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Yaxley J. Anaesthesia in chronic dialysis patients: A narrative review. World J Crit Care Med 2025; 14:100503. [DOI: 10.5492/wjccm.v14.i1.100503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Revised: 10/27/2024] [Accepted: 11/12/2024] [Indexed: 12/11/2024] Open
Abstract
The provision of anaesthesia for individuals receiving chronic dialysis can be challenging. Sedation and anaesthesia are frequently managed by critical care clinicians in the intensive care unit or operating room. This narrative review summarizes the important principles of sedation and anaesthesia for individuals on long-term dialysis, with reference to the best available evidence. Topics covered include the pharmacology of anaesthetic agents, the impacts of patient characteristics upon the pre-anaesthetic assessment and critical illness, and the fundamentals of dialysis access procedures.
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Affiliation(s)
- Julian Yaxley
- Department of Medicine, Queensland Health, Meadowbrook 4131, Qld, Australia
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D'Amiano NM, Bertram A, Matthew Stewart C, Stewart RW. Excessive Preoperative Testing in Otolaryngology: A Retrospective Comparison of Primary Care and Perioperative Providers. Otolaryngol Head Neck Surg 2024; 171:1394-1400. [PMID: 38881410 DOI: 10.1002/ohn.852] [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: 01/09/2024] [Revised: 04/23/2024] [Accepted: 05/23/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To assess the association between provider type (primary care provider [PCP] or perioperative provider) and excessive preoperative testing. STUDY DESIGN Cross-sectional study. SETTING Academic medical center. METHODS Electronic medical records of adult patients who obtained an outpatient preoperative assessment and underwent surgery in the Department of Otolaryngology-Head and Neck Surgery during the first 2 weeks of January 2019 (n = 94) were reviewed. Patients receiving preoperative tests beyond those recommended by the guidelines were deemed to have had excessive testing. Descriptive statistics were used to characterize the study population. Simple and multivariate logistic regression were used to analyze the association between the outcome and the predictor variables. RESULTS Overall, 44.7% of preoperative evaluations had excessive testing. Patients who had their preoperative evaluation performed by a perioperative provider had 89% lower odds of having excessive preoperative testing compared to those evaluated by a PCP (odds ratio = 0.11, 95% confidence interval: [0.03, 0.37], P < .001). Female sex, younger age, and higher risk of major adverse cardiac events were associated with greater odds of excessive testing. CONCLUSION Excessive preoperative testing is more commonly performed by PCPs compared to perioperative providers. These results give preliminary evidence in support of a potential shift in the clinical responsibility of preoperative evaluation from PCPs to perioperative providers in order to reduce excessive testing and promote high-value health care. The next steps include validating these findings, identifying reasons for differential guideline concordance, and intervening accordingly.
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Affiliation(s)
- Nina M D'Amiano
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amanda Bertram
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles Matthew Stewart
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rosalyn W Stewart
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Wen M, Li L, Zhang Y, Shao J, Chen Z, Wang J, Zhang L, Sun J. Advancements in defensive medicine research: Based on current literature. Health Policy 2024; 147:105125. [PMID: 39018785 DOI: 10.1016/j.healthpol.2024.105125] [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: 01/05/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/19/2024]
Abstract
To investigate and comprehend the evolving research hotspots, cutting-edge trends, and frontiers associated with defensive medicine. The original data was collected from the Web of Science core collection and then subjected to a preliminary retrieval process. Following screening, a total of 654 relevant documents met the criteria and underwent subsequent statistical analysis. Software CiteSpace was employed for conducting a customized visual analysis on the number of articles, keywords, research institutions, and authors associated with defensive medicine. The defensive medicine research network was primarily established in Western countries, particularly the United States, and its findings and conceptual framework have significantly influenced defensive medicine research in other regions. Currently, quantitative methods dominated most studies while qualitative surveys remained limited. Defensive medicine research mainly focused on high-risk medical specialties such as surgery and obstetrics. Research on defensive medicine pertained to the core characteristics of its conceptual framework. An in-depth investigation into the factors that give rise to defensive medicine is required, along with the generation of more generalizable research findings to provide valuable insights for improving and intervening in defensive medicine.
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Affiliation(s)
- Minhui Wen
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Limin Li
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Yuqing Zhang
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Jiayi Shao
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Zhen Chen
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jinian Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Liping Zhang
- School of Marxism, Anhui Medical University, Hefei, China
| | - Jiangjie Sun
- School of Health Care Management, Anhui Medical University, Hefei, China; School of Management, Hefei University of Technology, Hefei, Anhui, China.
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Barón-Esquivias G, Quintanilla M, Díaz-Martín AJ, Barón-Solís C, Almeida-González CV, García-Romero C, Paneque I, Rubio-Guerrero C, Rodríguez-Corredor R, Valle-Racero JI, Ordóñez A, Morillo CA. Long-term recurrences and mortality in patients with noncardiac syncope. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:568-575. [PMID: 34969644 DOI: 10.1016/j.rec.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/07/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES There are no in-depth studies of the long-term outcome of patients with syncope after exclusion of cardiac etiology. We therefore analyzed the long-term outcome of this population. METHODS For 147 months, we included all patients with syncope referred to our syncope unit after exclusion of a cardiac cause. RESULTS We included 589 consecutive patients. There were 313 (53.1%) women, and the median age was 52 [34-66] years. Of these, 405 (68.8%) were diagnosed with vasovagal syncope (VVS), 65 (11%) with orthostatic hypotension syncope (OHS), and 119 (20.2%) with syncope of unknown etiology (SUE). During a median follow-up of 52 [28-89] months, 220 (37.4%) had recurrences (21.7% ≥ 2 recurrences), and 39 died (6.6%). Syncope recurred in 41% of patients with VVS, 35.4% with OHS, and 25.2% with SUE (P=.006). In the Cox multivariate analysis, recurrence was correlated with age (P=.002), female sex (P <.0001), and the number of previous episodes (< 5 vs ≥ 5; P <.0001). Death occurred in 15 (3.5%) patients with VVS, 11 (16.9%) with OHS, and 13 (10.9%) with SUE (P=.001). In the multivariate analysis, death was associated with age (P=.0001), diabetes (P=.007), and diagnosis of OHS (P=.026) and SUE (P=.020). CONCLUSIONS In patients with noncardiac syncope, the recurrence rate after 52 months of follow-up was 37.4% and mortality was 6.6% per year. Recurrence was higher in patients with a neuromedial profile and mortality was higher in patients with a nonneuromedial profile.
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Affiliation(s)
- Gonzalo Barón-Esquivias
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain; Unidad Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Macarena Quintanilla
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Antonio J Díaz-Martín
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Carmen Barón-Solís
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Carmen V Almeida-González
- Unidad de Metodología, Estadística e Investigación, Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain
| | - Carmen García-Romero
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Inmaculada Paneque
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Carmen Rubio-Guerrero
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Rosario Rodríguez-Corredor
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Juan I Valle-Racero
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain
| | - Antonio Ordóñez
- Servicio de Cardiología y Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Seville, Spain; Unidad Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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Barón-Esquivias G, Quintanilla M, Díaz-Martín AJ, Barón-Solís C, Almeida-González CV, García-Romero C, Paneque I, Rubio-Guerrero C, Rodríguez-Corredor R, Valle-Racero JI, Ordóñez A, Morillo CA. Recurrencia y mortalidad a largo plazo de los pacientes con síncope no cardiogénico. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Professional Performance Audit and Feedback for Quality Improvement: Necessary but Insufficient. Jt Comm J Qual Patient Saf 2021; 48:129-130. [PMID: 35012878 DOI: 10.1016/j.jcjq.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Schaffer AC, Yu-Moe CW, Babayan A, Wachter RM, Einbinder JS. Rates and Characteristics of Medical Malpractice Claims Against Hospitalists. J Hosp Med 2021; 16:390-396. [PMID: 34197302 DOI: 10.12788/jhm.3557] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hospitalists practice in high-stakes and litigious settings. However, little data exist about the malpractice claims risk faced by hospitalists. OBJECTIVE To characterize the rates and characteristics of malpractice claims against hospitalists. DESIGN, SETTING, AND PARTICIPANTS An analysis was performed of malpractice claims against hospitalists, as well as against select other specialties, using data from a malpractice claims database that includes approximately 31% of US malpractice claims. MAIN OUTCOMES AND MEASURES For malpractice claims against hospitalists (n = 1,216) and comparator specialties (n = 18,644): claims rates (using a data subset), percentage of claims paid, median indemnity payment amounts, allegation types, and injury severity. RESULTS Hospitalists had an annual malpractice claims rate of 1.95 claims per 100 physician-years, similar to that of nonhospitalist general internal medicine physicians (1.92 claims per 100 physician-years), and significantly greater than that of internal medicine subspecialists (1.30 claims per 100 physician-years) (P < .001). Claims rates for hospitalists nonsignificantly increased during the study period (2009-2018), whereas claims rates for four of the five other specialties examined significantly decreased over this period. The median indemnity payment for hospitalist claims was $231,454 (interquartile range, $100,000-$503,015), significantly higher than the amounts for all the other specialties except neurosurgery. The greatest predictor of a hospitalist case closing with payment (compared with no payment) was an error in clinical judgment as a contributing factor, with an adjusted odds ratio of 5.01 (95% CI, 3.37-7.45). CONCLUSION During the study period, hospitalist claims rates did not drop, whereas they fell for other specialties. Hospitalists' claims had relatively high injury severity and median indemnity payment amounts. The malpractice environment for hospitalists is becoming less favorable.
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Affiliation(s)
- Adam C Schaffer
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Chihwen Winnie Yu-Moe
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
| | - Astrid Babayan
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
| | - Robert M Wachter
- University of California, San Francisco, San Francisco, California
| | - Jonathan S Einbinder
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Roczniewska M, von Thiele Schwarz U, Augustsson H, Nilsen P, Ingvarsson S, Hasson H. How do healthcare professionals make decisions concerning low-value care practices? Study protocol of a factorial survey experiment on de-implementation. Implement Sci Commun 2021; 2:50. [PMID: 34011415 PMCID: PMC8136038 DOI: 10.1186/s43058-021-00153-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A large number of practices used in health care lack evidence of effectiveness and may be unnecessary or even cause harm. As such, they should be de-implemented. While there are multiple actors involved in de-implementation of such low-value care (LVC) practices, ultimately, the decision to abandon a practice is often made by each health care professional. A recent scoping review identified 6 types of factors affecting the utilization vs. abandonment of LVC practices. These factors concern health care professionals, patients, outer context, inner context, processes, and the characteristics of LVC practice itself. However, it is unclear how professionals weigh these different factors in and how these determinants influence their decisions about abandoning LVC practices. This project aims to investigate how health care professionals account for various factors as they make decisions regarding de-implementation of LVC practices. METHODS This project will be carried out in two main steps. First, a factorial survey experiment (a vignette study) will be applied to empirically test the relevance of factors previously identified in the literature for health care professionals' decision-making about de-implementation. Second, interactive workshops with relevant stakeholders will be carried out to develop a framework for professionals' decision-making and to offer suggestions for interventions to support de-implementation of LVC practices. DISCUSSION The project has the potential to contribute to improved understanding of the decision-making involved in de-implementation of LVC practices. We will identify which factors are more important when they make judgments about utilizing versus abandoning LVC practices. The results will provide the basis for recommendations concerning appropriate interventions to support de-implementation decision-making processes.
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Affiliation(s)
- Marta Roczniewska
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychology, SWPS University of Social Sciences and Humanities, Sopot, Poland
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Health and Society, Linköping University, Linköping, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden.
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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: 50] [Impact Index Per Article: 12.5] [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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Reza JA, Steve Eubanks W, de la Fuente SG. Clinical and Financial Implications of Consulting Physicians in the Management of Surgical Patients. Am Surg 2020; 88:578-586. [PMID: 33291943 DOI: 10.1177/0003134820952439] [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: 11/16/2022]
Abstract
BACKGROUND The present study was designed to evaluate the immediate consequences that the number of consulting physicians has on length of stay (LOS), in-hospital mortality, 30-day readmission rates, direct health care costs, and contribution margins. METHODS A retrospective review of administrative databases for the years 2013 and 2014 was performed at the Florida Hospital Adventist Healthcare System. RESULTS 11 274 patients were included in the analysis. Total and variable costs increased by $1347 and $592, respectively, with each consulting physician service per patient. The contribution margin decreased by $354 per patient/consulting physician. Each consulting physician increased LOS by .72 days and increased odds ratio of mortality and 30-day readmission by 5% and 3%, respectively. CONCLUSIONS Our research suggests that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, in-hospital mortality, and costs.
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Affiliation(s)
- Joseph A Reza
- Department of Surgery, AdventHealth Orlando, FL, USA
| | - W Steve Eubanks
- Department of Surgery, AdventHealth Orlando, FL, USA.,University of Central Florida, Orlando, FL, USA
| | - Sebastian G de la Fuente
- Department of Surgery, AdventHealth Orlando, FL, USA.,University of Central Florida, Orlando, FL, USA
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Kherad O, Peiffer-Smadja N, Karlafti L, Lember M, Aerde NV, Gunnarsson O, Baicus C, Vieira MB, Vaz-Carneiro A, Brucato A, Lazurova I, Leśniak W, Hanslik T, Hewitt S, Papanicolaou E, Boeva O, Dicker D, Ivanovska B, Yldiz P, Lacor P, Cranston M, Weidanz F, Costantino G, Montano N. The challenge of implementing Less is More medicine: A European perspective. Eur J Intern Med 2020; 76:1-7. [PMID: 32303454 DOI: 10.1016/j.ejim.2020.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/12/2020] [Accepted: 04/04/2020] [Indexed: 01/05/2023]
Abstract
The concept of Less is More medicine emerged in North America in 2010. It aims to serve as an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health, tackling the erroneous assumption that more care is always better. In response, several medical societies across the world launched quality-driven campaigns ("Choosing Wisely") and published "top-five lists" of low-value medical interventions that should be used to help make wise decisions in each clinical domain, by engaging patients in conversations about unnecessary tests, treatments and procedures. However, barriers and challenges for the implementation of Less is More medicine have been identified in several European countries, where overuse is rooted in the culture and demanded by a society that requests certainty at almost any cost. Patients' high expectations, physician's behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement Less is More recommendations. These also consist of a top-five list of actions: (1) a novel cultural approach starting from medical graduation courses, up to (2) patient and society education, (3) physician behavior change with data feedback, (4) communication training and (5) policy maker interventions. In contrast with the prevailing maximization of care, the optimization of care promoted by Less is More medicine can be an intellectual challenge but also a real opportunity to promote sustainable medicine. This project will constitute part of the future agenda of the European Federation of Internal Medicine.
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Affiliation(s)
- Omar Kherad
- Department of Internal Medicine, La Tour Hospital and University of Geneva, Geneva, Switzerland.
| | - Nathan Peiffer-Smadja
- Assistance Publique - Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Lina Karlafti
- 1st Proedeutic Internal Medicine Clinic, AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Greece
| | - Margus Lember
- Department of Internal Medicine, University of Tartu and University Hospital, Tartu, Estonia
| | - Nathalie Van Aerde
- Invited member of the Belgian Society of Internal Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Orvar Gunnarsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Cristian Baicus
- Department of Internal Medicine, Carol Davila University of Medicine and Pharmacy, Colentina University Hospital, Bucharest, Romania
| | - Miguel Bigotte Vieira
- Serviço de Nefrologia, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Centro de Estudos de Medicina Baseados na Evidência, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Cochrane Portugal, Lisboa, Portugal
| | - António Vaz-Carneiro
- Centro de Estudos de Medicina Baseados na Evidência, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Cochrane Portugal, Lisboa, Portugal
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Fatebenefratelli Hospital, Milan, Italy
| | - Ivica Lazurova
- PJ Safarik University I. Internal Clinic, Kosice, Slovakia
| | - Wiktoria Leśniak
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Thomas Hanslik
- Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Paris, France
| | - Stephen Hewitt
- Medical Division, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway
| | | | - Olga Boeva
- Imaging Department, Stavropol State Medical University and Stavropol Territory Hospital, Russian Federation
| | - Dror Dicker
- Department of Internal Medicine, Rabin Medical Center, Petah Tikva, Israel
| | - Biljana Ivanovska
- Private Health Organization, Office of Internal Medicine, Skopje, Macedonia
| | - Pinar Yldiz
- Department of Internal Medicine İstanbul, Eskisehir Osmangazi University, Eskişehir, Turkey
| | - Patrick Lacor
- Department of Internal Medicine and Infectiology, Universitair Ziekenhuis, Brussel, Belgium
| | - Mark Cranston
- MBBS Hinchingbrooke Hospital, Huntingdon, United Kingdom
| | | | - Giorgio Costantino
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, and Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Nicola Montano
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, and Department of Clinical Science and Community Health, University of Milan, Milan, Italy.
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Fernando RJ, Goeddel LA, Shah R, Ramakrishna H. Analysis of the 2019 ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS Appropriate Use Criteria for Multimodal Imaging in the Assessment of Structural Heart Disease. J Cardiothorac Vasc Anesth 2019; 34:805-818. [PMID: 31196720 DOI: 10.1053/j.jvca.2019.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh J Fernando
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Lee A Goeddel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ronak Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Philadelphia, PA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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13
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Preoperative Evaluation for Minimally Invasive Gynecologic Surgery: What Is the Best Evidence and Recommendations for Clinical Practice. J Minim Invasive Gynecol 2019; 26:312-320. [DOI: 10.1016/j.jmig.2018.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/16/2018] [Accepted: 08/24/2018] [Indexed: 11/23/2022]
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Han PJ, Tsai BT, Martin JW, Keen WD, Waalen J, Kimura BJ. Evidence Basis for a Point-of-Care Ultrasound Examination to Refine Referral for Outpatient Echocardiography. Am J Med 2019; 132:227-233. [PMID: 30691553 DOI: 10.1016/j.amjmed.2018.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few data exist on the potential utility of a cardiac point-of-care ultrasound (POCUS) examination in the outpatient setting to assist diagnosis of significant cardiac disease. Using a retrospective sequential cohort design, we sought to derive and then validate a POCUS examination for cardiac application and model its potential use for prognostication and cost-effective echo referral. METHODS For POCUS examination derivation, we reviewed 233 consecutive outpatient echo studies for 4 specific POCUS "signs" contained therein representing left ventricular systolic dysfunction, left atrial enlargement, inferior vena cava plethora, and lung apical B-lines. The corresponding formal echo reports were then queried for any significant abnormality. The optimal POCUS examination for identifying an abnormal echo was determined. We then reviewed 244 consecutive outpatient echo studies from another institution for associations between the optimal POCUS examination, clinical variables, and referral source with major adverse cardiac events and all-cause mortality in univariate and multivariate models. Assuming a referral model where the absence of POCUS signs or variables would negate initial echo referral, theoretical cost savings were expressed as a percentage in reduction of echo studies. RESULTS In the derivation cohort, the combination of two signs, denoting left atrial enlargement and inferior vena cava plethora resulted in the highest accuracy of 72% [95% CI: 65%, 78%] in detecting an abnormal echocardiogram. In the validation cohort, mortality at 5.5 years was 14.6% overall, 23% in patients with the left atrial enlargement sign (OR 3.5 [1.6, 7.6]), 25% with inferior vena cava plethora sign (OR 2.2 [0.8, 6.0]), and 8.0% (OR 0.3 [0.2, 0.7]) in those lacking both signs. After adjusting for age, both diabetes (OR 4.8 [2.0, 11.6]), and the left atrial enlargement sign (OR 2.4 [1.1, 5.4]) remained independently associated with mortality (p<0.05). In the referral model, patients younger than 65 years of age without diabetes and without the left atrial enlargement sign would not have received echo referral, resulting in a 33% reduction in total echo cost and would have constituted a low-risk group with a 1.2% 5.5-year mortality. CONCLUSIONS A quick-look sign for left atrial enlargement is associated with 5-year mortality and could function as an easily obtained outpatient POCUS examination to help in identifying patients in need of echo referral.
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Affiliation(s)
- Paul J Han
- Department of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, Calif
| | - Ben T Tsai
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - Julie W Martin
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - William D Keen
- Department of Cardiology, Kaiser Permanente, San Diego, Calif
| | - Jill Waalen
- Scripps Translational Science Research Institute, San Diego, Calif
| | - Bruce J Kimura
- Department of Cardiology and Graduate Medical Education, Scripps Mercy Hospital, San Diego, Calif.
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15
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Korenstein D, Chimonas S, Barrow B, Keyhani S, Troy A, Lipitz-Snyderman A. Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments. JAMA Intern Med 2018; 178:1401-1407. [PMID: 30105371 PMCID: PMC7505335 DOI: 10.1001/jamainternmed.2018.3573] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Overuse of medical tests and treatments is an increasingly recognized problem across health systems; best practices for reducing overuse are not clear. Framing the problem in terms of the spectrum of potential patient harm is likely to be an effective strategy for clinician and patient engagement in efforts to reduce overuse, but the scope of negative consequences of overuse for patients has not been well described. OBSERVATIONS We sought to generate a comprehensive conceptual map documenting the processes through which overused tests and treatments lead to multiple domains of negative consequences for patients. For map development, an iterative consensus process was informed by structured review of the literature on overuse using PubMed and input from a panel of 6 international experts. For map verification, a systematic review was performed of case reports involving overused services, identified through literature review and manual review of relevant article collections. The conceptual map documents that overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop. Case reports on overuse confirmed the processes and domains of the conceptual map. Cases also revealed strengths and weaknesses in published communication about overuse: they were dominated by physical harms, with other negative consequences receiving far less attention. CONCLUSIONS AND RELEVANCE This evidence-based conceptual map clarifies the processes by which overused tests and treatments result in negative consequences for patients; it also documents multiple domains of negative consequences experienced by patients. The map will be useful for facilitating comprehensive communication about overuse, estimating harms and costs associated with overused services, and informing health system efforts to reduce overuse.
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Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan Chimonas
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brooke Barrow
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Salomeh Keyhani
- Division of General Internal Medicine, University of California, San Francisco.,Precision Monitoring to Transform Care Quality Enhancement Research Initiative, San Francisco Veterans Affairs Hospital, San Francisco, California
| | - Aaron Troy
- New York University School of Medicine, New York, New York
| | - Allison Lipitz-Snyderman
- Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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16
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Rehman H, Ali F, Mangi MA. Choosing Wisely Campaign - Innovations in Cardiovascular Science and The United States Healthcare System. Cureus 2018; 10:e2931. [PMID: 30310762 PMCID: PMC6170190 DOI: 10.7759/cureus.2931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The United States (US) is the third most expensive health care system in the world, but despite that, the US ranked last in the top 50 countries of the world when it comes to the performance measures, such as healthcare efficiency, life expectancy, health care costs, and gross domestic product (GDP) percentage. The spending health care cost keeps increasing and most of the healthcare costs go to waste. Due to this reason, it is therefore extremely important to focus on improving the quality and to bring the costs in appropriate control. To avoid this issue, the Choosing Wisely Campaign (CWC) came into being in 2012. The CWC encourages discussions between providers and patients regarding the care based on the evidence base, free from harm, duplicative or redundant tests/procedures that the patient already received, and whether medications, tests, or procedures are really necessary. Although diagnostic tests or procedures are highly valued for decision-making, unnecessary testing creates harmful health services and an economic impact on the healthcare system. The CWC has spread widely throughout the world but has many challenges which are limiting the CWC in further adoption and spread in the US. To overcome challenges in implementing and spreading the CWC, the government, physicians, social media, and mass media play an important role.
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Affiliation(s)
- Hiba Rehman
- Internal Medicine, Hamdard University Hospital, Karachi, PAK
| | - Fahad Ali
- Cardiology, Lehigh Valley Hospital Network, Allentown, USA
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18
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Asuzu DT, Chao GF, Pei KY. Revised cardiac risk index poorly predicts cardiovascular complications after adhesiolysis for small bowel obstruction. Surgery 2018; 164:1198-1203. [PMID: 29945781 DOI: 10.1016/j.surg.2018.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/08/2018] [Accepted: 05/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The number of patients undergoing preoperative risk stratification in the United States is expected to increase as the population ages. A large percentage of patients undergo some form of preoperative testing, and society guidelines suggest that up to 50% of the testing in lower risk surgical subgroups is unnecessary. The Revised Cardiac Risk Index and the risk calculator of the American College of Surgeons National Surgical Quality Improvement Program are widely used tools as the first step of preoperative cardiac evaluation. The Revised Cardiac Risk Index was developed to fill a need for objective perioperative cardiac risk evaluation. Despite the ease of use of Revised Cardiac Risk Index, it is uncertain if the stratification is accurate for surgical patients because its accuracy in large surgical samples has not been tested. With the National Surgical Quality Improvement Program risk calculator having excellent accuracy in estimating cardiac complications (area under the receiver operating characteristic 0.895), a unique opportunity to test the predictive accuracy of postsurgical cardiac events became available. The purpose of this study is to determine the accuracy of the Revised Cardiac Risk Index for predicting cardiovascular complications after adhesiolysis for small bowel obstruction. METHODS From 2005 to 2015, 34,032 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for small bowel obstruction (International Classification of Diseases, 10th edition [ICD-10]) were analyzed using the National Surgical Quality Improvement Program dataset. Revised Cardiac Risk Index estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (area under the receiver operating characteristic) and model calibration (Hosmer-Lemeshow chi-squared statistics). RESULTS Although the Revised Cardiac Risk Index predicted cardiovascular complications with an odds ratio of 2.3 and a 95% confidence interval of 1.9 to 2.8 (P < .001) and the Hosmer-Lemeshow chi-square was significant (0.22, P = 0.64), the area under the receiver operating characteristic was poor (0.63, 95% confidence interval 0.59-0.67). CONCLUSION Despite its relative simplicity, the Revised Cardiac Risk Index performed poorly as a predictor of cardiovascular complications after adhesiolysis for small bowel obstruction. These findings question the utility of the Revised Cardiac Risk Index in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy.
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Affiliation(s)
- David T Asuzu
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Grace F Chao
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, CT.
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O'Sullivan JW, Albasri A, Nicholson BD, Perera R, Aronson JK, Roberts N, Heneghan C. Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open 2018; 8:e018557. [PMID: 29440142 PMCID: PMC5829845 DOI: 10.1136/bmjopen-2017-018557] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste. OBJECTIVE To identify overuse and underuse of diagnostic tests in primary care. DESIGN Systematic review and meta-analysis. DATA SOURCES AND ELIGIBILITY CRITERIA We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care. RESULTS We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively. CONCLUSIONS There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO REGISTRATION NUMBER CRD42016048832.
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Affiliation(s)
- Jack W O'Sullivan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Ali Albasri
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Rafael Perera
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
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20
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Saint S, Vaughn VM, Chopra V, Fowler KE, Kachalia A. Perception of Resources Spent on Defensive Medicine and History of Being Sued Among Hospitalists: Results from a National Survey. J Hosp Med 2018; 13:26-29. [PMID: 29068439 DOI: 10.12788/jhm.2800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The United States spends substantially more per capita for healthcare than any other nation. Defensive medicine is 1 source of such spending, but its extent is unclear. Using a national survey of approximately 1500 US hospitalists, we report the estimates the US hospitalists provided of the percent of resources spent on defensive medicine and correlates of their estimates. We also ascertained how many reported being sued. Sixty-eight percent of eligible recipients responded. Overall, respondents estimated that 37.5% of healthcare costs are due to defensive medicine. Just over 25% of our respondents, including 55% of those in practice for 20 years or more, reported being sued for medical malpractice. Veterans Affairs (VA) hospital affiliation, more years practicing as a physician, being male, and being a non-Hispanic white individual were all independently associated with decreased estimates of resources spent for defensive medicine.
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Affiliation(s)
- Sanjay Saint
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Health Policy and Innovation & Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Health Policy and Innovation & Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Health Policy and Innovation & Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Karen E Fowler
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Allen Kachalia
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Scott IA, Soon J, Elshaug AG, Lindner R. Countering cognitive biases in minimising low value care. Med J Aust 2017; 206:407-411. [PMID: 28490292 DOI: 10.5694/mja16.00999] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 11/09/2016] [Indexed: 11/17/2022]
Abstract
Cognitive biases in decision making may make it difficult for clinicians to reconcile evidence of overuse with highly ingrained prior beliefs and intuition. Such biases can predispose clinicians towards low value care and may limit the impact of recently launched campaigns aimed at reducing such care. Commonly encountered biases comprise commission bias, illusion of control, impact bias, availability bias, ambiguity bias, extrapolation bias, endowment effects, sunken cost bias and groupthink. Various strategies may be used to counter such biases, including cognitive huddles, narratives of patient harm, value considerations in clinical assessments, defining acceptable levels of risk of adverse outcomes, substitution, reflective practice and role modelling, normalisation of deviance, nudge techniques and shared decision making. These debiasing strategies have considerable face validity and, for some, effectiveness in reducing low value care has been shown in randomised trials.
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Affiliation(s)
| | - Jason Soon
- Royal Australasian College of Physicians, Sydney, NSW
| | - Adam G Elshaug
- Menzies Centre for Health Policy, University of Sydney, Sydney, NSW
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22
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Zikmund-Fisher BJ, Kullgren JT, Fagerlin A, Klamerus ML, Bernstein SJ, Kerr EA. Perceived Barriers to Implementing Individual Choosing Wisely ® Recommendations in Two National Surveys of Primary Care Providers. J Gen Intern Med 2017; 32:210-217. [PMID: 27599491 PMCID: PMC5264674 DOI: 10.1007/s11606-016-3853-5] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/01/2016] [Accepted: 08/11/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND While some research has examined general attitudes about efforts to reduce overutilization of services, such as the Choosing Wisely® (CW) initiative, little data exists regarding primary care providers' attitudes regarding individual recommendations. OBJECTIVE We sought to identify whether particular CW recommendations were perceived by primary care providers as difficult to follow, difficult for patients to accept, or both. DESIGN Two national surveys, one by mail to a random sample of 2000 U.S. primary care physicians in November 2013, and the second electronically to a random sample of 2500 VA primary care providers (PCPs) in October-December 2014. PARTICIPANTS A total of 603 U.S. primary care physicians and 1173 VA primary care providers. Response rates were 34 and 48 %, respectively. MAIN MEASURES PCP ratings of whether 12 CW recommendations for screening, testing and treatments applicable to adult primary care were difficult to follow and difficult for patients to accept; and ratings of potential barriers to reducing overutilization. KEY RESULTS For four recommendations regarding not screening or testing in asymptomatic patients, less than 20 % of PCPs found the CW recommendations difficult to accept (range 7.2-16.6 %) or difficult for patients to follow (12.2-19.3 %). For five recommendations regarding testing or treatment for symptomatic conditions, however, there was both variation in reported difficulty to follow (9.8-32 %) and a high level of reported difficulty for patients to accept (35.7-87.1 %). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists. CONCLUSIONS While PCPs found many CW recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. Overcoming PCPs' perceptions of patient acceptability will require approaches beyond routine physician education, feedback and financial incentives.
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Affiliation(s)
- Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA.
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Jeffrey T Kullgren
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Angela Fagerlin
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Mandi L Klamerus
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Steven J Bernstein
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Eve A Kerr
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Abstract
IMPORTANCE Overuse of medical care is an increasingly recognized problem in clinical medicine. OBJECTIVE To identify and highlight original research articles published in 2015 that are most likely to reduce overuse of medical care, organized into 3 categories: overuse of testing, overtreatment, and questionable use of services. The articles were reviewed and interpreted for their importance to clinical medicine. EVIDENCE REVIEW A structured review of English-language articles on PubMed published in 2015 and review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults. FINDINGS Between January 1, 2015, and December 31, 2015, we reviewed 1445 articles, of which 821 addressed overuse of medical care. Of these, 112 were deemed most relevant based on their originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by consensus using the same criteria. Findings included a doubling of specialty referrals and advanced imaging for simple headache (from 6.7% in 2000 to 13.9% in 2010); unnecessary hospital admission for low-risk syncope, often leading to adverse events; and overly frequent colonoscopy screening for 34% of patients. Overtreatment was common in the following areas: 1 in 4 patients with atrial fibrillation at low risk for thromboembolism received anticoagulation; 94% of testosterone replacement therapy was administered off guideline recommendations; 91% of patients resumed taking opioids after overdose; and 61% of patients with diabetes were treated to potentially harmfully low hemoglobin A1c levels (<7%). Findings also identified medical practices to question, including questionable use of treatment of acute low-back pain with cyclobenzaprine and oxycodone/acetaminophen; of testing for Clostridium difficile with molecular assays; and serial follow-up of benign thyroid nodules. CONCLUSIONS AND RELEVANCE The number of articles on overuse of medical care nearly doubled from 2014 to 2015. The present review promotes reflection on the top 10 articles and may lead to questioning other non-evidence-based practices.
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore2Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore3Center for Disease Dynamics, Economics, and Policy (CDDEP), Washington, DC
| | - Sanket S Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut5Department of Veterans Affairs West Haven, West Haven, Connecticut
| | - Scott M Wright
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mandatory Assignment of Modified Wells Score Before CT Angiography for Pulmonary Embolism Fails to Improve Utilization or Percentage of Positive Cases. AJR Am J Roentgenol 2016; 207:442-9. [DOI: 10.2214/ajr.15.15394] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Moriates C, Shah NT, Arora VM. A framework for the frontline: How hospitalists can improve healthcare value. J Hosp Med 2016; 11:297-302. [PMID: 26425782 DOI: 10.1002/jhm.2494] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 08/25/2015] [Accepted: 09/09/2015] [Indexed: 11/10/2022]
Abstract
As healthcare costs continue to grow, hospitalists may be able to help patients and health system administrators make decisions that generate higher-value care. In this article, we discuss 3 ways hospitalists can contribute to the mission of delivering value-based healthcare: design innovative strategies to coordinate care, advocate for appropriate utilization of tests and treatments, and lead local value-improvement initiatives. We also describe specific tools hospitalists can use in their daily practice, including the Choosing Wisely lists and the COST (Culture, Oversight, Systems Change, Training) framework for value-improvement initiatives.
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Affiliation(s)
- Christopher Moriates
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California
- Costs of Care, Inc, Boston, Massachusetts
| | - Neel T Shah
- Costs of Care, Inc, Boston, Massachusetts
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Vineet M Arora
- Costs of Care, Inc, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Burkowitz J, Merzenich C, Grassme K, Brüggenjürgen B. Insertable cardiac monitors in the diagnosis of syncope and the detection of atrial fibrillation: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 23:1261-72. [PMID: 26864396 DOI: 10.1177/2047487316632628] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Insertable or implantable cardiac monitors (ICMs) continuously monitor the heart rhythm and record irregularities over 3 years, enabling the diagnosis of infrequent rhythm abnormalities associated with syncope and stroke. The enhanced recognition capabilities of recent ICM models are able to accurately detect atrial fibrillation (AF) and have led to new applications of ICMs for the detection and monitoring of AF. METHODS AND RESULTS Based on a systematic literature search, two indications were identified for ICMs for which considerable evidence, including randomized studies, exists: diagnosing the underlying cardiac cause of unexplained recurrent syncope and detecting AF in patients after cryptogenic stroke (CS). Three randomized controlled trials (RCTs) were identified that compared the effectiveness of ICMs in diagnosing patients with unexplained syncope (n = 556) to standard of care. A meta-analysis was conducted in order to generate an overall effect size and confidence interval of the diagnostic yield of ICMs versus conventional monitoring. In the indication CS, one RCT and five observational studies were included in order to assess the performance of ICMs in diagnosing patients with AF (n = 1129). Based on these studies, there is strong evidence that ICMs provide a higher diagnostic yield for detecting arrhythmias in patients with unexplained syncope and for detection of AF in patients after CS compared to conventional monitoring. CONCLUSIONS Prolonged monitoring with ICMs is an effective tool for diagnosing the underlying cardiac cause of unexplained syncope and for detecting AF in patients with CS. In all RCTs, ICMs have a superior diagnostic yield compared to conventional monitoring.
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Affiliation(s)
- Jörg Burkowitz
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Carina Merzenich
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Kathrin Grassme
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Bernd Brüggenjürgen
- Charité University Medicine Berlin, Institute for Social Medicine, Epidemiology and Health Economy, Berlin, Germany
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Morgan DJ, Brownlee S, Leppin AL, Kressin N, Dhruva SS, Levin L, Landon BE, Zezza MA, Schmidt H, Saini V, Elshaug AG. Setting a research agenda for medical overuse. BMJ 2015; 351:h4534. [PMID: 26306661 PMCID: PMC4563792 DOI: 10.1136/bmj.h4534] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Daniel J Morgan
- Epidemiology, and Public Health, Veterans Affairs Maryland Healthcare System, University of Maryland School of Medicine, 685 W Baltimore St, Baltimore, MD 21201, USA
| | | | - Aaron L Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, MN, USA
| | | | | | - Les Levin
- University of Toronto, Toronto, Ontario, Canada
| | - Bruce E Landon
- Department of Health Care Policy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark A Zezza
- Lewin Group's Federal Health And Human Services Practice, Washington, DC, USA
| | - Harald Schmidt
- Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Vikas Saini
- Lown Institute, Harvard Medical School, Brookline, MA, USA
| | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Australia Lown Institute, Sydney, Australia
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28
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[Why there are so many overdiagnoses in clinics]. MMW Fortschr Med 2015; 157:38. [PMID: 26012453 DOI: 10.1007/s15006-015-2968-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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