in Iran: a qualitative study to explore experts' views. Hosp Pract (1995) 2022; 50:416-424. [PMID: 36222088 DOI: 10.1080/21548331.2022.2134679] [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: 02/24/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES This study aimed to investigate the viewpoints of the main stakeholders of the Iranian healthcare system about the overutilization of hospital services and strategies to eliminate or reduce it in Iran. METHODS This is a qualitative study and thematic data analysis using face-to-face semi-structured interviews and Focus Group Discussions (FGDs). We conducted eight interviewers and two FGDs with hospital stakeholders including faculty members, insurance organizations' authorities, experienced hospital administrative staff, hospital managers, and health-care providers. RESULTS The factors leading to the overutilization of hospital services were categorized into four main themes including site of service, quality, supplier push, and demand pull. Strategies for eliminating or reducing the overutilization of hospital services are also identified based on the influential factors. CONCLUSION Addressing overutilization of hospital services in the health system and adherence to policies for reducing or eliminating overutilization is a way to make preventive strategies to overcome overutilization. Developing a national plan to integrate utilization management into health system programs is a strategy to combat overutilization in various levels of the health system including hospital setting.
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Affiliation(s)
- Leila Doshmangir
- Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Social Determinants of Health Research Centre, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Jabbari
- Department of Community Medicine, School of Medicine, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Zeinab Abedi
- Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hakimeh Mostafavi
- Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Overmars LM, Niemantsverdriet MSA, Groenhof TKJ, De Groot MCH, Hulsbergen-Veelken CAR, Van Solinge WW, Musson REA, Ten Berg MJ, Hoefer IE, Haitjema S. A Wolf in Sheep’s Clothing: Reuse of Routinely Obtained Laboratory Data in Research. J Med Internet Res 2022; 24:e40516. [DOI: 10.2196/40516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/19/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
Electronic health records (EHRs) contain valuable data for reuse in science, quality evaluations, and clinical decision support. Because routinely obtained laboratory data are abundantly present, often numeric, generated by certified laboratories, and stored in a structured way, one may assume that they are immediately fit for (re)use in research. However, behind each test result lies an extensive context of choices and considerations, made by both humans and machines, that introduces hidden patterns in the data. If they are unaware, researchers reusing routine laboratory data may eventually draw incorrect conclusions. In this paper, after discussing health care system characteristics on both the macro and micro level, we introduce the reader to hidden aspects of generating structured routine laboratory data in 4 steps (ordering, preanalysis, analysis, and postanalysis) and explain how each of these steps may interfere with the reuse of routine laboratory data. As researchers reusing these data, we underline the importance of domain knowledge of the health care professional, laboratory specialist, data manager, and patient to turn routine laboratory data into meaningful data sets to help obtain relevant insights that create value for clinical care.
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Muris DMJ, Molenaers M, Nguyen T, Bergmans PWMP, van Acker BAC, Krekels MME, Cals JWL. Effect of a price display intervention on laboratory test ordering behavior of general practitioners. BMC FAMILY PRACTICE 2021; 22:242. [PMID: 34861828 PMCID: PMC8639847 DOI: 10.1186/s12875-021-01591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/16/2021] [Indexed: 11/25/2022]
Abstract
Background Redundant use of diagnostic tests in primary care has shown to be a contributor to rising Dutch healthcare costs. A price display in the test ordering system of the electronic health records (EHRs) could potentially be a low-cost and easy to implement intervention to a decrease in test ordering rate in the primary care setting by creating more cost-awareness among general practitioners (GPs). The aim of this study was to assess the effect of a price display for diagnostic laboratory tests in the EHR on laboratory test ordering behavior of GPs in the Westelijke Mijnstreek region in the Netherlands. Methods A pre-post intervention study among 154 GPs working in 57 general practices was conducted from September 2019, until March 2020, in the Netherlands. The intervention consisted of displaying the costs of 22 laboratory tests at the time of ordering. The primary outcome was the mean test ordering rate per 1.000 patients per month, per general practice. Results Test ordering rates were on average rising prior to the intervention. The total mean monthly test order volume showed a non-statistically significant interruption in this rising trend after the intervention, with the mean monthly test ordering rate levelling out from 322.4 to 322.2 (P = 0.86). A subgroup analysis for solely individually priced tests showed a statistically significant decrease in mean monthly test ordering rate after implementation of the price display for the sum of all tests from 67.2 to 63.3 (P = 0.01), as well as for some of these tests individually (i.e. thrombocytes, ALAT, TSH, folic acid). Leucocytes, ESR, vitamin B12, anti-CCP and NT-proBNP also showed a decrease, albeit not statistically significant (P > 0.05). Conclusions Our study suggests that a price display intervention is a simple tool that can alter physicians order behavior and constrain the expanding use of laboratory tests. Future research might consider alternative study designs and a longer follow-up period. Furthermore, in future studies, the combination with a multitude of interventions, like educational programs and feedback strategies, should be studied, while potentially adverse events caused by reduced testing should also be taken into consideration. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01591-w.
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Affiliation(s)
- Dennis M J Muris
- MCC Omnes Centre for Diagnostics and Innovation, Sittard, The Netherlands. .,Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, PO BOX 616, 6200, MD, Maastricht, The Netherlands.
| | - Max Molenaers
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, PO BOX 616, 6200, MD, Maastricht, The Netherlands
| | - Trang Nguyen
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, PO BOX 616, 6200, MD, Maastricht, The Netherlands
| | | | | | - Mariëlle M E Krekels
- MCC Omnes Centre for Diagnostics and Innovation, Sittard, The Netherlands.,Department of Internal Medicine, Zuyderland Medical Centre, Sittard, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, PO BOX 616, 6200, MD, Maastricht, The Netherlands
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Kraus KR, Buller LT, Caccavallo PP, Ziemba-Davis M, Meneghini RM. Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty? J Arthroplasty 2021; 36:24-29. [PMID: 32778415 PMCID: PMC7364149 DOI: 10.1016/j.arth.2020.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/03/2020] [Accepted: 07/10/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthoplasty (TJA) cost containment has been a key focus for the Centers for Medicare and Medicaid Services spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions before discharge, but the type and quantity of interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA. METHODS 1725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures, results of interventions, and readmissions. RESULTS 759 patients were discharged on postoperative day 1. Eighty-four percent (641 of 759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. Ninety-two percent (11 of 12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in and out catheterizations for urinary retention. 90-day all-cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention. CONCLUSION Most patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.
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Affiliation(s)
- Kent R. Kraus
- Indiana University School of Medicine, Indianapolis, IN
| | - Leonard T. Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN,Indiana University Health Orthopedics, Indiana University Health Physicians, Indianapolis, IN,Reprint requests: Leonard T. Buller, MD, Department of Orthopaedic Surgery, Indiana University School of Medicine, 13000 East 136th Street Suite 2000, Fishers, IN 46037
| | | | - Mary Ziemba-Davis
- Indiana University Health Orthopedics, Indiana University Health Physicians, Indianapolis, IN
| | - R. Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN,Indiana University Health Orthopedics, Indiana University Health Physicians, Indianapolis, IN
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Bindraban RS, van Beneden M, Kramer MHH, van Solinge WW, van de Ven PM, Naaktgeboren CA, Al-Dulaimy M, van der Wekken LC, Bandt YC, Stam F, Neppelenbroek SIM, Griffioen-Keijzer A, Castelijn DAR, Wevers BA, Boerman AW, van Wijnen M, ten Berg MJ, Nanayakkara PWB. Association of a Multifaceted Intervention With Ordering of Unnecessary Laboratory Tests Among Caregivers in Internal Medicine Departments. JAMA Netw Open 2019; 2:e197577. [PMID: 31339544 PMCID: PMC6659142 DOI: 10.1001/jamanetworkopen.2019.7577] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Inappropriate use of laboratory testing is a challenging problem. Estimated overuse rates of approximately 20% have been reported. Effective, sustainable solutions to stimulate optimal use are needed. OBJECTIVE To determine the association of a multifaceted intervention with laboratory test volume. DESIGN, SETTING, AND PARTICIPANTS A before-after quality improvement study was performed between August 1, 2016, and April 30, 2018, in the internal medicine departments of 4 teaching hospitals in the Netherlands. Data on laboratory order volumes from 19 comparable hospitals were used as controls. The participants were clinicians ordering laboratory tests. INTERVENTIONS The intervention included creating awareness through education and feedback, intensified supervision of residents, and changes in order entry systems. Interventions were performed by local project teams and guided by a central project team during a 6-month period. Sustainability was investigated during an 8-month follow-up period. MAIN OUTCOMES AND MEASURES The primary outcome was the change in slope for laboratory test volume. Secondary outcomes were change in slope for laboratory expenditure, order volumes and expenditure for other diagnostic procedures, and clinical outcomes. Data were collected on duration of hospital stay, rate of repeated outpatient visits, 30-day readmission rate, and rate of unexpected prolonged duration of hospital stay for patients admitted for pneumonia. RESULTS The numbers of internists and residents ordering tests in hospitals 1 to 4 were 16 and 30, 18 and 20, 13 and 17, and 21 and 60, respectively. Statistically significant changes in slope for laboratory test volume per patient contact were found at hospital 1 (change in slope, -1.55; 95% CI, -1.98 to -1.11; P < .001), hospital 3 (change in slope, -0.74; 95% CI, -1.42 to -0.07; P = .03), and hospital 4 (change in slope, -2.18; 95% CI, -3.27 to -1.08; P < .001). At hospital 2, the change in slope was not statistically significant (-0.34; 95% CI, -2.27 to 1.58; P = .73). Laboratory test volume per patient contact decreased by 11.4%, whereas the volume increased by 2.4% in 19 comparable hospitals. Statistically significant changes in slopes for laboratory costs and volumes and costs for other diagnostic procedures were also observed. Clinical outcomes were not associated with negative changes. Important facilitators were education, continuous attention for overuse, feedback, and residents' involvement. Important barriers were difficulties in data retrieval, difficulty in incorporation of principles in daily practice, and high resident turnover. CONCLUSIONS AND RELEVANCE A set of interventions aimed at changing caregivers' mindset was associated with a reduction in the laboratory test volume in all departments, whereas the volume increased in comparable hospitals in the Netherlands. This study provides a framework for nationwide implementation of interventions to reduce unnecessary laboratory testing.
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Affiliation(s)
- Renuka S. Bindraban
- Section of Acute Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marlou van Beneden
- Section of Acute Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Mark H. H. Kramer
- Section of Acute Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wouter W. van Solinge
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter M. van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Christiana A. Naaktgeboren
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Muhammad Al-Dulaimy
- Department of Internal Medicine, Zaans Medical Center, Zaandam, the Netherlands
| | | | - Yvonne C. Bandt
- Department of Clinical Pharmacy, Zaans Medical Center, Zaandam, the Netherlands
| | - Frank Stam
- Department of Internal Medicine, North-West Hospital Group, Alkmaar, the Netherlands
| | | | - Anita Griffioen-Keijzer
- Department of Internal Medicine, Spaarne Gasthuis, Haarlem, the Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Daan A. R. Castelijn
- Department of Internal Medicine, Spaarne Gasthuis, Haarlem, the Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | | | - Anneroos W. Boerman
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - Merel van Wijnen
- Department of Clinical Chemistry, Meander Medical Center, Amersfoort, the Netherlands
| | - Maarten J. ten Berg
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Prabath W. B. Nanayakkara
- Section of Acute Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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