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"Unnecessary Procedures - utilization"
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A Cluster-Randomized Trial to Reduce Cesarean Delivery Rates in Quebec
This multicenter, cluster-randomized trial showed that an intervention involving audits of indications for cesarean delivery, feedback, and implementation of best practices resulted in a significant but small reduction in the cesarean delivery rate as compared with usual care.
Rates of cesarean delivery are high in developed countries.
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In Canada, these rates increased from 21.2% to 28.0% between 2000 and 2008 and remained stable until 2011.
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High rates of cesarean delivery are of substantial concern owing to the potential harm to the mother and her baby associated with a medically unnecessary cesarean delivery and to the related costs of health care.
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Providing evidence-based guidance to health professionals regarding the appropriate selection of women who could benefit from cesarean delivery is now a priority.
Systematic reviews of strategies designed to reduce cesarean delivery rates and to improve . . .
Journal Article
Worried Sick
Nortin Hadler's clearly reasoned argument surmounts the cacophony of the health care debate. Hadler urges everyone to ask health care providers how likely it is that proposed treatments will afford meaningful benefits and he teaches how to actively listen to the answer. Each chapter ofWorried Sickis an object lesson on the uses and abuses of common offerings, from screening tests to medical and surgical interventions. By learning to distinguish good medical advice from persuasive medical marketing, consumers can make better decisions about their personal health care and use that wisdom to inform their perspectives on health-policy issues.
eBook
Reducing duplicate testing: a comparison of two clinical decision support tools
Unnecessary duplicate laboratory testing is common and costly. Systems-based means to avert unnecessary testing should be investigated and employed.
We compared the effectiveness and cost savings associated with two clinical decision support tools to stop duplicate testing. The Hard Stop required telephone contact with the laboratory and justification to have the duplicate test performed, whereas the Smart Alert allowed the provider to bypass the alert at the point of order entry without justification.
The Hard Stop alert was significantly more effective than the Smart Alert (92.3% vs 42.6%, respectively; P < .0001). The cost savings realized per alert activation was $16.08/alert for the Hard Stop alert vs $3.52/alert for the Smart Alert.
Structural and process changes that require laboratory contact and justification for duplicate testing are more effective than interventions that allow providers to bypass alerts without justification at point of computerized physician order entry.
Journal Article
Is Computed Tomography Safe?
Dr. Rebecca Smith-Bindman writes that the risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high, given the capacity to reduce these doses of radiation.
Ms. C., a 59-year-old schoolteacher, awoke on September 8, 2009, with facial paralysis. In a local emergency room, she underwent computed tomographic (CT) and magnetic resonance imaging (MRI) brain scanning. The scans were normal, Bell's palsy was diagnosed, and the symptoms resolved over the next few weeks. Two weeks later, Ms. C. began losing her hair in a band-like distribution, and the following week she awoke with vertigo and confusion and returned to the emergency room, where repeat CT and MRI scans were normal. Fatigue, malaise, memory loss, and confusion began soon thereafter and have continued, making it difficult for . . .
Journal Article
Impact of an Educational Intervention on the Frequency of Daily Blood Test Orders for Hospitalized Patients
Objectives:
During hospitalizations, blood is drawn for diagnostic laboratory tests to help guide patient care. Often, blood tests continue to be ordered even in the face of clinical and laboratory stability. Blood draws are painful and costly, and they may be associated with anemia. We hypothesized that provider education could reduce the frequency of daily blood tests ordered for hospitalized patients.
Methods:
During a 2-month intervention period, internal medicine providers were educated through flyers displayed in providers’ offices and periodic email communications reminding them to order daily blood tests only if the results would change patient care. Two-month preintervention data from 982 patients and 2-month postintervention data from 988 patients were analyzed. The primary outcome measured was the number of daily blood tests ordered per patient per day.
Results:
Mean orders of CBC decreased from 1.46 to 1.37 tests per patient per day (P < .05) after the intervention. Basic metabolic panel orders were reduced from 0.91 to 0.83 tests per patient per day (P < .05). Cost analyses showed a reduction of $6.33 per patient day based on the decrease in the number of daily laboratory tests ordered.
Conclusions:
Provider education and reminders can reduce the frequency of daily blood tests ordered by providers for hospitalized patients. This can decrease health care costs and may reduce the risk of complications such as anemia.
Journal Article
Overuse of Colonoscopy for Colorectal Cancer Screening and Surveillance
ABSTRACT
BACKGROUND
Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources.
OBJECTIVE
Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse.
DESIGN, SETTING, AND PARTICIPANTS
Our approach was a retrospective cohort study using electronic health record data for patients 50–65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice.
MAIN OUTCOME MEASURES
We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies.
KEY RESULTS
We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88 %) and many surveillance colonoscopies (49 %) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1–10.0; hyperplastic polyp: 5.7 years, IQR: 4.9–9.7; low-risk adenoma: 5.1 years, IQR: 3.3–6.3; high-risk adenoma: 2.9 years, IQR: 2.0–3.4,
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< 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95 % CI: 3.15–12.50) and surveillance colonoscopy (OR 13.47, 95 % CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam.
CONCLUSIONS
Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.
Journal Article
Elements of Danger — The Case of Medical Imaging
Dr. Michael Lauer writes that medical imaging has become increasingly common in the United States. Though the danger of radiation exposure may be small, it is cumulative and hence of particular relevance to the small but substantial minority of people who undergo clusters of tests.
According to the Book of Exodus, a man who assaults another must pay a physician to heal the wounds. A careful examination of the Hebrew text reveals that the word “heal” appears twice; the literal reading is “and heal he shall be healed.” The 13th-century medieval physician and philosopher Nachmanides interprets this redundant phrase to mean that physicians require permission to heal, for “without the warrant to treat, physicians might hesitate to treat patients . . . `in that there is an element of danger in every medical procedure; that which heals one may kill another.'” This 800-year-old warning seems self-evident, yet . . .
Journal Article
The Uncritical Use of High-Tech Medical Imaging
Dr. Bruce Hillman and Jeff Goldsmith argue that the root cause of unnecessary use of imaging may be the style and content of clinical education. Minimizing unnecessary imaging will require a change in mindset among physicians.
The use of advanced imaging methods such as computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography (PET) has made diagnosis more accurate and less invasive for nearly all organ systems. Unfortunately, as the use of imaging has rapidly increased, imaging costs have grown as well. Indeed, until recently, these costs were the fastest-growing physician-directed expenditures in the Medicare program, far outstripping general medical inflation.
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Such dramatic growth has placed imaging in the policy spotlight. There is broad agreement that an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care. . . .
Journal Article
High Physician Concern About Malpractice Risk Predicts More Aggressive Diagnostic Testing In Office-Based Practice
Despite widespread agreement that physicians who practice defensive medicine drive up health care costs, the extent to which defensive medicine increases costs is unclear. The differences in findings to date stem in part from the use of two distinct approaches for assessing physicians' perceived malpractice risk. In this study we used an alternative strategy: We linked physicians' responses regarding their levels of malpractice concern as reported in the 2008 Health Tracking Physician Survey to Medicare Parts A and B claims for the patients they treated during the study period, 2007-09. We found that physicians who reported a high level of malpractice concern were most likely to engage in practices that would be considered defensive when diagnosing patients who visited their offices with new complaints of chest pain, headache, or lower back pain. No consistent relationship was seen, however, when state-level indicators of malpractice risk replaced self-rated concern. Reducing defensive medicine may require approaches focused on physicians' perceptions of legal risk and the underlying factors driving those perceptions. [PUBLICATION ABSTRACT]
Journal Article