Presse
Patient ohne Verfügung – Das Geschäft am Lebensende, Piper Verlag, 320 Seiten, ISBN 978-3-492-05776-9, 22,00 €
ZDF: Mann, Sieber! Wer kriegt die Oma. FILM ZUM BUCH!
Frontal 21 vom 24.04.2018, Herzeingriffe nehmen deutlich zu – 42jähriger Vater stirbt ohne Grund (link)
Borasio: „Durch Übertherapie sterben wir schlechter und früher“ Zeit online vom 02.04.2018 (link)
Zahnspangen nehmen grundlos zu (link)
Herzkatheter: Gier am Aortenbogen (link)
Auch das Instrument „Patientenverfügung“ ist wirkungslos, aus einer Uniklinik wird berichtet, dass diese in den letzten 5 Jahren nur einmal beachtet wurde: Bei einem Arzt als Patient: Er hatte sich Intensivmedizin verbeten.(link)
Ergebnisse einer Interviewstudie Wehkamp/ Naegler 2018. So viele Ärzte (Prozentangaben) geben eklatantes Fehlverhalten in Kliniken zu (link):
Aus wirtschaftlichen Motiven …
… werden Herzkatheter oder Darmspiegelungen gemacht, die nicht medizinisch notwendig sind.69%
… werden Patienten mehrfach aufgenommen, obgleich ein Aufenthalt reichen würde. 75%
… werden Patienten operiert, obwohl das nicht nötig war. 75%
… wird die Beatmungsdauer durch die Vergütung bestimmt 71%
… wird der Entlassungszeitpunkt gewählt 58%
… werden Patienten aufgenommen, die nicht unbedingt ins Krankenhaus gehören. 94%
– bis hierhin handelt es sich um mehr oder weniger schlimme Körperverletzungen –
… werden lukrative Abteilungen am Bedarf vorbei aufgebaut. 100%
… werden „lukrative DRG’s“ bevorzugt aufgenommen. 50%
… werden Wahlleistungspatienten bevorzugt aufgenommen. 66%
Therapien bis zum letzten Atemzug. Die Zeit 02.02.17 von Elisabeth Niejahr und Martin Spiewak
NDR vom 07.11.2017: Operation für den Profit.
Weltnarkosetag am 16.10.2017 unter dem Motto: Problem Übertherapie: Experten fordern „neue Humanisierung der Intensivmedizin“
Ärztezeitung vom 08.11.2017: Monetik statt Ethik.
Methadonwunsch bei Krebs erfüllen? Ja…
MMW 09.11.2017: Gravierende Zweifel an teuren Krebsmitteln.
Thöns M: Leidensverlängerung gilt als Behandlungsfehler. Die Schwester, der Pfleger 56 (2017) 75 (link)
Thöns M., Heit, B: Ernährungsmedizinische Aspekte in der Palliativversorgung. Schmerzmedizin 33 (2017) 28 (link)
Thöns M: Intensivmedizin oder Palliativversorgung am Lebensende? Schmerzmedizin 32 (2016) 31 (link)
Entschließung Deutscher Ärztetag 2017: Der von der Politik ausgerufene „Wettbewerb im Gesundheitswesen“ erweist sich zunehmend als verhängnisvoll….Dieser primär finanzorientierte Wettbewerb setzt die falschen Anreize. Er schadet der
Qualität der Patientenversorgung und untergräbt das Vertrauen in das gesamte System.
Gerd Reuther: Der Betrogene Patient.2017
Gean Borasio: Über das Sterben. DTV 2013
Männer unter 55 Jahren und über 70 Jahren nützt der Test überhaupt nicht, er rettet kein Leben.
Ausschließlich bei Männern zwischen 56-69 Jahren wird ein Mann von 1000 gerettet, wenn 10-15 Jahre lang der PSA Test läuft. 60 andere allerdings werden durch teils unnütze Operationen impotent und können ihren Harn nicht mehr halten.
Im Detail: von 1000 Männern mit Test
240 bekommen gesagt: „Der Test ist positiv, sie könnten Krebs haben“, diesen entnimmt man durch mit einer langen Nadel durch den Enddarm zahlreiche Proben aus der Prostata. 140 bekommen gesagt: Ups das war unnötig, der PSA Test war „falsch positiv“, es bleibt das „Restgefühl“ – ob man mit den Nadel nicht daneben gestochen hat.
100 haben definitiv „Krebs“, von denen allerdings die Hälfte niemals Beschwerden von dem Tumor bekommen würde. Diese Tumoren streuen auch nicht. Aber man kann das eben nicht aus den Proben erkennen.
80 von den 100 lassen sich operieren.
60 von ihnen bekommen Harninkontinenz und Impotenz
77 profitieren von dem Eingriff nicht (da der Tumor „harmlos“ ist, oder bereits so bösartig, dass auch die Operation nicht mehr hilft, weil er schon gestreut hat).
Schließlich stirbt nur 1 Patient nicht, wenn 10-15 Jahre lang das Screening gemacht wird.
Mühlhauser, Ingrid: Unsinn Vorsorgemedizin. Wem sie nützt, wann sie schadet. (erscheint im Septemer 2017)
When Evidence Says No, but Doctors Say Yes. The Atlantic 22.02.17
Patientenverfügung schützt vor qualvoller Übertherapie am Lebensende. Ärztezeitung vom 15.02.17
EBM wurde entführt- Lown 2016 – Dr. John Ioannidis Keynote: Evidence-Based Medicine Has Been Hijacked
Wie moderne Medizin zum unwürdigen Tod führen kann. Badische Zeitung 14.02.17
Palliativmediziner veröffentlicht Buch: Hausärzte sind Schutzwall. Ärztezeitung 13.02.17 von Ilse Schlingensiefen
Right care. Avoiding overuse—the next quality frontier. The Lancet 08.01.17
Ärzte greifen vorschnell zum Skalpell. Fünf Jahre Fallpauschalen. NZZ 11.02.17
Überwiegend negative Testergebnisse: selbstgezahlte Gesundheitsleistungen in der Kritik. Echo-online 24.02.17 von Sabine Schiner
Viele Asthmapatienten sind wohl gar keine. Ärztezeitung, 07.02.17 von Beate Schumacher
Ein Arzt, der Klartext redet: Palliativmediziner Dr. Matthias Thöns füllt das PZ-Autorenforum. PZ 01.02.17
Plädoyer für ein friedliches Sterben. Pharmazeutische Zeitung 05/17 von Christiane Berg
Sinnlos gelitten. Die Zeit 16.02.17 von Miriam Gebhard
Sinnlose Therapien an Sterbenskranken. „Leider traurige Realität“. Deutschlandradio Kultur 26.01.17 von Korbinian Frenzel
Palliativmediziner hält Behandlung Todkranker für eine „ans Kriminelle grenzenden Fachrichtung“ Focus vom 18.01.17
Sterbenskranke haben keinen Rechtsschutz. Forum 13.01.17 von Kristina Scherer-Siegwarth
Das Geschäft mit dem Sterben. SternTV 10.01.17 mit Steffen Hallaschka, Constantin Thelen und Alexander Harbi
Ex-Chefarzt rechnet ab: „Im Krankenhaus ist der Mensch kein Mensch mehr“. Der Spiegel 21.12.16 von Kristina Gnirke und Isabell Hülsen
Qual oder ärztliche Pflicht. SZ 28.11.17 von Ekkehard Müller-Jentsch
Umsonst ist der Tod schon lange nicht mehr. FAZ 18.12.2016, von MARTINA LENZEN-SCHULTE
Thöns M: Übertherapie am Lebensende. Columba 12 (2016) 19 (link)
Thöns M: Überversorgung am Lebensende: eine Menge unsinniger Maßnahmen. MMW 158 (2016) 17 (link)
Thöns, Pötter, Schmelzer, van Lengen, Dargel, Ilsen, Nelle, Glaremin, Gramatke: Palliativversorgung in Witten: Das Palliativnetz Witten. Witten Transparent 12 (2016) 8 (link)
Thöns M: Intensivtherapie oder Palliativmedizin am Lebensende? Schmerzmedizin 32 (2016) 6 (link)
Thöns M, Huenges B, Rusche H:Übertherapie am Lebensende vermeiden. Der Hausarzt 14 (2016) 52 (link)
Verschreibungspflichtig. Zeitmagazin 25.01.16 Von Julia Friedrichs
Viele Selbstzahler-Gesundheitsleistungen bringen mehr Schaden als Nutzen. SZ 16.02.17 von Felix Hütten
Brustkrebspatientinnen werden häufig übertherapiert. Bild der Frau 01.02.17 von Vera Laumann
Warum Deutschland lange nicht das gesündeste Land Europas ist. SZ vom 24.11.16 von Werner Bartens^
Krebsforscher blamieren sich mit Vorzeigestudie. Der Spiegel, 22.11.16 von Tanja Wolf
Skrupellose Ärzte machen Geschäfte mit Todkranken. Votum1 von dimitris kazarnovskis
Redezeit WDR 5 mit Jürgen Wiebicke vom 04.10.16
ARD-Magazin „Monitor“: Pflegedienste halten sich nicht an Patientenverfügungen. Focus Money,08.09.16 von Thomas Münchner
Hilflos ausgeliefert. Wirtschaftswoche 08.09.16 von Anke Heinrich
Thöns M: Überversorgung am Lebensende: eine Menge unsinniger Maßnahmen. Neuro & Psycho 18 (2016) 6 (link)
WAZ vom 12.11.16: Wittener Publikum steht hinter Kritiker Thöns.
SWR Odysso vom 10.11.2016: Profitgier verhindert stressfreien Tod.
Deutschlandradio Kultur vom 20.10.16: Altern, Pflegen und Demenz
NDR Info vom 08.10.16: Defizite in der ambulanten Versorgung.
NWZ vom 19.10.16: Vom Geschäft mit dem Lebensende.
Buchnews vom 12.10.16: Patient ohne Verfügung von Matthias Thöns
Lokalkompass vom 07.10.16: Zahlreiche Buchtips im Kapfe Leselust 60plus.
WDR 5 vom 04.10.16: Redezeit mit Matthias Thöns
TAZ vom 29.09.16: Tod und Trost (mit Dennis Scheck)
WAZ vom 28.09.16: Buchbesprechung: Das Geschäft mit dem Lebensende
ARD Druckfrisch vom 25.09.16 mit Dennis Scheck: Matthias Thöns: Patient ohne Verfügung Platz 10
HPD vom 23.09.16: Der nicht verfügte Patient.
Erzbistum Köln vom 22.09.16: Der Tod kann eine gute Lösung sein.
Focus online vom 22.09.16: Infonachmittag: Patientenverfügung, die gesetzliche Regelung.
ZDF Volle Kanne vom 21.09.16: Übertherapie am Lebensende. Probleme mit der Patientenverfügung.
WAZ vom 20.09.16: Bürger und Bauherren feiern Richtfest am Wittener Hospiz.
WAZ vom 16.09.16: Palliativmedizin Thema im alten Rathaus.
WAZ vom 15.09.16: Ärzte nehmen Kritiker Thöns in die Mangel
ZDF – Markus Lanz vom 08.09.16 mit Journalist Ranga Yogeshwar, Publizist Wolfram Weimer, Kabarettist Philip Simon, Autorin Juli Zeh und Palliativmediziner Dr. Matthias Thöns.
Focus online vom 08.09.16: Lanz führt AfD-Diskussion, die keiner braucht.
ARD vom 08.09.16, Moma: Palliativmedizin. Patientenverfügung versus Profitgier.
Thöns M, Huenges B, Rusche H: Übertherapie vermeiden. Der Hausarzt 14 (2016) 52
Deutschlandfunk vom 05.09.2016, Andruck: Das Geschäft vor dem Tod. (mit Mirco Smiljanic)
Bild vom 02.09.16: Claudia S. hätte nicht leiden müssen. Das miese Geschäft mit den Todkranken.
WDR vom 01.09.16: Geschäftemacherei am Ende des Lebens (von Nina Giamarita)
Votum 1 vom 31.08.16: Skrupellose Ärzte machen Geschäfte mit Todkranken
WAZ vom 30.08.16: Kliniken: Kritik am Umgang mit Sterbenden zu pauschal
WAZ vom 29.08.16, Hauptseite: Arzt kritisiert Kliniken für ihr „Geschäft mit dem Sterben“
WDR vom 29.08.16: Wittener Mediziner kämpft gegen das Geschäft mit Todkranken.
kma online 29.08.16: Palliativmediziner wirft Ärzten Geldgier vor
Pressemeldung der Ruhr-Universität-Bochum 29.08.16: Das Geschäft mit dem Sterben (von Meike Drießen)
Medizin Aspekte vom 29.08.16: Das Geschäft mit dem Sterben.
WAZ vom 29.08.16: Patienten brauchen Information.
Votum1 vom 28.09.16: Skrupellose Ärzte machen Geschäfte mit Todkranken.
Der Spiegel 35/16: Sie verdienen am Sterben.
Medizin im Text: Buchtipp: Patient ohne Verfügung. Das Geschäft mit dem Lebensende
WAZ vom 09.08.16: Medens Autoren-Herbst lockt mit Top-Stars.
WiWo vom 08.09.16: Missbrauch bei Patientenverfügung: Hilflos ausgeliefert.
WAZ vom 15.06.15: Experten warnen vor „Palliativmedizin als Geldquelle“.
Ärzte Zeitung vom 01.06.15: Keine Therapie auf Teufel komm raus.
Literatur international
Zu choosing wisely:
Zur Polypharmazie:
ARD: Sterben verboten. Von Renate Werner.
wissenschaftliche Literatur zum Thema Übertherapie:
These unnecessary procedures cost taxpayers $7 billion each year
Folgenden unnötigen (!) Eingriffen sollte in den USA die Kostenerstattung entzogen werden, sie verursachen 30% der Gesamtausgaben:
- Vorsorgeuntersuchungen bei älteren Patienten gegen Prostata- und Dickdarmkrebs (Fehlausgaben in den USA 525 Mio $)
- Herzkatheter mit Stent außerhalb eines Herzinfarktes (Fehlausgaben in den USA 1300 Mio $)
- Rückenschmerzen: Frühe Schnittbilduntersuchungen, Injektionen oder Vertebroplastie (Bandscheibenoperationen) (Fehlausgaben in den USA 1865 Mio $)
Gerade zu Spritzentherapie an der Wirbelsäule gibt es die höchste wissenschaftliche Untersuchung, dass die Verfahren keine Wirksamkeit nachgewiesen haben (Cochrane). Trotzdem werden sie gerade in der deutschen Orthopädie tausendfach täglich gemacht – mit hohem Nebenwirkungsrisiko.
- Anästhesisten
- Orthopäden
- Pharmaunternehmen (Pfizer)
- Augenärzte
Conflicts of interest in health care journalism. Who’s watching the watchdogs? We are. Part 1 of 3
Wilson A: 1 in 4 Incidental Findings from Diagnostic Imaging Linked to Increased LOS. Medea health leaders 15.05.2017
For Knee Pain, Experts Say Don’t Think About Scoping It. KHN 1005.2017
Screening for Thyroid CancerUS Preventive Services Task Force Recommendation Statement.
Warum zuviel Medizin krank macht.
Too much medical care: bad for you, bad for health care systems
Pearl R: Our health care system still massively overtreats patients, but we can change that
Finneberg HV et al: Conflict of InterestWhy Does It Matter?
The strain of overtreatment
A CLOSER LOOK AT THE OVERUSE OF ESTABLISHED MEDICAL PRACTICES BY
Healthcare Triage: Regional Difference in Procedures and Prices. March 24, 2017 at 9:30 am Aaron Carroll
Lippitz-Snyderman A: Reducing Overuse—Is Patient Safety the Answer?
Few people actually benefit from ‘breakthrough’ cancer immunotherapy
The American Greed Report: Is your doctor prescribing too much medication? Watch for the signs Scott Cohn
Consequences of Medical Overuse. 03/2017
Japsen B: When Arteries Narrow, Fee-For-Service Doctors Choose Surgery. Forbes, 1.3.2017
Experts Concerned That Depression Screening Will Lead to Overdiagnosis
Does Payer Type—Commercial Insurance or Medicare—Affect the Use of Low-Value Care?
Difference Between Estimated Purchase Price and Insurance Payments for Knee and Hip Implants in Privately Insured Patients Younger Than 65 Years
Expert calls for shorter radiation use in prostate cancer treatment. 21.02.2017
Pubmed search overuse cost
Med J Aust. 2017 May 15;206(9):407-411.
Countering cognitive biases in minimising low value care.
Scott IA1, Soon J2, Elshaug AG3, Lindner R4.
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.
J Hosp Med. 2017 May;12(5):346-351. doi: 10.12788/jhm.2738.
Morgan DJ1, Leppin AL2, Smith CD3, Korenstein D4.
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
© 2017 Society of Hospital Medicine.
JAMA Intern Med. 2017 Jun 1;177(6):829-837. doi: 10.1001/jamainternmed.2017.0401.
Low-Value Medical Services in the Safety-Net Population.
Barnett ML1, Linder JA2, Clark CR2, Sommers BD1.
Abstract
IMPORTANCE:
National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined.
OBJECTIVE:
To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians.
DESIGN, SETTING, AND PARTICIPANTS:
This multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics.
EXPOSURES:
Comparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non-safety-net physicians (seeing 1%-10%).
MAIN OUTCOMES AND MEASURES:
Delivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit.
RESULTS:
Overall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non-safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services.
CONCLUSIONS AND RELEVANCE:
Overuse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.
Neurosurgery. 2017 May 1;80(5):816-819. doi: 10.1093/neuros/nyw180.
The Ethics of „Choosing Wisely“: The Use of Neuroimaging for Uncomplicated Headache.
Abstract
The use of magnetic resonance imaging (MRI) for evaluation of headache remains excessive among physicians across many specialties according to both the American Headache Society and the American College of Radiology, despite recent attempts at limiting overuse of imaging and procedures. As part of the Choosing Wisely campaign, both of these organizations have explicitly recommended against imaging in patients with uncomplicated or typical migraine headaches. Yet, the practice nevertheless remains prevalent, with estimates ranging from 12.4% to 15.9% of patients with uncomplicated headache receiving MRI in outpatient practices. The low prevalence of serious pathological findings on imaging in patients who present without other indicative symptoms and the high cost of such exams necessitates a thorough evaluation of appropriate use of MRI for headache. Here, we debate the problematic use of MRI for uncomplicated headache and put forth a discussion of possible interventions that could promote more efficient use of imaging. Overuse of imaging has the potential to open a box that cannot readily be closed, and physicians upstream of surgical decision making must remain aware of the downstream effects of their clinical choices.
CMAJ. 2017 Feb 13;189(6):E255. doi: 10.1503/cmaj.1095386.
As much as 20% of Newfoundland’s health budget may be inappropriately spent.
Soc Sci Med. 2017 Mar;176:77-84. doi: 10.1016/j.socscimed.2017.01.020. Epub 2017 Jan 18.
„Too much medicine“: Insights and explanations from economic theory and research.
Hensher M1, Tisdell J2, Zimitat C3.
Abstract
Increasing attention has been paid in recent years to the problem of „too much medicine“, whereby patients receive unnecessary investigations and treatments providing them with little or no benefit, but which expose them to risks of harm. Despite this phenomenon potentially constituting an inefficient use of health care resources, it has received limited direct attention from health economists. This paper considers „too much medicine“ as a form of overconsumption, drawing on research from health economics, behavioural economics and ecological economics to identify possible explanations for and drivers of overconsumption. We define overconsumption of health care as a situation in which individuals consume in a way that undermines their own well-being. Extensive health economics research since the 1960s has provided clear evidence that physicians do not act as perfect agents for patients, and there are perverse incentives for them to provide unnecessary services under various circumstances. There is strong evidence of the existence of supplier-induced demand, and of the impact of various forms of financial incentives on clinical practice. The behavioural economics evidence provides rich insights on why clinical practice may depart from an „evidence-based“ approach. Moreover, behavioural findings on health professionals‘ strategies for dealing with uncertainty, and for avoiding potential regret, provide powerful explanations of why overuse and overtreatment may frequently appear to be the „rational“ choice in clinical decision-making, even when they cause harm. The ecological economics literature suggests that status or positional competition can, via the principal-agent relationship in health care, provide a further force driving overconsumption. This novel synthesis of economic perspectives suggests important scope for interdisciplinary collaboration; signals potentially important issues for health technology assessment and health technology management policies; and suggests that cultural change might be required to achieve significant shifts in clinical behaviour.
Lancet. 2017 Jan 6. pii: S0140-6736(16)32585-5. doi: 10.1016/S0140-6736(16)32585-5. [Epub ahead of print]
Evidence for overuse of medical services around the world.
Brownlee S1, Chalkidou K2, Doust J3, Elshaug AG4, Glasziou P3, Heath I5, Nagpal S6, Saini V7, Srivastava D8, Chalmers K9, Korenstein D10.
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
Copyright © 2017 Elsevier Ltd. All rights reserved.
Lancet. 2017 Jan 6. pii: S0140-6736(16)32586-7. doi: 10.1016/S0140-6736(16)32586-7. [Epub ahead of print]
Levers for addressing medical underuse and overuse: achieving high-value health care.
Elshaug AG1, Rosenthal MB2, Lavis JN3, Brownlee S4, Schmidt H5, Nagpal S6, Littlejohns P7, Srivastava D8, Tunis S9, Saini V10.
Abstract
The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective-ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
Copyright © 2017 Elsevier Ltd. All rights reserved.
Workplace Health Saf. 2017 Feb;65(2):54-56. doi: 10.1177/2165079916679415. Epub 2016 Dec 27.
Overuse of Diagnostic Imaging for Work-Related Injuries.
Clendenin BR1, Conlon HA1, Burns C1.
Abstract
Overuse of health care in the United States is a growing concern. This article addresses the use of diagnostic imaging for work-related injuries. Diagnostic imaging drives substantial cost for increases in workers‘ compensation. Despite guidelines published by the American College of Radiology and the American College of Occupational Medicine and the Official Disability Guidelines, practitioners are prematurely ordering imaging sooner than recommended. Workers are exposed to unnecessary radiation and are incurring increasing costs without evidence of better outcomes. Practitioners caring for workers and submitting workers‘ compensation claims should adhere to official guidelines, using their professional judgment to consider financial impact and health outcomes of diagnostic imaging including computed tomography, magnetic resonance imaging, nuclear medicine imaging, radiography, and ultrasound.
KEYWORDS:
advance practice nurses; application of evidence; best practices; cost benefit analysis; disability case management; occupational health and safety team; research; workers’ compensation
Circ J. 2017 Jan 25;81(2):195-198. doi: 10.1253/circj.CJ-16-0772. Epub 2016 Dec 7.
Regional Variation in the Use of Percutaneous Coronary Intervention in Japan.
Inoue T1, Kuwabara H, Fushimi K.
Abstract
BACKGROUND:
Regional variations in health-care delivery, processes and spending have been reported across the world. Differences in revascularization procedures have been observed in the USA and Canada, but little is known about regional variation in revascularization procedures in Japan.Methods and Results:Diagnostic procedure combination summary tables for 2013 issued by the Japanese government were used. The rates of percutaneous coronary intervention (PCI) per 100,000 population aged ≥40 years in each prefecture were summarized by angina and myocardial infarction (MI). Linear regression analysis was performed to investigate the factors associated with regional variation in the rate of PCI for angina. The mean PCI rates were 189 and 67 per 100,000 population for angina and MI, respectively. The ratios between the highest and lowest regions were 4.9-fold in angina and 1.8-fold in MI. The factor most associated with generating regional variation in the use of PCI for angina was the rate of coronary angiography (CAG; P<0.001).
CONCLUSIONS:
Wide regional variation was observed in the use of PCI both for angina and for MI. The variation was larger for angina, in which PCI were mostly elective and positively associated with the use of CAG. Further research is needed to prevent overuse and underuse of PCI to ensure more appropriate health-care delivery and to control health-care expenditure.
Sci Eng Ethics. 2016 Nov 28. [Epub ahead of print]
Moral Polemics of Far-Reaching Economic Consequences of Antibiotics Overuse.
Vochozka M1, Maroušková A2, Šuleř P3.
Abstract
The unethical overuse of antibiotics to seek to achieve a shortening of the treatment period raises the cost of health services and poses a threat to humanity due to the gradual development of antibiotic resistance. Other consequences of our modern passion for antibiotics have appeared. Small concentrations of antibiotic residues in sewage waters slow down the metabolism of anaerobic microorganism thereby reducing the overall performance of the anaerobic fermentation used to detoxify and digest sewage and other collected organic wastes. Reduced biogas yields represents a serious threat to the energy self-sufficiency of some waste-water treatment plants, so it might change them from energy producers into energy consumers. Morally justifiable production of renewable energy from bio-waste is also threatened by antibiotic residues that remain in the bio-waste.
KEYWORDS:
Economy; Health management; Reengineering; Social responsibility; Valuation
Am J Emerg Med. 2017 Feb;35(2):306-310. doi: 10.1016/j.ajem.2016.11.016. Epub 2016 Nov 5.
Overuse targets for Choosing Wisely: Do emergency physicians and nurses agree?
Venkatesh AK1, Anderson A2, Rothenberg C3, Parwani V3, Schwartz I4, Haggan J5, Sevilla M5, Shapiro MJ3.
KEYWORDS:
Choosing Wisely; Emergency medicine; Emergency nurses; Overuse
JAMA Cardiol. 2016 Dec 1;1(9):1038-1042. doi: 10.1001/jamacardio.2016.3153.
Cardiac Stress Test Trends Among US Patients Younger Than 65 Years, 2005-2012.
Kini V1, McCarthy FH2, Dayoub E3, Bradley SM4, Masoudi FA5, Ho PM4, Groeneveld PW6.
Abstract
IMPORTANCE:
After a period of rapid growth, use of cardiac stress testing has recently decreased among Medicare beneficiaries and in a large integrated health system. However, it is not known whether declines in cardiac stress testing are universal or are confined to certain populations.
OBJECTIVE:
To determine trends in rates of cardiac stress testing among a large and diverse cohort of commercially insured patients.
DESIGN, SETTING, AND PARTICIPANTS:
A serial cross-sectional study with time trends was conducted using administrative claims from all members aged 25 to 64 years belonging to a large, national managed care company from January 1, 2005, to December 31, 2012. Linear trends in rates were determined using negative binomial regression models with procedure count as the dependent variable, calendar quarter as the key independent variable, and the size of the population as a logged offset term. Data analysis was performed from January 1, 2005, to December 31, 2012.
MAIN OUTCOMES AND MEASURES:
Age- and sex-adjusted rates of cardiac stress tests per calendar quarter (reported as number of tests per 100 000 person-years).
RESULTS:
A total of 2 085 591 cardiac stress tests were performed among 32 921 838 persons (mean [SD] age, 43.2 [10.9] years; 16 625 528 women [50.5%] and 16 296 310 [49.5%] men; 7 604 945 nonwhite [23.1%]). There was a 3.0% increase in rates of cardiac stress testing from 2005 (3486 tests; 95% CI, 3458-3514) to 2012 (3589 tests; 95% CI, 3559-3619; P = .01 for linear trend). Use of nuclear single-photon emission computed tomography decreased by 14.9% from 2005 (1907 tests; 95% CI, 1888-1926) to 2012 (1623 tests; 95% CI, 1603-1643; P = .03). Use of stress echocardiography increased by 27.8% from 2005 (709 tests; 95% CI, 697-721) to 2012 (906 tests; 95% CI, 894 to 920; P < .001). Use of exercise electrocardiography increased by 12.5% from 2005 (861 tests; 95% CI, 847-873) to 2012 (969 tests; 95% CI, 953-985; P < .001). Use of other stress testing modalities increased 65.5% from 2006 (55 tests; 95% CI, 51-59) to 2012 (91 tests; 95% CI, 87-95; P < .001). For individuals aged 25 to 34 years, rates of cardiac stress testing increased 59.1% from 2005 (543 tests; 95% CI, 532-554) to 2012 (864 tests; 95% CI, 852-876; P < .001). For individuals aged 55 to 64 years, rates of cardiac stress testing decreased by 12.3% from 2005 (7894 tests; 95% CI, 7820-7968) to 2012 (6923 tests; 95% CI, 6853-6993; P < .001).
CONCLUSIONS AND RELEVANCE:
In contrast to declines in the use of cardiac stress testing in some health care systems, we observed a small increase in its use among a nationally representative cohort of commercially insured patients. Our findings suggest that observed trends in the use of cardiac stress testing may have been driven more by unique characteristics of populations and health systems than national efforts to reduce the overuse of testing.
Ann Thorac Med. 2016 Oct-Dec;11(4):254-260.
Alhassan S1, Sayf AA1, Arsene C1, Krayem H2.
Abstract
BACKGROUND:
Majority of our computed tomography-pulmonary angiography (CTPA) scans report negative findings. We hypothesized that suboptimal reliance on diagnostic algorithms contributes to apparent overuse of this test.
METHODS:
A retrospective review was performed on 2031 CTPA cases in a large hospital system. Investigators retrospectively calculated pretest probability (PTP). Use of CTPA was considered as inappropriate when it was ordered for patients with low PTP without checking D-dimer (DD) or following negative DD.
RESULTS:
Among the 2031 cases, pulmonary embolism (PE) was found in 7.4% (151 cases). About 1784 patients (88%) were considered „PE unlikely“ based on Wells score. Out of those patients, 1084 cases (61%) did not have DD test prior to CTPA. In addition, 78 patients with negative DD underwent unnecessary CTPA; none of them had PE.
CONCLUSIONS:
The suboptimal implementation of PTP assessment tools can result in the overuse of CTPA, contributing to ineffective utilization of hospital resources, increased cost, and potential harm to patients.
KEYWORDS:
Compliance rate; D-dimer; computed tomography-pulmonary angiography overuse; pulmonary embolism
Nat Rev Clin Oncol. 2016 Dec;13(12):740-749. doi: 10.1038/nrclinonc.2016.109. Epub 2016 Jul 26.
Improving early diagnosis of symptomatic cancer.
Hamilton W1, Walter FM2, Rubin G3, Neal RD4.
Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
J Pediatr. 2016 Dec;179:178-184.e4. doi: 10.1016/j.jpeds.2016.08.093. Epub 2016 Sep 30.
Variation in Utilization and Need for Tympanostomy Tubes across England and New England.
Parker DM1, Schang L2, Wasserman JR3, Viles WD3, Bevan G4, Goodman DC5.
Abstract
OBJECTIVES:
To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries.
STUDY DESIGN:
This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion.
RESULTS:
Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was -3.41 per 1000 child-years in England and -0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates.
CONCLUSIONS:
Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.
Copyright © 2016 Elsevier Inc. All rights reserved.
JAMA Intern Med. 2016 Nov 1;176(11):1687-1692. doi: 10.1001/jamainternmed.2016.5381.
2016 Update on Medical Overuse: A Systematic Review.
Morgan DJ1, Dhruva SS2, Wright SM3, Korenstein D4.
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.
Med Care. 2016 Oct;54(10):901-6. doi: 10.1097/MLR.0000000000000625.
Florence CS1, Zhou C, Luo F, Xu L.
Abstract
IMPORTANCE:
It is important to understand the magnitude and distribution of the economic burden of prescription opioid overdose, abuse, and dependence to inform clinical practice, research, and other decision makers. Decision makers choosing approaches to address this epidemic need cost information to evaluate the cost effectiveness of their choices.
OBJECTIVE:
To estimate the economic burden of prescription opioid overdose, abuse, and dependence from a societal perspective.
DESIGN, SETTING, AND PARTICIPANTS:
Incidence of fatal prescription opioid overdose from the National Vital Statistics System, prevalence of abuse and dependence from the National Survey of Drug Use and Health. Fatal data are for the US population, nonfatal data are a nationally representative sample of the US civilian noninstitutionalized population ages 12 and older. Cost data are from various sources including health care claims data from the Truven Health MarketScan Research Databases, and cost of fatal cases from the WISQARS (Web-based Injury Statistics Query and Reporting System) cost module. Criminal justice costs were derived from the Justice Expenditure and Employment Extracts published by the Department of Justice. Estimates of lost productivity were based on a previously published study.
EXPOSURE:
Calendar year 2013.
MAIN OUTCOMES AND MEASURES:
Monetized burden of fatal overdose and abuse and dependence of prescription opioids.
RESULTS:
The total economic burden is estimated to be $78.5 billion. Over one third of this amount is due to increased health care and substance abuse treatment costs ($28.9 billion). Approximately one quarter of the cost is borne by the public sector in health care, substance abuse treatment, and criminal justice costs.
CONCLUSIONS AND RELEVANCE:
These estimates can assist decision makers in understanding the magnitude of adverse health outcomes associated with prescription opioid use such as overdose, abuse, and dependence.
Q J Nucl Med Mol Imaging. 2016 Dec;60(4):318-23. Epub 2016 Sep 9.
Critical appraisal of appropriateness in nuclear cardiology.
Abstract
Radionuclide myocardial perfusion imaging (MPI) is a large component of the healthcare spending both in developed and developing countries. MPI is also responsible for a significant increase in the exposition of patients and health care operators to ionizing radiations for medical purposes. Thus, health-care systems and pertinent scientific societies were involved in developing criteria to contain the non-appropriate use by implementing Appropriate Use Criteria and Clinical Indications Guidelines. The present manuscript will review the concept and limitations of such an approach.
Breast. 2017 Feb;31:309-317. doi: 10.1016/j.breast.2016.06.024. Epub 2016 Jul 21.
Over-treatment in metastatic breast cancer.
Abstract
Metastatic breast cancer is an incurable disease and the main goals of treatment are prolongation of survival and preservation/improvement of quality of life. Thus the main philosophy of treatment should be to use the least toxic methods, as long as they provide sufficient disease control. In ER-positive tumours this can be in many cases achieved by endocrine therapy; in HER2-positive cancers efficacy of backbone therapy can be enhanced by an anti-HER2 agent. In patients requiring chemotherapy, consecutive single agent regimen provide disease control of a duration at least comparable to multidrug regimen, at a cost of significantly lower toxicity and are a preferred strategy in the majority of cases. Available data demonstrate, however, that aggressive chemotherapy is still overused in many metastatic breast cancer patients. The objective of this manuscript is to critically review available data on treatment choices and sequence in metastatic breast cancer across all breast cancer subtypes in relation to possible overtreatment, including therapies which are not recommended by current guidelines or not even approved. Our aim is to provide guidance on applying these data to clinical practice, but also to describe various, often non-scientific factors influencing therapeutic decisions in an aim to identify areas requiring educational and possibly political actions.
Copyright © 2016 Elsevier Ltd. All rights reserved.
KEYWORDS:
Breast cancer; Chemotherapy; Endocrine therapy; Metastatic; Overtreatment; Targeted therapy
Stud Health Technol Inform. 2016;226:190-3.
Exploring Lab Tests Over Utilization Patterns Using Health Analytics Methods.
Khalifa M1, Zabani I1, Khalid P1.
Abstract
Healthcare resources are over utilized contributing more to the growing costs of care. Although laboratory testing is essential, yet it can be expensive and excessive. King Faisal Specialist Hospital and Research Center, Saudi Arabia studied lab tests utilization patterns using health analytics methods. The objective was to identify patterns of utilizing lab tests and to develop recommendations to control over utilization. Three over utilization patterns were identified; using expensive tests for many patients as routine, unnecessarily repeating lab test and a combined one. Two recommendations were suggested; a user approach, modifying user behavior through orientation about the impact of over utilization on the cost effectiveness of healthcare, and a system approach, implementing system alerts to help physicians check the results and identify the date of the last lab tests done with information about appropriate frequency of ordering such lab test and medically significant intervals at which such test should be repeated.
J Am Coll Radiol. 2016 Sep;13(9):1057-66. doi: 10.1016/j.jacr.2016.04.013. Epub 2016 Jun 22.
Evaluating Two Measures of Lumbar Spine MRI Overuse: Administrative Data Versus Chart Review.
Avoundjian T1, Gidwani R2, Yao D3, Lo J4, Sinnott P4, Thakur N3, Barnett PG5.
Abstract
PURPOSE:
Lumbar spine (LS) MRI overuse may be identified in administrative data, but these data may lack the detailed clinical information needed to correctly assess overuse. The aim of this study was to compare chart review with analysis of administrative data to determine the appropriateness of LS MRI.
METHODS:
The sensitivity and specificity of the administrative method were determined, with inappropriateness regarded as the positive result, as if chart review determined the true state. Patients were the first 146 veterans who underwent LS MRI in the outpatient setting in fiscal year 2012 at the Veterans Affairs Palo Alto Health Care System. The InterQual criteria for chart review and the method of evaluating administrative data developed by CMS and endorsed by the National Quality Forum were used. Slight modifications were made to each measure to ensure completeness and comparability.
RESULTS:
Of the 146 scans reviewed, 23% were considered inappropriate by the administrative measure, whereas 59% were considered inappropriate by chart review. Compared with chart review, the administrative measure had specificity of 82% for identifying inappropriate scans and sensitivity of 27% for identifying appropriate scans.
CONCLUSIONS:
Compared with chart review, analysis of administrative data identified scans that were appropriate but underestimated inappropriate ordering. Contrary to expectations, chart review resulted in more scans being classified as inappropriate. The administrative method is economically feasible for identifying the overuse of LS MRI, but it underestimates the true extent of inappropriate ordering.
Published by Elsevier Inc.
KEYWORDS:
Low back pain; chart review; claims data; magnetic resonance imaging; quality assessment
Value Health. 2016 Jun;19(4):404-12. doi: 10.1016/j.jval.2015.06.006. Epub 2015 Sep 11.
Rafia R1, Brennan A2, Madan J3, Collins K4, Reed MW5, Lawrence G6, Robinson T7, Greenberg D8, Wyld L9.
Abstract
BACKGROUND:
Currently in the United Kingdom, the National Health Service (NHS) Breast Screening Programme invites all women for triennial mammography between the ages of 47 and 73 years (the extension to 47-50 and 70-73 years is currently examined as part of a randomized controlled trial). The benefits and harms of screening in women 70 years and older, however, are less well documented.
OBJECTIVES:
The aim of this study was to examine whether extending screening to women older than 70 years would represent a cost-effective use of NHS resources and to identify the upper age limit at which screening mammography should be extended in England and Wales.
METHODS:
A mathematical model that allows the impact of screening policies on cancer diagnosis and subsequent management to be assessed was built. The model has two parts: a natural history model of the progression of breast cancer up to discovery and a postdiagnosis model of treatment, recurrence, and survival. The natural history model was calibrated to available data and compared against published literature. The management of breast cancer at diagnosis was taken from registry data and valued using official UK tariffs.
RESULTS:
The model estimated that screening would lead to overdiagnosis in 6.2% of screen-detected women at the age of 72 years, increasing up to 37.9% at the age of 90 years. Under commonly quoted willingness-to-pay thresholds in the United Kingdom, our study suggests that an extension to screening up to the age of 78 years represents a cost-effective strategy.
CONCLUSIONS:
This study provides encouraging findings to support the extension of the screening program to older ages and suggests that further extension of the UK NHS Breast Screening Programme up to age 78 years beyond the current upper age limit of 73 years could be potentially cost-effective according to current NHS willingness-to-pay thresholds.
Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
Am J Manag Care. 2016 May;22(5):337-43.
Physician perceptions of Choosing Wisely and drivers of overuse.
Colla CH1, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD.
Abstract
OBJECTIVES:
Little is known regarding physicians‘ views on health service overuse or their awareness of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. Through the Survey on Overuse and Knowledge of Choosing Wisely, we assessed physician views on hypothesized drivers of overuse and Choosing Wisely.
STUDY DESIGN:
We designed the survey to investigate physicians‘ knowledge of, awareness of, and feelings toward Choosing Wisely, along with their concerns about malpractice, perception of patient demand, discomfort with uncertainty, and cost-consciousness. Where possible, we used pre-validated survey instruments.
METHODS:
We distributed the survey to clinicians practicing at Atrius Health, the largest ambulatory care provider in Massachusetts. We analyzed 584 responses (72% response rate) and calculated 3 previously validated scales.
RESULTS:
Primary care physicians reported significantly greater awareness of Choosing Wisely (47.2%) than medical specialists (37.4%) and surgical specialists (27%). A majority (62%) of all respondents reported they found uncertainty involved in providing care disconcerting. Approximately one-third felt it unfair to ask physicians to be both cost-conscious and concerned with welfare, thought too much emphasis was placed on costs, and thought doctors were too busy to worry about costs. Surgical specialists were more concerned about malpractice, whereas primary care physicians reported feeling significantly more pressure from patients for tests and procedures.
CONCLUSIONS:
Knowledge of Choosing Wisely is limited, but primary care physicians are more aware of the campaign than specialists. Although hypothesized drivers of overuse are prevalent, most physicians support cost-consciousness in medicine and embrace their responsibility in reducing costs.
Curr Hematol Malig Rep. 2016 Aug;11(4):295-302. doi: 10.1007/s11899-016-0332-3.
Bending the Cost Curve in Childhood Cancer.
Abstract
Healthcare for children with cancer costs significantly more than other children. Cost reduction efforts aimed toward relatively small populations of patients that use a disproportionate amount of care, like childhood cancer, could have a dramatic impact on healthcare spending. The aims of this review are to provide stakeholders with an overview of the drivers of financial costs of childhood cancer and to identify possible directions to curb or decrease these costs. Costs are incurred throughout the spectrum of care. Recent trends in pharmaceutical costs, evidence identifying the contribution of administration costs, and overuse of surveillance studies are described. Awareness of cost and value, i.e., the outcome achieved per dollar or burden spent, in delivery of care and research is necessary to bend the cost curve. Incorporation of these dimensions of care requires methodology development, prioritization, and ethical balance.
Dtsch Med Wochenschr. 2016 May;141(10):e96-e103. doi: 10.1055/s-0042-101467. Epub 2016 May 13.
[Quality Assurance using routine data: Overdiagnosis by radiological imaging for back pain].
[Article in German]
Linder R, Horenkamp-Sonntag D, Engel S, Schneider U, Verheyen F.
Erratum in
- [Quality Assurance using routine data: Overdiagnosis by radiological imaging for back pain].[Dtsch Med Wochenschr. 2016]
Abstract
Background and Problem: Acute nonspecific back pain disorders are typically self-limiting. According to the national guideline low back pain, only in case of clinical suspicion of a serious course radiological imaging should take place immediately. Otherwise, the guideline recommends waiting at least six weeks.
PATIENTS AND METHODOLOGY:
Using Statutory Health Insurance (SHI) routine data of the Techniker Krankenkasse we analyzed how many of the insured persons suffering from acute back pain for the first time with no indication of a serious outcome received a non-indicated diagnostic imaging.
RESULTS:
In about 10 % diagnostic imaging is conducted after initial diagnosis. If an imaging is carried out, roughly one third of these cases takes place ahead of time or is completely unnecessary. Methodically this is a very conservative estimation, thus it seems likely that the extent of overdiagnosis in actual medical care situation is even larger.
CONCLUSIONS:
Every third patient who received radiological diagnostics due to first acute nonspecific back pain underwent the procedure more quickly than recommended (less than six weeks). Overdiagnosis is not only economically problematic but also with respect to patient orientation and patient safety. It may cause substantial damage to patients – either by the use of diagnostics itself or by means of therapies initiated after diagnostics.
© Georg Thieme Verlag KG Stuttgart · New York.
HPB (Oxford). 2016 May;18(5):470-8. doi: 10.1016/j.hpb.2015.11.005. Epub 2016 Feb 5.
Overuse of surgery in patients with pancreatic cancer. A nationwide analysis in Italy.
Balzano G1, Capretti G2, Callea G3, Cantù E3, Carle F4, Pezzilli R5.
Abstract
BACKGROUND:
According to current guidelines, pancreatic cancer patients should be strictly selected for surgery, either palliative or resective.
METHODS:
Population-based study, including all patients undergoing surgery for pancreatic cancer in Italy between 2010 and 2012. Hospitals were divided into five volume groups (quintiles), to search for differences among volume categories.
RESULTS:
There were 544 hospitals performing 10 936 pancreatic cancer operations. The probability of undergoing palliative/explorative surgery was inversely related to volume, being 24.4% in very high-volume hospitals and 62.5% in very low-volume centres (adjusted OR 5.175). Contrarily, the resection rate in patients without metastases decreased from 86.9% to 46.1% (adjusted OR 7.429). As for resections, the mortality of non-resective surgery was inversely related to volume (p < 0.001). Surprisingly, mortality of non-resective surgery was higher than that for resections (8.2% vs. 6.7%; p < 0.01). Approximately 9% of all resections were performed on patients with distant metastases, irrespective of hospital volume group. The excess cost for the National Health System from surgery overuse was estimated at 12.5 million euro.
DISCUSSION:
Discrepancies between guidelines on pancreatic cancer treatment and surgical practice were observed. An overuse of surgery was detected, with serious clinical and economic consequences.
Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.
Am J Med Sci. 2016 May;351(5):459-66. doi: 10.1016/j.amjms.2016.02.022. Epub 2016 Feb 17.
Overuse of Head Computed Tomography in Cirrhosis With Altered Mental Status.
Abstract
BACKGROUND:
Head computed tomography (CT) scans are ordered in patients with cirrhosis along with altered mental status (AMS) during admission, often, despite lack of evidence of any structural abnormality. Thus, we aimed to examine the use of head CT scans in patients with cirrhosis along with AMS and to correlate scan abnormalities with causes of AMS and physical findings.
MATERIALS AND METHODS:
We defined AMS as having impaired cognition, diminished attention, reduced awareness or altered level of consciousness or all of these, and categorized AMS into the following groups: hepatic encephalopathy (HE), sepsis or infectious, metabolic, exogenous drugs or toxins, structural lesions or psychiatric abnormalities. The primary outcome was presence of any structural brain lesion on head CT scan in patients with cirrhosis along with AMS with correlation of focal neurologic deficits, specifically in patients with HE.
RESULTS:
In total, 349 of 1,218 patients with cirrhosis who were admitted to the hospital had AMS; HE was the most common cause of AMS (164 of 349, 47%). A total of 64% (223 of 349) of patients with cirrhosis along with AMS underwent head CT scanning on admission, including 99 of 164 (60%) patients with HE. No patient with HE had focal neurologic findings, or a focal abnormality on head CT scan. Of the patients with focal abnormalities on CT scans, 100% had focal neurologic findings. Patients with cirrhosis along with AMS undergoing head CT scan had similar mortality (76 of 223, 34%) as those with AMS not undergoing head CT scans (47 of 126, 37%; P = nonsignificant).
CONCLUSIONS:
Nearly two-thirds of patients with cirrhosis along with AMS had head CT scans performed on admission; all patients with a structural lesion on head CT scan had abnormal neurologic examinations. The data suggest that routine brain imaging in patients with cirrhosis that do not have focal neurologic findings is likely not indicated.
Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
Altered mental status; Cirrhosis; Computed tomography; Hepatic encephalopathy; Overutilization
Eur J Cardiothorac Surg. 2016 Jul;50(1):29-33. doi: 10.1093/ejcts/ezw043. Epub 2016 Mar 22.
Lung cancer screening: did we really need a randomized controlled trial?
Abstract
Lung cancer is the leading cause of cancer mortality in the USA. Within the past decade, two large trials (the National Lung Screening Trial Research and the International Early Lung Cancer Action Program) confirmed a significant role for low-dose CT (LDCT) screening in identifying early stages of cancer leading to reduced mortality in high-risk patients. Given the evidence, the US Preventive Services Task Force issued a recommendation in favour of LDCT screening for high-risk individuals. Despite the strong support for LDCT among physicians who treat lung cancer and cumulative data demonstrating a survival benefit for screening and early detection, it took more than a decade for lung cancer screening to be embraced at the policy level. With many lives lost in the interim, did we really need a randomized controlled trial to make this decision?
© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
KEYWORDS:
I-ELCAP; Low-dose CT screening; Lung cancer; NLST
Comment in
- Re: Lung cancer screening: did we really need a randomized controlled trial?[Eur J Cardiothorac Surg. 2016]
Can Fam Physician. 2016 Mar;62(3):199-200, 207-9.
Addressing overuse starts with physicians: Choosing Wisely Canada.
[Article in English, French]
Wintemute K1, McDonald K2, Huynh T3, Pendrith C4, Wilson L5.
Can Fam Physician. 2016 Mar;62(3):195-6.
The 1% versus the 99%: Reducing unnecessary health care costs.
[Article in English, French]
Vertex. 2015 Sep-Oct;26(123):343-9.
[QUATERNARY PREVENTION: AN ATTEMPT TO AVOID THE EXCESSES OF MEDICINE].
[Article in Spanish]
Abstract
Seduced by technology, biometrics, practical guidelines and the use of medication, medicine has been driven away from the subject of its care. Quaternary prevention is, among other voices around the world, trying to denounce the consequent excesses of medical practice given by this situation. There are visible excesses, such as the long list of studies being performed on patients without indication, and others, much more subtle, as excessive prevention and the continuous and progressive medicalization of life itself that are rooted in our culture and demanded by a society that requests certainty at almost any cost. Quaternary prevention proposes a series of actions leaning towards avoiding and diminishing the damage produced by health care activities, in order to protect the subject of overdiagnosis and overtreatment; offering also ethical and viable alternatives in which the balance of risks and benefits (based on the best evidences) respects the autonomy of the subject by properly informing and allowing him to decide among the best options he has; altogether in a process that contemplates a rational and equitable use of resources. In order to achieve this, reliable sources of information and a medical education not dependent on industries related to technology or pharmaceuticals, are vital; in conjuction with a medicine that restablishes the subject as its main and central interest.
Chron Respir Dis. 2016 Aug;13(3):240-6. doi: 10.1177/1479972316636989. Epub 2016 Mar 10.
Spyratos D1, Chloros D1, Michalopoulou D2, Sichletidis L3.
Abstract
The aim of the present study was to estimate the frequency of under- and over-diagnosis as well as overtreatment and their impact on the financial burden of inhaled drugs for stable chronic obstructive pulmonary disease (COPD). We examined 3200 subjects (65.5% males) of the general population (>40 year old, current or former smokers, and asthma patients were excluded) during a 3-year period. All participants gave detailed medical history, underwent spirometry, and their current and past inhaled medications were registered through the national electronic prescription system. We diagnosed 342 subjects (10.7%) with COPD of whom 180 (52.6%) had no prior medical diagnosis. Overdiagnosis was the case for 306 subjects (9.6%) of whom 35.1% were treated with inhaled drugs during the last year. We calculated that 55.4% of the current cost for inhaled drugs is wasted to overtreatment and overdiagnosis. If there was adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines both for the diagnosis and treatment it would be a net profit of 36,059€ annually, which would be increased to 116,017€ if we had excluded underdiagnosed patients. Under- and over-diagnosis of COPD as well as non-adherence to GOLD guidelines for treatment are common problems in the primary care setting that increase significantly the economic burden of inhaled medications.
© The Author(s) 2016.
KEYWORDS:
COPD; medication cost; overdiagnosis; overtreatment; primary care; underdiagnosis
J Oncol Pract. 2016 Apr;12(4):e423-36. doi: 10.1200/JOP.2015.007344. Epub 2016 Mar 8.
Ellis SD1, Chen RC2, Dusetzina SB2, Wheeler SB2, Jackson GL2, Nielsen ME2, Carpenter WR2, Weinberger M2.
Abstract
PURPOSE:
The Centers for Medicare and Medicaid Services recently initiated small reimbursement adjustments to improve the value of care delivered under fee-for-service. To estimate the degree to which reimbursement influences physician decision making, we examined utilization of gonadotropin-releasing hormone (GnRH) agonists among urologists as Part B drug reimbursement varied in a fee-for-service environment.
METHODS:
We analyzed treatment patterns of urologists treating 15,128 men included in SEER-linked Medicare claims who were diagnosed with localized prostate cancer between January 1, 2000, and December 31, 2003. We calculated a reimbursement generosity index to measure differences in GnRH agonist reimbursement among regional Medicare carriers and over time. We used multilevel analysis to control for patient and provider characteristics.
RESULTS:
Among urologists treating early-stage and lower grade prostate cancer, variation in reimbursement was not associated with overuse of GnRH agonists from 2000 to 2003, a period of guideline stability (odds ratio, 1.00; 95% CI, 0.99 to 1.00).
CONCLUSION:
Small differences in androgen-deprivation therapy reimbursement generosity were not associated with differential use. Fee-for-service reimbursement changes currently being implemented to improve quality in fee-for-service Medicare may not affect patterns of cancer care.
Copyright © 2016 by American Society of Clinical Oncology.
Br J Gen Pract. 2016 Mar;66(644):e152-7. doi: 10.3399/bjgp16X683965.
Overdiagnosis of asthma in children in primary care: a retrospective analysis.
Looijmans-van den Akker I1, van Luijn K1, Verheij T2.
Abstract
BACKGROUND:
Asthma is one of the most common chronic diseases in childhood. According to guidelines, a diagnosis of asthma should be confirmed using lung function testing in children aged >6 years. Previous studies indicate that asthma in children is probably overdiagnosed. However, the extent has not previously been assessed.
AIM:
To assess the extent and characteristics of confirmed and unconfirmed diagnoses of asthma in children who were diagnosed by their GP as having asthma or who were treated as having asthma.
DESIGN AND SETTING:
Retrospective analysis in four academic primary healthcare centres in Utrecht, the Netherlands.
METHOD:
Routine care registration data of children aged 6-18 years who received a diagnosis of asthma or were treated as having asthma were analysed.
RESULTS:
In only 16.1% (n = 105) of the children diagnosed with asthma was the diagnosis confirmed with spirometry, whereas in 23.2% (n = 151) the signs and symptoms did give rise to suspected asthma but the children should have undergone further lung function tests. In more one-half (53.5%, n = 349) of the children the signs and symptoms made asthma unlikely and thus they were most likely overdiagnosed. The remaining 7.2% (n = 47) were probably correctly classified as not having asthma. The main reasons for classifying asthma without children undergoing further lung function tests were dyspnoea (31.9%, n = 174), cough (26.0%, n = 142), and wheezing (10.4%, n = 57).
CONCLUSION:
Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life. However, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.
© British Journal of General Practice 2016.
KEYWORDS:
asthma; children; diagnosis; guidelines; respiratory function tests; spirometry
Comment in
- Asthma overdiagnosed in the Netherlands.[Br J Gen Pract. 2016]
J Natl Cancer Inst. 2016 Feb 22;108(7). doi: 10.1093/jnci/djv429. Print 2016 Jul.
Healy MA1, Yin H1, Reddy RM1, Wong SL1.
Abstract
BACKGROUND:
Positron emission tomography (PET) scans are often used in cancer patients for staging, restaging, and monitoring for treatment response. These scans are also often used to detect recurrence in asymptomatic patients, despite a lack of evidence demonstrating improved survival. We sought to evaluate utilization of PET for this purpose and relationships with survival for patients with lung and esophageal cancers.
METHODS:
Using national Surveillance, Epidemiology, and End Results (SEER) and Medicare-linked data, we identified incident patient cases from 2005 to 2009, with follow-up through 2011. We identified cohorts with primary lung (n = 97 152) and esophageal (n = 4446) cancers. Patient and tumor characteristics were used to calculate risk-adjusted two-year overall survival. Using Medicare claims, we examined PET utilization in person-years (to account for variable time in cohorts), excluding scans for staging and for follow-up of CT findings. We then stratified hospitals by quintiles of PET utilization for adjusted two-year survival analysis. All statistical tests were two-sided.
RESULTS:
There was statistically significant variation in utilization of PET. Lowest vs highest utilizing hospitals performed .05 (SD = 0.04) vs 0.70 (SD = 0.44) scans per person-year for lung cancer and 0.12 (SD = 0.06) vs 0.97 (SD = 0.29) scans per person-year for esophageal cancer. Despite this, for those undergoing PET, lowest vs highest utilizing hospitals had an adjusted two-year survival of 29.0% (SD = 12.1%) vs 28.8% (SD = 7.2%) for lung cancer (P = .66) and 28.4% (SD = 7.2%) vs 30.3% (SD = 5.9%) for esophageal cancer (P = .55).
CONCLUSIONS:
Despite statistically significant variation in use of PET to detect tumor recurrence, there was no association with improved two-year survival. These findings suggest possible overuse of PET for recurrence detection, which current Medicare policy would not appear to substantially affect.
© The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
Wien Med Wochenschr. 2016 Apr;166(5-6):147-8. doi: 10.1007/s10354-016-0441-6.
Wise therapeutic decisions for older patients.
Am J Manag Care. 2016 Feb 1;22(2):e68-76.
Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers Choosing Wisely?
Gidwani R1, Sinnott P, Avoundjian T, Lo J, Asch SM, Barnett PG.
Abstract
OBJECTIVES:
To analyze inappropriate use of magnetic resonance imaging (MRI) for patients with low back pain in a healthcare system with no financial incentives for overuse.
STUDY DESIGN:
We used administrative data to assess the appropriateness of lumbar spine (LS) MRI in the Veterans Health Administration.
METHODS:
All veterans who received LS MRI in the outpatient setting in fiscal year 2012 were included. We based our assessments of appropriateness on CMS criteria, which have been endorsed by the National Quality Forum. Generalized estimating equations were used to evaluate characteristics of inappropriate scans.
RESULTS:
Of the 110,661 LS MRIs performed, 31% were classified as inappropriate. Most scans that were considered appropriate were characterized as such because they were preceded by conservative therapy (53%). „Red flag“ conditions were responsible for a much smaller percentage of scans being considered appropriate; 13% of scans were preceded by conservative therapy and were performed in patients with a red flag condition, while only 4% of scans were considered appropriate because of red flag conditions only. Scans ordered in the emergency department and in urgent care, primary care, and internal medicine clinics were most likely to be classified as inappropriate. Resident physicians were significantly less likely than other provider types to order inappropriate LS MRIs (odds ratio, 0.80; P < .0001). Approximately 24% of providers ordered 74% of inappropriate scans.
CONCLUSIONS:
We found that 31% of LS MRIs were inappropriate in a healthcare system largely absent of financial and other incentives for ordering. The problem of inappropriate ordering of LS MRI is concentrated in a small number of providers; any provider-facing interventions to reduce inappropriate order should therefore be targeted, rather than aimed at all providers who order LS MRI.
Appl Health Econ Health Policy. 2016 Aug;14(4):409-418. doi: 10.1007/s40258-016-0226-5.
Raymakers AJN1,2, Mayo J3, Lam S4,5, FitzGerald JM5, Whitehurst DGT6,7, Lynd LD8,9.
Abstract
BACKGROUND:
Lung cancer screening with low-dose computed tomography (LDCT) has been shown to deliver appreciable reductions in mortality in high-risk patients. However, in an era of constrained medical resources, the cost-effectiveness of such a program needs to be demonstrated.
OBJECTIVE:
The aim of this study was to systematically review the literature analyzing the cost-effectiveness of lung cancer screening using LDCT.
METHODS:
We searched MEDLINE, EMBASE, EBM Reviews-Health Technology Assessment, the National Health Service Economic Evaluation Database (NHS-EED), and the Cochrane Database of Systematic Reviews. Due to technological progress in CT, we limited our search to studies published between January 2000 and December 2014. Our search returned 393 unique results. After removing studies that did not meet our inclusion criteria, 13 studies remained. Costs are presented in 2014 US dollars (US$).
RESULTS:
The results from the economic evaluations identified in this review were varied. All identified studies reported outcomes using either additional survival (life-years gained) or quality-adjusted life-years (QALYs gained). Results ranged from US$18,452 to US$66,480 per LYG and US$27,756 to US$243,077 per QALY gained for repeated screening. The results of cost-effectiveness analyses were sensitive to several key model parameters, including the prevalence of lung cancer, cost of LDCT for screening, the proportion of lung cancer detected as localized disease, lead time bias, and, if included, the characteristics of a smoking cessation program.
CONCLUSIONS:
The cost-effectiveness of a lung cancer screening program using LDCT remains to be conclusively resolved. It is expected that its cost-effectiveness will largely depend on identifying an appropriate group of high-risk subjects.
Lakartidningen. 2016 Feb 2;113. pii: DTAE.
[Many people over 80 years had been able to get care outside the hospital].
[Article in Swedish]
Myredal A1, Mauritzon I2, Blom M3, Ivarsson K4.
Abstract
Ageing populations and higher ambitions continuously drive healthcare costs in Sweden and worldwide. During the last two decades, downsizing hospital bed capacity has been the strategy for cutting expenditure in the Swedish healthcare system. However, the lack of implementation of new and viable outpatient alternatives has led to a widespread overcrowding problem in Swedish hospitals and emergency departments. The present study was conducted as a survey in hospital wards at two emergency hospitals in southwestern Sweden. Study aims were to assess the causes of hospitalization and indications for continuing in-hospital care in hospitalized geriatric patients (>80 years). The study shows that a very small number of patients are admitted barely because of social factors; however, there is a significant group where hospitalization is due to both social and medical factors. A large group of hospitalized patients over 80 year (37%) could receive their care outside the emergency hospital. About 30% of hospitalized patients are waiting for planning, and the majority of them waiting for social action and planning. Older patients with multiple diseases require healthcare but not hospitalization to the present extent. We should focus on developing additional forms of healthcare since avoidable hospitalization is a high cost for the society, but above all a risk for the individual.
Wien Med Wochenschr. 2016 Apr;166(5-6):155-60. doi: 10.1007/s10354-015-0424-z. Epub 2016 Jan 26.
[Article in German]
Gogol M1, Siebenhofer A2,3.
Abstract
In 2012, the American Board of Internal Medicine (ABIM) Foundation initiated the Choosing Wisely campaign to promote discussion between physicians and patients (or proxies) on decision-making in medicine, and to reduce the use of procedures and therapies which are not necessary, or harmful to patients. The American Geriatrics Society (AGS), the American Medical Directors Association and the Society of Post-Acute and Long-Term Medicine (AMDA) participated in this initiative and both published 10 recommendations on procedures that should be discussed and avoided. Furthermore, some scientific societies have also published recommendations concerning elderly patients. As the campaign attracted considerable international attention, an International Roundtable was established in 2014. In Germany a similar initiative to address overuse and underuse was established by the German Society of Internal Medicine (DGIM) in 2015. The German Society of Geriatrics (DGG) was invited to address subjects affecting elderly patients that are of relevance to the German health care system. As a member of the Commission of the Association of the Scientific Medical Societies in Germany (AWMF), it also participated actively in the development of a methods paper on how to prepare recommendations. The German College of General Practitioners and Family Physicians (DEGAM) has developed a new guideline on this topic and in Austria preliminary activities are already underway. A clear, transparent, structured and evidence-based approach may help avoid some of the methodological weaknesses to be found in the development of the U.S. recommendations. Whereas the U.S. campaign only addresses overuse, the German campaign will also address underuse and misuse.
KEYWORDS:
Choosing wisely; Collective wise decision making; Misuse; Overuse; Underuse
J Prim Care Community Health. 2016 Apr;7(2):135-8. doi: 10.1177/2150131915624112. Epub 2016 Jan 13.
Clinicians Report Difficulty Limiting Low-Value Services in Daily Practice.
Grover M1, McLemore R2, Tilburt J3.
Abstract
Health care services that increase costs but fail to improve health are of low value. Limiting low-value services has potential to decrease health care expenditures by eliminating waste. We examined the opinions of Continuing Medical Education attendees about the „Choosing Wisely“ campaign and decreasing use of potentially unnecessary services of low value. We compared our attendees‘ responses to those of participants who completed a survey a year earlier. Respondents acknowledged waste of resources as a common and serious problem and noted frequent opportunities to address low-value services with their patients. They also reported limited ability to successfully reduce unnecessary services in daily clinical care. Lack of familiarity with „Choosing Wisely“ may be related.
© The Author(s) 2016.
KEYWORDS:
costs and costs analyses; guideline adherence; health expenditures
J Natl Compr Canc Netw. 2015 Dec;13(12):1566-74.
PSA Screening for Prostate Cancer: Why Saying No is a High-Value Health Care Choice.
Abstract
Enthusiasm for cancer screening and treatment of screen-detected cancer has led to widespread prostate-specific antigen (PSA) screening, a marked increase in prostate cancer incidence, and high use of surgical, radiation, and androgen deprivation treatment for screen-detected disease. This has occurred in advance of a full understanding of the clinical and financial tradeoffs. Although questions remain whether lifetime benefits outweigh harms and costs, data indicate that this balance is not favorable through at least 15 years. This article outlines a conceptual framework for determining the value of screening strategies according to screening and treatment intensity. We describe 4 main cancer screening goals and examine whether PSA screening and treatment achieve these goals and thus provide high-value care. Available evidence demonstrates that PSA screening provides at best a small reduction in prostate cancer mortality, and no reduction in all-cause mortality. High-intensity PSA screening and treatment currently practiced in the United States result in substantial harms and large health care expenditures-it is low-value care. The health importance of prostate cancer and the financial costs to patients and society require improved detection and treatment strategies that produce greater value to patients. We propose lower-intensity, higher-value options. However, until evidence supports a higher-value alternative to current PSA screening strategies, physicians should recommend against PSA screening, policymakers should encourage reduced screening, and most men should say no to the PSA test.
Copyright © 2015 by the National Comprehensive Cancer Network.
Int J Urol. 2016 Mar;23(3):211-8. doi: 10.1111/iju.13016. Epub 2015 Nov 30.
Active surveillance for prostate cancer.
Romero-Otero J1, García-Gómez B1, Duarte-Ojeda JM1, Rodríguez-Antolín A1, Vilaseca A2, Carlsson SV2,3, Touijer KA2.
Abstract
It is worth distinguishing between the two strategies of expectant management for prostate cancer. Watchful waiting entails administering non-curative androgen deprivation therapy to patients on development of symptomatic progression, whereas active surveillance entails delivering curative treatment on signs of disease progression. The objectives of the two management strategies and the patients enrolled in either are different: (i) to review the role of active surveillance as a management strategy for patients with low-risk prostate cancer; and (ii) review the benefits and pitfalls of active surveillance. We carried out a systematic review of active surveillance for prostate cancer in the literature using the National Center for Biotechnology Information’s electronic database, PubMed. We carried out a search in English using the terms: active surveillance, prostate cancer, watchful waiting and conservative management. Selected studies were required to have a comprehensive description of the demographic and disease characteristics of the patients at the time of diagnosis, inclusion criteria for surveillance, and a protocol for the patients‘ follow up. Review articles were included, but not multiple papers from the same datasets. Active surveillance appears to reduce overtreatment in patients with low-risk prostate cancer without compromising cancer-specific survival at 10 years. Therefore, active surveillance is an option for select patients who want to avoid the side-effects inherent to the different types of immediate treatment. However, inclusion criteria for active surveillance and the most appropriate method of monitoring patients on active surveillance have not yet been standardized.
© 2015 The Japanese Urological Association.
KEYWORDS:
active surveillance; biological markers; biopsy; magnetic resonance imaging; prostatic neoplasms
AMA J Ethics. 2015 Nov 1;17(11):1079-81. doi: 10.1001/journalofethics.2015.17.11.msoc1-1511.
Countering Medicine’s Culture of More.
Cho HJ1.
Nature. 2015 Nov 19;527(7578):S118-9. doi: 10.1038/527S118a.
Acad Emerg Med. 2015 Dec;22(12):1506-10. doi: 10.1111/acem.12821. Epub 2015 Nov 14.
Maughan BC1,2,3, Baren JM2, Shea JA4,3, Merchant RM2,3.
Abstract
OBJECTIVES:
The Choosing Wisely campaign was launched in 2011 to promote stewardship of medical resources by encouraging patients and physicians to speak with each other regarding the appropriateness of common tests and procedures. Medical societies including the American College of Emergency Physicians (ACEP) have developed lists of potentially low-value practices for their members to address with patients. No research has described the awareness or attitudes of emergency physicians (EPs) regarding the Choosing Wisely campaign. The study objective was to assess these beliefs among leaders of academic departments of emergency medicine (EM).
METHODS:
This was a Web-based survey of emergency department (ED) chairs and division chiefs at institutions with allopathic EM residency programs. The survey examined awareness of Choosing Wisely, anticipated effects of the program, and discussions of Choosing Wisely with patients and professional colleagues. Participants also identified factors they associated with the use of potentially low-value services in the ED. Questions and answer scales were refined using iterative pilot testing with EPs and health services researchers.
RESULTS:
Seventy-eight percent (105/134) of invited participants responded to the survey. Eighty percent of respondents were aware of Choosing Wisely. A majority of participants anticipate the program will decrease costs of care (72% of respondents) and use of ED diagnostic imaging (69%) but will have no effect on EP salaries (94%) or medical-legal risks (65%). Only 45% of chairs have ever addressed Choosing Wisely with patients, in contrast to 88 and 82% who have discussed it with faculty and residents, respectively. Consultant-requested tests were identified by 97% of residents as a potential contributor to low-value services in the ED.
CONCLUSIONS:
A substantial majority of academic EM leaders in our study were aware of Choosing Wisely, but only slightly more than half could recall any ACEP recommendations for the program. Respondents familiar with Choosing Wisely anticipated generally positive effects, but chairs reported only infrequently discussing Choosing Wisely with patients. Future research should identify potentially low-value tests requested by consultants and objectively measure the utility and cost of these tests among ED patient populations.
© 2015 by the Society for Academic Emergency Medicine.
JAMA Pediatr. 2015 Dec;169(12):1085-6. doi: 10.1001/jamapediatrics.2015.2702.
Doing More vs. Doing Good: Aligning Our Ethical Principles From the Personal to the Societal.
J Trauma Acute Care Surg. 2016 Feb;80(2):313-7. doi: 10.1097/TA.0000000000000904.
Helicopter interfacility transport of pediatric trauma patients: Are we overusing a costly resource?
Meyer MT1, Gourlay DM, Weitze KC, Ship MD, Drayna PC, Werner C, Lerner EB.
Abstract
BACKGROUND:
Helicopter emergency medical services (HEMS) provide an important service to decrease interfacility transport times compared with ground ambulances. Although transport via HEMS is typically faster, the decreased transportation time comes at the expense of increased risks to the patient and flight crew and higher costs. Therefore, it is important to balance the immediate patient needs with the risk and expense of HEMS transport. Our objective was to determine how frequently pediatric patients who are interfacility transported to a Level 1 pediatric trauma center (PTC) receive a time-sensitive intervention.
METHODS:
This was a 4-year (2008-2012) retrospective study of children aged 0 year to 18 years who were interfacility transported to a single Level 1 PTC by HEMS. Patients were identified using the trauma registry at the PTC. A previously published outcome was used to determine if patients received time-sensitive interventions. Driving distance to the PTC was determined using Google Maps. Data were analyzed using descriptive statistics.
RESULTS:
A total of 207 cases were identified (median age, 7 years; interquartile range, 2-12 years; 29% female; median Injury Severity Score [ISS], 11; median Revised Trauma Score [RTS], 8). Forty-three percent (90 patients; 95% confidence interval, 37-50%) of patients received a time-sensitive intervention; these cases had a median age of 6 years (interquartile range, 2-11 years; 32% female; median ISS, 13; median RTS, 8). Of the 117 patients who did not receive time-sensitive interventions, 81% were within 120 driving miles of the PTC and 49% were within 60 miles.
CONCLUSION:
This study suggests an overuse of HEMS for interfacility transfer of injured pediatric patients to a PTC. Although these patients likely required the resources of a PTC, they could perhaps have been transported by ground ambulance without detriment. Further research is needed to investigate how interfacility transport modes are selected and if these decisions can be improved without increasing evaluation times at transferring facilities.
LEVEL OF EVIDENCE:
Epidemiologic study, level V.
J Pediatr Rehabil Med. 2015;8(2):105-11. doi: 10.3233/PRM-150324.
Emergency department use among children with tracheostomies: Avoidable visits.
Meier JD1, Valentine KJ2,3, Hagedorn C4, Hartling C2, Gershan W4, Muntz HR1, Murphy NA4.
Abstract
PURPOSE:
To characterize high emergency department (ED) use by children with tracheostomies and complex chronic conditions, to distinguish avoidable from unavoidable ED visits, and to describe the financial impact of avoidable visits.
METHODS:
Children with tracheostomies in a pediatric tertiary care center with the highest ED utilization were identified via analysis of administrative data. Six experts in interdisciplinary dyads reviewed the records from all ED visits for these children, and distinguished avoidable from unavoidable visits. Hospital cost data for avoidable visits is described.
RESULTS:
Among 75 children with tracheostomies and complex chronic conditions, 23 (31%) were high ED utilizers. These 23 children accounted for 74% of all ED discharges the total group of 75 children from 2008 to 2011. Four of these 23 children with high utilization were excluded, leaving 19 subjects for review. These 19 children had 312 ED visits, of which 103 (33%) were deemed avoidable. Leading reasons for avoidable visits were uncomplicated upper respiratory infections, gastrointestinal infections, and enteral feeding system problems. Avoidable visits cost the hospital {$}67,940.
CONCLUSIONS:
One-third of ED visits by children with tracheostomies and complex chronic conditions may be avoidable. Increased ambulatory access to interdisciplinary teams of providers familiar with these children’s unique needs might reduce avoidable ED visits and improve health outcomes. Further studies on how this model of ambulatory care might affect ED utilization and total healthcare costs are needed.
KEYWORDS:
Child; emergencies; tracheostomy
Am Heart J. 2015 Oct;170(4):805-11. doi: 10.1016/j.ahj.2015.07.016. Epub 2015 Jul 26.
Kini V1, McCarthy FH2, Rajaei S3, Epstein AJ4, Heidenreich PA5, Groeneveld PW4.
Abstract
BACKGROUND:
Rapid growth in the provision of cardiac imaging tests has led to concerns about overuse. Little is known about the degree to which health care delivery system characteristics influence use and variation in echocardiography.
METHODS:
We analyzed administrative claims of veterans with heart failure older than 65 years from 2007 to 2010 across 34 metropolitan service areas (MSAs). We compared overall rates and geographic variation in use of transthoracic echocardiography (TTE) between veterans who used the Veterans Health Administration (VA) and propensity-matched veterans who used Medicare. „Dual users“ were excluded.
RESULTS:
There were no significant differences in clinical characteristics or mortality between the propensity-matched cohorts (overall n = 30,404 veterans, mean age 76 years, mortality rate 52%). The Medicare cohort had a significantly higher overall rate of TTE use compared with the VA cohort (1.25 vs 0.38 TTEs per person-year, incidence rate ratio 2.89 [95% CI 2.80-3.00], both P < .001), but a similar coefficient of variation across MSAs (0.36 [95% CI 0.27-0.45] vs 0.48 [95% CI 0.37-0.59]). There was a moderate to strong correlation in variation at the MSA level between cohorts (Spearman r = 0.58, P < .001).
CONCLUSION:
Overall rates of TTE use were significantly higher in a Medicare cohort compared with a propensity score-matched VA cohort of veterans with heart failure living in urban areas, with similar relative degrees of geographic variation and moderate to strong regional correlation. Rates of TTE use may be strongly influenced by health care system characteristics, but local practice styles influence echocardiography rates irrespective of health system.
Copyright © 2015 Elsevier Inc. All rights reserved.
Clin Chem Lab Med. 2016 Mar;54(3):473-82. doi: 10.1515/cclm-2015-0329.
Gion M, Peloso L, Trevisiol C, Squarcina E, Zappa M, Fabricio AS.
Abstract
BACKGROUND:
Evaluation of appropriateness of laboratory tests on the basis of individual requests remains a serious problem as the clinical question is usually not reported with the test order. This study explored the comparison of the rate of tumor marker orders with cancer prevalence as a putative indicator of inappropriateness.
METHODS:
Tumor marker orders (2011 and 2012) were obtained from the Ministry of Health and cancer prevalence from the Italian Association of Cancer Registries. The rate of tumor marker orders was matched with demographic data and tumor prevalence and examined by using the confidence interval approach. Region-to-region and year-to-year variations were also examined. Focus was placed on CEA, CA125, CA19.9 and CA15.3.
RESULTS:
Tumor markers ordered in Italy were 13,207,289 in 2012 (221.3/1000 individuals). Given an estimated prevalence of 2,243,953 cancer cases, 7.04 tumor markers appear to be requested for each prevalent case of epithelial cancer per year. The rate of requests of CEA, CA125, CA19.9 and CA15.3 (in aggregate 5,834,167 requests in 2012, 44.2% of total) from the first and the last ranked region (96 and 244/1000 individuals) are significantly different (p<0.01). Region-to-region differences do not correspond to any known variation of prevalence in the different regions.
CONCLUSIONS:
The developed approach provides a proxy indicator of inappropriateness showing that tumor markers are overused in Italy and their ordering pattern is not related to tumor prevalence. The model is suitable to be validated in other laboratory tests used in diseases whose prevalence is known.
Am J Manag Care. 2015 Jul 1;21(7):e447-9.
Colorectal cancer screening in the 21st century: where do we go from here?
Abstract
Our approach to colorectal cancer screening is undergoing a much-needed paradigm shift. The evidence that screening „works“ and is of high value is indisputable, yet screening remains underused at a population level. In contrast, other data suggest overuse of screening. Traditional population-oriented efforts to promote screening utilization have not only failed to adequately address underuse, they have simultaneously promoted overuse of screening in selected groups of patients. Clearly, new approaches are needed if we are to deliver the right care to the right patients at the right time. By shifting our focus from populations to patients, we can aim to achieve the goal set by Healthy People 2020 of ensuring that 70% of the appropriate US population is up-to-date with colorectal cancer screening.
J Oncol Pract. 2015 Sep;11(5):372-7. doi: 10.1200/JOP.2015.003921. Epub 2015 Aug 4.
Zerillo JA1, Stuver SO2, Fraile B2, Dodek AD2, Jacobson JO2.
Abstract
PURPOSE:
Receipt of chemotherapy in the last 14 days of life is a measure of potential overuse of care. Specific measures defining appropriate end-of-life use of oral agents have not yet been described, and little is known about prescribing patterns.
METHODS:
We conducted an exploratory analysis of 371 patients at Dana-Farber Cancer Institute who were covered by the Blue Cross Blue Shield of Massachusetts pharmacy benefit and died during 2012 to 2013. We analyzed processed claims as a surrogate for chemotherapy administration. We compared oral with parenteral chemotherapy claims in the last 6 months of life.
RESULTS:
In the last 6 months of life, 294 patients (79%) had chemotherapy claims, including 81 (22%) prescribed an oral agent; 20 patients had claims for oral chemotherapy in the last 30 days of life. For eight patients (40%), this was the initial start of that oral agent. In the last 14 days of life, only 23 patients had chemotherapy claims, including six patients prescribed an oral agent.
CONCLUSION:
The collection of oral chemotherapy use data through insurance claims was feasible. Processed claims for chemotherapy, including oral, sharply declined during the last 30 days of life, consistent with a shift to palliative management. These results highlight the need for a more comprehensive analysis of oral chemotherapy prescribing patterns and development of specific measures to define the appropriate use of oral chemotherapy at the end of life.
Copyright © 2015 by American Society of Clinical Oncology.
Circulation. 2015 Jul 21;132(3):205-14. doi: 10.1161/CIRCULATIONAHA.114.012668.
Overuse of Cardiovascular Services: Evidence, Causes, and Opportunities for Reform.
Huang X1, Rosenthal MB2.
KEYWORDS:
cardiovascular diseases; cost–benefit analysis; economics, medical; health care reform; health policy; quality of health care
Jt Comm J Qual Patient Saf. 2015 Jul;41(7):313-22.
Melnick ER1, Keegan J, Taylor RA.
Abstract
BACKGROUND:
A study was conducted to (1) determine the testing threshold for head computed tomography (CT) in minor head injury in the emergency department using decision analysis with and without costs included in the analysis, (2) to determine which variables have significant impact on the testing threshold, and (3) to compare this calculated testing threshold to the pretest risk estimate previously reported when the Canadian CT Head Rule (CCHR) was applied. It was hypothesized that the CCHR might not identify all patients above the testing threshold.
METHODS:
A decision analytic model was constructed using commercially available software and data from published literature. Outcomes were assigned values on the basis of quality-adjusted life-years (QALYs) and cost. Two testing thresholds were calculated, the first based only on the effectiveness of either strategy, the second on the overall net monetary benefit. Two-way sensitivity analyses were performed to determine which variables most affected the testing threshold.
RESULTS:
When only effectiveness (QALYs) was considered, the testing threshold for obtaining head CT was 0.039%. This threshold increased to 0.421% when the net monetary benefit was considered in lieu of QALYs. Age, probability of lesion on CT requiring neurosurgery, and cost of CT were the main drivers of the model.
CONCLUSION:
If only effectiveness is considered, current clinical decision rules might not provide a sufficient degree of certainty to ensure identification of all patients for whom the benefits of CT outweigh its risks. However, inclusion of cost in the analysis increases the testing threshold by an order of magnitude and well outside the range of uncertainty of current clinical decision rules. These results suggest that the term overuse should be redefined to include the provision of medical services with no benefits or for which harms including cost outweigh benefits.
BMC Med Ethics. 2015 Jun 19;16:43. doi: 10.1186/s12910-015-0036-6.
Kazemian A1,2,3, Berg I4,5, Finkel C6, Yazdani S7, Zeilhofer HF8,9, Juergens P10,11, Reiter-Theil S12.
Abstract
BACKGROUND:
Overtreatment (or unnecessary treatment) is when medical or dental services are provided with a higher volume or cost than is appropriate. This study aimed to investigate how a group of dentists in Switzerland, a wealthy country known to have high standards of healthcare including dentistry, evaluated the meaning of unnecessary treatments from an ethical perspective and, assessed the expected frequency of different possible behaviors among their peers.
METHODS:
A vignette describing a situation that is susceptible for overtreatment of a patient was presented to a group of dentists. The vignette was followed by five options. A questionnaire including the vignette was posted to 2482 dentists in the German-speaking areas of Switzerland. The respondents were asked to rate each option according to their estimation about its prevalence and their judgment about the degree to which the behavior is ethically sound.
RESULTS:
732 completed questionnaires were returned. According to the responses, the most ethical and the most unethical options are considered to be the most and the least prevalent behaviors among dentists practicing in Switzerland, respectively.
CONCLUSIONS:
Suggesting unnecessary treatments to patients seems to be an ethically unacceptable conduct in the eyes of a sample of dentists in Switzerland. Although the respondents believed their colleagues were very likely to behave in an ethical way in response to a situation that is susceptible to overtreatment, they still seemed to be concerned about the prevalence of unethical behaviors in this regard.
J Cardiovasc Comput Tomogr. 2015 Jul-Aug;9(4):329-36. doi: 10.1016/j.jcct.2015.03.014. Epub 2015 Apr 7.
Thomas DM1, Shaw DJ1, Barnwell ML1, Jones RL1, Ahmadian HR1, Prentice RL1, Lin CK1, Triana T1, Cheezum MK2, Cury RC3, Slim AM4.
Abstract
OBJECTIVE:
The purpose of this study is to investigate the cost and resource use due to chest pain (CP) evaluations after initial coronary CT angiography (CCTA) stratified by coronary artery disease (CAD) burden.
METHODS:
We examined 1518 patients referred for CCTA from January 2005 to July 2012 for downstream evaluation after CCTA during a median follow-up of 351 days. Results were stratified by CAD burden as quantified on CCTA into no CAD, nonobstructive CAD (<50% stenosis), or obstructive CAD (≥50% stenosis). The incidence of ischemic testing at the time of recurrent evaluation (defined as a composite of clinic visit, emergency department encounter, or ischemic testing after the index CCTA for CP, atypical CP, or angina defined by ICD-9 code), the testing modality used, and frequency of testing were abstracted and used to calculate the direct costs of downstream utilization. Major adverse cardiovascular events defined as all-cause mortality, nonfatal myocardial infarction, stroke, or revascularization >90 days from CCTA were abstracted using ICD-9 codes and Social Security Death Index query.
RESULTS:
A total of 174 patients (11.5%) underwent evaluation for CP after index CCTA with a higher rate of subsequent clinical visits among obstructive CAD patients compared to those with nonobstructive CAD and no CAD (17.8% vs 13.9% vs. 7.5%; P < .001). A significant reduction in the incidence of repeat ischemic testing was observed in patients with no CAD and nonobstructive CAD (P = .002). This resulted in a lower per-patient cost in the nonobstructive CAD and no CAD patients (median [interquartile range 25-75]: $2952 [$307-2952] and $235 [$0-2880]) when compared with patients with obstructive CAD (median [interquartile range 25-75]: $5832 [$5498-17,459]; P < .001). Major adverse cardiovascular events were not different in the 90 patients that underwent repeat testing at the time of CP evaluation when compared with the 84 patients for whom testing was deferred.
CONCLUSION:
Absence of CAD on initial CCTA was associated with lower costs and decreased downstream utilization compared to the presence of nonobstructive and obstructive CAD on CCTA during median follow-up of 351 days.
Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
CCTA; Coronary computed tomography angiography; Cost; Downstream; Recurrent chest pain; Utilization
Comment in
- What does the PROMISE trial mean for cardiac CT? Outcome of coronary CT angiography vs functional testing in suspected coronary artery disease.[J Cardiovasc Comput Tomogr. 2015]
Arch Dis Child. 2015 Oct;100(10):958-9. doi: 10.1136/archdischild-2015-308428. Epub 2015 Jun 4.
Do we prescribe medicines rationally?
KEYWORDS:
Health Service; Pharmacology; Therapeutics
Otolaryngol Head Neck Surg. 2015 Jun;152(6):991-2. doi: 10.1177/0194599815583477.
Do geographic variations signify overuse?
KEYWORDS:
Medicare; geographic; incentives; practice patterns; regional; reimbursement; utilization; variation
Comment on
- Practice arrangement and medicare physician payment in otolaryngology.[Otolaryngol Head Neck Surg. 2015]
Ther Clin Risk Manag. 2015 May 24;11:649-57. doi: 10.2147/TCRM.S81759. eCollection 2015.
Shin S1.
Abstract
BACKGROUND:
Stress ulcers and related upper gastrointestinal bleeding are well-known complications in intensive care unit (ICU) patients. Proton pump inhibitor (PPI)-based stress ulcer prophylaxis (SUP) has been widely prescribed in noncritically ill patients who are at low risk for clinically significant bleeding, which is then injudiciously continued after hospital discharge. This study aimed to evaluate the incidence of inappropriate prescribing of PPI-based preventative therapy in ICU versus non-ICU patients that subsequently continued postdischarge, and to estimate the costs incurred by the unwarranted outpatient continuation of PPI therapy.
METHODS:
A retrospective review of patient data at a major teaching hospital in Korea was performed. During the 4-year study period, adult patients who were newly initiated on PPI-based SUP during hospital admission and subsequently discharged on a PPI without a medical indication for such therapy were captured for data analysis. The incidence rates of inappropriate prescribing of PPIs were compared between ICU and non-ICU patients, and the costs associated with such therapy were also examined.
RESULTS:
A total of 4,410 patients, more than half of the inpatient-initiated PPI users, were deemed to have been inadvertently prescribed a PPI at discharge in the absence of a medical need for acid suppression. The incidence of inappropriate outpatient continuation of the prophylaxis was higher among ICU patients compared with non-ICU patients (57.7% versus 52.2%, respectively; P=0.001). The total expenditure accrued through the continuation of nonindicated PPI therapy was approximately US$40,175.
CONCLUSION:
This study confirmed that excess usage of PPIs for SUP has spread to low-risk, non-ICU patients. The overuse of unwarranted PPI therapy can incur large health care expenditure, as well as clinical complications with minimal therapeutic benefits. Educating clinicians regarding SUP guidelines and the adverse effects of long-term use of acid suppression can improve the cost effectiveness of PPI therapy.
KEYWORDS:
critical care; gastrointestinal bleeding; intensive care unit; prophylaxis; proton pump inhibitor; stress ulcer
AM SOC CLIN ONCOL EDUC BOOK. 2015:e426-33. doi: 10.14694/EdBook_AM.2015.35.e426.
The Value of Lung Cancer CT Screening: It Is All about Implementation.
Abstract
Hospitals have been gradually implementing new lung cancer CT screening programs following the release of the U.S. Preventive Services Task Force grade B recommendation to screen individuals at high risk for lung cancer. Policy makers have legitimately questioned whether adoption of CT screening in the community will reproduce the mortality benefits seen in the National Lung Screening Trial (NLST) and whether the benefits of screening will justify the potentially high costs. Although three annual CT screening exams proved cost-effective for the patient population enrolled in the NLST, uncertainty still exists about whether CT screening will be cost-effective in practice. The value of CT screening will depend largely on the strategies used to implement it. This manuscript reviews the current reimbursement policies for CT screening and explains the relationship between implementation strategies and screening value on the basis of the NLST cost-effectiveness analysis and other published data. A subsequent discussion ensues about the potential implementation inefficiencies that can negatively affect the value of CT screening (e.g., selection of low-risk individuals for screening, inappropriate follow-up visits for screening-detected lung nodules, failure to offer smoking cessation interventions, and overuse of medical resources for clinically irrelevant incidental findings) and the actions that can be taken to mitigate these inefficiencies and increase the value of screening.
Ann Intern Med. 2015 May 19;162(10):718-25. doi: 10.7326/M14-2326.
Screening for cancer: advice for high-value care from the American College of Physicians.
Wilt TJ, Harris RP, Qaseem A; High Value Care Task Force of the American College of Physicians.
Abstract
BACKGROUND:
Cancer screening is one approach to reducing cancer-related morbidity and mortality rates. Screening strategies vary in intensity. Higher-intensity strategies are not necessarily higher value. High-value strategies provide a degree of benefits that clearly justifies the harms and costs incurred; low-value screening provides limited or no benefits to justify the harms and costs. When cancer screening leads to benefits, an optimal intensity of screening maximizes value. Some aspects of screening practices, especially overuse and underuse, are low value.
METHODS:
Screening strategies for asymptomatic, average-risk adults for 5 common types of cancer were evaluated by reviewing clinical guidelines and evidence syntheses from the American College of Physicians (ACP), U.S. Preventive Services Task Force, American Academy of Family Physicians, American Cancer Society, American Congress of Obstetricians and Gynecologists, American Gastroenterological Association, and American Urological Association. „High value“ was defined as the lowest screening intensity threshold at which organizations agree about screening recommendations for each type of cancer and „low value“ as agreement about not recommending overly intensive screening strategies. This information is supplemented with additional findings from randomized, controlled trials; modeling studies; and studies of costs or resource use, including information found in the National Cancer Institute’s Physician Data Query and UpToDate. The ACP provides high-value care screening advice for 5 common types of cancer; the specifics are outlined in this article. The ACP strongly encourages clinicians to adopt a cancer screening strategy that focuses on reaching all eligible persons with these high-value screening options while reducing overly intensive, low-value screening.
Summary for patients in
- Summaries for Patients. Screening for cancer.[Ann Intern Med. 2015]
Glob Adv Health Med. 2015 Mar;4(2):4-6. doi: 10.7453/gahmj.2014.077.
Abstract
In the United States, healthcare expenditures have continued to rise at alarming rates despite numerous strategies to contain costs. One area of focus that is underappreciated is doctor-patient communication about expectations of treatment. Studies have shown that clinicians‘ misperceptions of assumptions about patients‘ expectations are an essential component to our nation’s healthcare overuse problem. Strategies to address these misperceptions and assumptions as a method of reducing costs and providing higher-quality care to our patients are warranted.
KEYWORDS:
Healthcare; communication; containment; doctor-patient relationship; expenditures; overuse; spending; waste
Health Aff (Millwood). 2015 Apr;34(4):576-83. doi: 10.1377/hlthaff.2014.1087.
Abstract
Populationwide mammography screening has been associated with a substantial rise in false-positive mammography findings and breast cancer overdiagnosis. However, there is a lack of current data on the associated costs in the United States. We present costs due to false-positive mammograms and breast cancer overdiagnoses among women ages 40-59, based on expenditure data from a major US health care insurance plan for 702,154 women in the years 2011-13. The average expenditures for each false-positive mammogram, invasive breast cancer, and ductal carcinoma in situ in the twelve months following diagnosis were $852, $51,837 and $12,369, respectively. This translates to a national cost of $4 billion each year. The costs associated with false-positive mammograms and breast cancer overdiagnoses appear to be much higher than previously documented. Screening has the potential to save lives. However, the economic impact of false-positive mammography results and breast cancer overdiagnoses must be considered in the debate about the appropriate populations for screening.
Project HOPE—The People-to-People Health Foundation, Inc.
KEYWORDS:
Cost of Health Care
Comment in
- Breast Cancer Diagnoses: The Authors Reply.[Health Aff (Millwood). 2015]
- False-Positive Mammograms, Breast Cancer Overdiagnoses.[Health Aff (Millwood). 2015]
- Risks And Benefits Of Breast Cancer Screening.[Health Aff (Millwood). 2016]
- Mammography Risks: The Authors Reply.[Health Aff (Millwood). 2016]
J Oncol Pract. 2015 May;11(3):168-70. doi: 10.1200/JOP.2015.004283. Epub 2015 Mar 24.
Reframing overuse in health care: time to focus on the harms.
Hicks LK1.
Acad Radiol. 2015 Aug;22(8):976-82. doi: 10.1016/j.acra.2014.10.011. Epub 2015 Mar 13.
Abstract
The National Lung Cancer Screening Trial (NLST) demonstrated a mortality reduction benefit associated with low-dose computed tomography (LDCT) screening for lung cancer. There has been considerable debate regarding the benefits and harms of LDCT lung cancer screening, including the challenges related to its practical implementation. One of the controversies regards overdiagnosis, which conceptually denotes diagnosing a cancer that, either because of its indolent, low-aggressiveness biologic behavior or because of limited life expectancy, is unlikely to result in significant morbidity during the patient’s remainder lifetime. In theory, diagnosing and treating these cancers offer no measurable benefit while incurring costs and risks. Therefore, if a screening test detects a substantial number of overdiagnosed cancers, it is less likely to be effective. It has been argued that LDCT screening for lung cancer results in an unacceptably high rate of overdiagnosis. This article aims to defend the opposite stance. Overdiagnosis does exist and to a certain extent is inherent to any cancer-screening test. Nonetheless, the concept is less dualistic and more nuanced than it has been suggested. Furthermore, the average estimates of overdiagnosis in LDCT lung cancer screening based on the totality of published data are likely much lower than the highest published estimates, if a careful definition of a positive screening test reflecting our current understanding of lung cancer biology is utilized. This article presents evidence on why reports of overdiagnosis in lung cancer screening have been exaggerated.
Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
Lung cancer CT screening; cost effectiveness; harms; overdiagnosis; randomized trials; risks
Comment in
- Overdiagnosis in Lung Cancer Screening can be Reduced to a Low, Manageable Level via a Multilayered Strategy Involving Perfecting Reporting Systems, Restricting Screening to High-Risk Groups, Developing Better Risk Stratification Models, and Improving Management Algorithms.[Acad Radiol. 2016]
- Overdiagnosis Detrimental, Resection Consequential, NLST Challengeable.[Acad Radiol. 2016]
Milbank Q. 2015 Mar;93(1):112-38. doi: 10.1111/1468-0009.12107.
Race/Ethnicity and overuse of care: a systematic review.
Abstract
POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients‘ outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.
CONTEXT:
The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients‘ outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.
METHODS:
We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.
FINDINGS:
We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.
CONCLUSIONS:
Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.
© 2015 Milbank Memorial Fund.
KEYWORDS:
guideline adherence; inappropriate test; inappropriate utilization
Eur J Health Econ. 2016 Apr;17(3):257-67. doi: 10.1007/s10198-015-0676-y. Epub 2015 Mar 7.
Drug overprescription in nursing homes: an empirical evaluation of administrative data.
Stroka MA1,2,3.
Abstract
A widely discussed shortcoming of long-term care in nursing homes for the elderly is the inappropriate or suboptimal drug utilization, particularly of psychotropic drugs. Using administrative data from the largest sickness fund in Germany, this study was designed to estimate the effect of institutionalization on the drug intake of the frail elderly. Difference-in-differences propensity score matching techniques were used to compare drug prescriptions for the frail elderly who entered a nursing home with those who remained in the outpatient care system; findings suggest that nursing home residents receive more doses of antipsychotics, antidepressants, and analgesics. The potential overprescription correlates with estimated drug costs of about €87 million per year.
KEYWORDS:
Drug over- and undersupply; Expenditures; Medical costs; Medication errors; Patient safety
J Trauma Acute Care Surg. 2015 Mar;78(3):510-5. doi: 10.1097/TA.0000000000000553.
Vercruysse GA1, Friese RS, Khalil M, Ibrahim-Zada I, Zangbar B, Hashmi A, Tang A, O’Keeffe T, Kulvatunyou N, Green DJ, Gries L, Joseph B, Rhee PM.
Abstract
BACKGROUND:
Mortality benefit has been demonstrated for trauma patients transported via helicopter but at great cost. This study identified patients who did not benefit from helicopter transport to our facility and demonstrates potential cost savings when transported instead by ground.
METHODS:
We performed a 6-year (2007-2013) retrospective analysis of all trauma patients presenting to our center. Patients with a known mode of transfer were included in the study. Patients with missing data and those who were dead on arrival were excluded from the study. Patients were then dichotomized into helicopter transfer and ground transfer groups. A subanalysis was performed between minimally injured patients (ISS < 5) in both the groups after propensity score matching for demographics, injury severity parameters, and admission vital parameters. Groups were then compared for hospital and emergency department length of stay, early discharge, and mortality.
RESULTS:
Of 5,202 transferred patients, 18.9% (981) were transferred via helicopter and 76.7% (3,992) were transferred via ground transport. Helicopter-transferred patients had longer hospital (p = 0.001) and intensive care unit (p = 0.001) stays. There was no difference in mortality between the groups (p = 0.6).On subanalysis of minimally injured patients there was no difference in hospital length of stay (p = 0.1) and early discharge (p = 0.6) between the helicopter transfer and ground transfer group. Average helicopter transfer cost at our center was $18,000, totaling $4,860,000 for 270 minimally injured helicopter-transferred patients.
CONCLUSION:
Nearly one third of patients transported by helicopter were minimally injured. Policies to identify patients who do not benefit from helicopter transport should be developed. Significant reduction in transport cost can be made by judicious selection of patients. Education to physicians calling for transport and identification of alternate means of transportation would be both safe and financially beneficial to our system.
LEVEL OF EVIDENCE:
Epidemiologic study, level III. Therapeutic study, level IV.
J Health Polit Policy Law. 2015 Apr;40(2):421-37. doi: 10.1215/03616878-2882281. Epub 2015 Feb 2.
Overutilization, overutilized.
Levine D1, Mulligan J1.
Abstract
Overutilization is commonly blamed for escalating costs, compromising quality, and limiting access to the US health care system. Recent estimates suggest that nearly one-third of health care spending in the United States is a result of unnecessary care. Despite the surge of exposés that purport to uncover this „new“ problem, narratives about overutilization have been circulating in health policy debates since the beginnings of the health insurance industry. This article traces how the term overutilization has spread in popularity from a relatively small community of mid-twentieth-century insurance experts to economists, physicians, epidemiologists, and eventually the news media of the early twenty-first century. A quick glimpse at the history of the term reveals that there has been constant disagreement and debate over the meaning and impact of overutilization. Moreover, the term has been put to very different uses, from keeping socialism at bay to preserving the fiscal integrity of Medicare to protecting the health of patients. The overutilization narrative, seductive in its promise of cutting costs without sacrificing access to quality care, too often drowns out other difficult conversations about social welfare, health equity, prices, and universal coverage.
Copyright © 2015 by Duke University Press.
KEYWORDS:
health insurance; health policy research; managed care; overutilization
Health Technol Assess. 2015 Jan;19(8):1-134. doi: 10.3310/hta19080.
Long L1, Briscoe S1, Cooper C1, Hyde C1, Crathorne L1.
Abstract
BACKGROUND:
Lateral elbow tendinopathy (LET) is a common complaint causing characteristic pain in the lateral elbow and upper forearm, and tenderness of the forearm extensor muscles. It is thought to be an overuse injury and can have a major impact on the patient’s social and professional life. The condition is challenging to treat and prone to recurrent episodes. The average duration of a typical episode ranges from 6 to 24 months, with most (89%) reporting recovery by 1 year.
OBJECTIVES:
This systematic review aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for LET.
DATA SOURCES:
A comprehensive search was conducted from database inception to 2012 in a range of databases including MEDLINE, EMBASE and Cochrane Databases.
METHODS AND OUTCOMES:
We conducted an overview of systematic reviews to summarise the current evidence concerning the clinical effectiveness and a systematic review for the cost-effectiveness of conservative interventions for LET. We identified additional randomised controlled trials (RCTs) that could contribute further evidence to existing systematic reviews. We searched MEDLINE, EMBASE, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Web of Science, The Cochrane Library and other important databases from inception to January 2013.
RESULTS:
A total of 29 systematic reviews published since 2003 matched our inclusion criteria. These were quality appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist; five were considered high quality and evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach. A total of 36 RCTs were identified that were not included in a systematic review and 29 RCTs were identified that had only been evaluated in an included systematic review of intermediate/low quality. These were then mapped to existing systematic reviews where further evidence could provide updates. Two economic evaluations were identified.
LIMITATIONS:
The summary of findings from the review was based only on high-quality evidence (scoring of > 5 AMSTAR). Other limitations were that identified RCTs were not quality appraised and dichotomous outcomes were also not considered. Economic evaluations took effectiveness estimates from trials that had small sample sizes leading to uncertainty surrounding the effect sizes reported. This, in turn, led to uncertainty of the reported cost-effectiveness and, as such, no robust recommendations could be made in this respect.
CONCLUSIONS:
Clinical effectiveness evidence from the high-quality systematic reviews identified in this overview continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new RCT evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them because of the small sample size. Conclusions regarding cost-effectiveness are also unclear. We consider that, although updated or new systematic reviews may also be of value, the primary focus of future work should be on conducting large-scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments.
STUDY REGISTRATION:
This study is registered as PROSPERO CRD42013003593.
FUNDING:
The National Institute for Health Research Health Technology Assessment programme.
Am Fam Physician. 2015 Jan 1;91(1):22-4.
Improving quality by doing less: overscreening.
Ebell M1, Herzstein J2.
Med Care. 2015 Mar;53(3):230-6. doi: 10.1097/MLR.0000000000000304.
An index for measuring overuse of health care resources with Medicare claims.
Segal JB1, Nassery N, Chang HY, Chang E, Chan K, Bridges JF.
Abstract
BACKGROUND:
Overuse can be defined as use of a service when the risk of harm exceeds its likely benefit. Yet, there has been little work with composite measures of overuse.
OBJECTIVE:
Our goal was to create a composite measure of overuse with claims data.
DESIGN:
Observational study using 5% of Medicare claims from 2008.
SETTING:
All inpatient and outpatient settings of care, excluding nursing homes.
PARTICIPANTS:
Older Americans receiving health care services in hospitals or outpatient settings.
MEASURES:
We applied algorithms to identify specific cases of overuse across 20 previously identified procedures and used multilevel modeling techniques to examine variation in overuse across all procedures. Included in the model were patient-level factors and both procedure and regional fixed effects for the 306 hospital referral regions (HRR). These estimated regional fixed effects, representing the systematic, region variation in overuse across all measures, was then normalized compared with the overall average to generate a Z score for each HRR. The resulting „Overuse Index“ was then compared with total costs, 30-day postdischarge mortality, and total mortality at the HRR level, graphically, and associations were tested using Spearman ρ.
RESULTS:
The Overuse Index varied markedly across regions, but 23 were higher than the average (P<0.05). The Index was positively associated with total costs (ρ=0.28, P<0.0001). It was positively correlated with 30-day postdischarge mortality (ρ=0.18 P≤0.005), and neither positively or negatively correlated with total mortality.
CONCLUSIONS:
This study confirms previous research hypothesizing that systematic regional variation in overuse exists and is measurable. Addition research is needed to validate index and to test its predictive and concurrent validity in panel data.
Hosp Pediatr. 2015 Jan;5(1):9-17. doi: 10.1542/hpeds.2014-0015.
Serum magnesium levels in pediatric inpatients: a study in laboratory overuse.
Narayanan S1, Scalici P2.
Abstract
BACKGROUND AND OBJECTIVE:
Hypomagnesemia, defined as a serum magnesium (Mg) level<1.5 mg/dL (0.62 mmol/L), is often asymptomatic. The goals of this study were to determine the incidence of clinically significant abnormal Mg levels in the inpatient setting and to identify diagnoses for which testing would be diagnostically helpful.
METHODS:
We obtained data from 2010 through 2011 on charges for serum Mg levels and Mg supplementation for all non-ICU inpatients from the 43 tertiary care children’s hospitals in the Pediatric Health Information System database. A manual chart review was performed for all patients at our institution with charges for both Mg levels and Mg supplementation.
RESULTS:
A median of 13.5% (interquartile range: 7.7-22.1) of non-ICU inpatients from Pediatric Health Information System centers had charges for Mg levels, at a total charge of $41 million in the 2010-2011 period. At our institution, 19.1% of non-ICU inpatients had charges for Mg levels, at a charge of $67.32/patient-day. Of the 4608 patients with Mg laboratory charges at our institution, 171 (3.7%) had an intervention, defined as addition or modification of an Mg supplement dose in response to a serum Mg level. The 4 most common groups of diagnoses (oncologic, abdominal surgery requiring total parenteral nutrition, solid organ transplant, and short bowel syndrome) accounted for 143 (83.6%) of these interventions.
CONCLUSIONS:
Serum Mg levels were frequently ordered in non-ICU inpatients, but levels were seldom abnormal and rarely resulted in changes in clinical management. These findings raise concerns about resource overutilization and provide a target for more judicious laboratory ordering practices.
Copyright © 2015 by the American Academy of Pediatrics.
KEYWORDS:
hypomagnesemia; laboratory; magnesium; overuse
Comment in
- Overuse in pediatrics: time to „pull the trigger“?[Hosp Pediatr. 2015]
Z Evid Fortbild Qual Gesundhwes. 2014;108(10):601-3. doi: 10.1016/j.zefq.2014.10.014. Epub 2014 Nov 7.
When Choosing Wisely meets clinical practice guidelines.
Strech D1, Follmann M2, Klemperer D3, Lelgemann M4, Ollenschläger G5, Raspe H6, Nothacker M7.
Abstract
The American Board of Internal Medicine (ABIM) Foundation launched the Choosing Wisely campaign in 2012 and until today convinced more than 50 US specialist societies to develop lists of interventions that may not improve people’s health but are potentially harmful. We suggest combining these new efforts with the already existing efforts in clinical practice guideline development. Existing clinical practice guidelines facilitate a more participatory and evidence-based approach to the development of top 5 lists. In return, adding top 5 lists (for overuse and underuse) to existing clinical practice guidelines nicely addresses a neglected dimension to clinical practice guideline development, namely explicit information on which Do or Don’t do recommendations are frequently disregarded in practice.
Copyright © 2014. Published by Elsevier GmbH.
KEYWORDS:
Choosing Wisely; Leitlinien; Unterversorgung; overuse; practice guidelines; underuse; Überversorgung
N Engl J Med. 2014 Nov 13;371(20):1857-9. doi: 10.1056/NEJMp1408974.
Marketing to physicians in a digital world.
Abstract
Pharmaceutical marketing can lead to overdiagnosis, overtreatment, and overuse of medications. Digital advertising creates new pathways for reaching physicians, allowing delivery of marketing messages at the point of care, when clinical decisions are being made.
Am Fam Physician. 2014 Nov 1;90(9):625-31.
Screening for cancer: concepts and controversies.
Gates TJ1.
Abstract
Early detection of cancer is a core task in family medicine, and patients have come to expect screening tests, sometimes out of proportion to what evidence can justify. To understand the controversies surrounding screening and to provide sound advice to patients, family physicians should be familiar with the fundamental concepts of screening. Failure to account for the effects of lead-time, length-time, and overdiagnosis biases can lead to overestimation of screening benefits. For this reason, the best method for evaluating the benefit of screening tests is a randomized controlled trial showing decreased disease-specific or all-cause mortality. The number needed to screen can be used to measure the magnitude of benefit of screening tests. Accepted screening tests often require screening several hundred to more than 1,000 asymptomatic patients to prevent one death from the disease. The U.S. Preventive Services Task Force and American Academy of Family Physicians recommend screening for colorectal cancer in adults 50 to 75 years of age, and recommend against prostate-specific antigen testing to screen for prostate cancer. Annual low-dose computed tomography screening for lung cancer reduces mortality in persons 55 to 80 years of age with at least a 30-pack-year history who are otherwise healthy smokers or who have quit smoking within the past 15 years; however, it is associated with a high false-positive rate, uncertain harms from radiation exposure, and overdiagnosis. Therefore, it should be performed only in conjunction with smoking cessation interventions.
Authors
Owens PL, Barrett ML, Weiss AJ, Washington RE, Kronick R.
Source
Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006-.
2014 Aug.
Excerpt
This HCUP Statistical Brief presents data on adult inpatient hospitalizations involving overuse of opioids, including opioid dependence, abuse, poisoning, and adverse effects. Hospitalizations that involved illegal drug use were excluded from this analysis. Trends in hospital inpatient stays related to opioid overuse among adults are presented along with characteristics of these types of stays. Differences between group rate estimates noted in the text are statistically significant at the 0.05 level or better and differ by at least 10 percent.
Sections
Am J Respir Crit Care Med. 2014 Oct 1;190(7):818-26. doi: 10.1164/rccm.201407-1317ST.
Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM; Choosing Wisely Taskforce; American Thoracic Society; American Association of Critical-Care Nurses; Society of Critical Care Medicine.
Abstract
RATIONALE:
The high costs of health care in the United States and other developed nations are attributable, in part, to overuse of tests, treatments, and procedures that provide little to no benefit for patients. To improve the quality of care while also combating this problem of cost, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of the top five medical services that patients and physicians should question.
OBJECTIVES:
To present the Critical Care Societies Collaborative’s Top 5 list in Critical Care Medicine and describe its development.
METHODS:
Each professional society in the Collaborative nominated members to the Choosing Wisely task force, which established explicit criteria for evaluating candidate items, generated lists of items, performed literature reviews on each, and sought external input from content experts. Task force members narrowed the list to the Top 5 items using a standardized scoring system based on each item’s likely overall impact and merits on the five explicit criteria.
MEASUREMENTS AND MAIN RESULTS:
From an initial list of 58 unique recommendations, the task force proposed a Top 5 list that was ultimately endorsed by each Society within the Collaborative. The five recommendations are: (1) do not order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions; (2) do not transfuse red blood cells in hemodynamically stable, nonbleeding ICU patients with an Hb concentration greater than 7 g/dl; (3) do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay; (4) do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation; and (5) do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
CONCLUSIONS:
These five recommendations provide a starting point for clinicians and patients to make decisions leading to higher-quality, lower-cost care. Future work is needed to promote adherence to these recommendations and to develop additional ways for intensive care clinicians to take leadership in reining in health-care costs.
KEYWORDS:
Choosing Wisely; cost effectiveness; critical care; quality improvement
Appl Health Econ Health Policy. 2015 Feb;13(1):1-6. doi: 10.1007/s40258-014-0126-5.
Systematic overuse of healthcare services: a conceptual model.
Nassery N1, Segal JB, Chang E, Bridges JF.
Abstract
A perfect storm of factors influences the overuse of healthcare services in the USA. Considerable attention has been placed on geographic variation in utilization; however, empiric data has shown that geographic variation in utilization is not associated with overuse. While there has been renewed interest in overuse in recent years, much of the focus has been on the overuse of individual procedures. In this paper we argue that overuse should be thought of as a widespread and pervasive phenomenon that we coin as systematic overuse. While not directly observable (i.e., a latent phenomenon), we suggest that systematic overuse could be identified by tracking a portfolio of overused procedures. Such a portfolio would reflect systematic overuse if it is associated with higher healthcare costs and no health benefit (including worse health outcomes) across a healthcare system. In this report we define and conceptualize systematic overuse and illustrate how it can be identified and validated via a simple empirical example using several Choosing Wisely indicators. The concept of systematic overuse requires further development and empirical verification, and this paper provides an important first step, a conceptual framework, to that end.
J Med Imaging Radiat Oncol. 2015 Feb;59(1):77-81. doi: 10.1111/1754-9485.12234. Epub 2014 Sep 4.
Kim L1, Min M, Roos D, Nguyen L, Yeoh E.
Abstract
INTRODUCTION:
According to international best practice guidelines, staging abdominal and pelvic computed tomography (CTAP) and whole body bone scan (WBBS) are not recommended for asymptomatic low and intermediate-risk prostate cancer. Despite this, many patients undergo these investigations. Our aim was to determine the rate and cost of scans being performed for this group of patients.
METHOD:
We utilised a database of prostate cancer patients treated by a radiation oncologist specialising in prostate cancer at the Royal Adelaide Hospital between January 2008 and December 2012. Risk criteria were defined according to the D’Amico system. We identified the staging investigations ordered.
RESULTS:
Of 236 consecutive eligible patients, 69 (70%) and 85 (86%) of 99 low risk, and 112 (82%) and 126 (92%) of 137 intermediate-risk patients, were found to have had staging CTAP and WBBS, respectively. In fact, only 9.7% of the patients followed the international best practice guidelines and had no staging investigations. None of these scans showed evidence of metastatic disease. The total costs of these investigations for the low and intermediate-risk groups were approximately AUD 75 000 and AUD 116 000, respectively.
CONCLUSION:
We found that there is clearly a significant overuse of staging investigations for both these groups while the incidence of metastases identified was very low. This is likely to have a significant impact on the waiting time for scans and lead to substantial waste of resources. It places unnecessary financial burden on the patients and the healthcare system. There are also issues of increased radiation and contrast exposure, and potentially unnecessary further investigations.
© 2014 The Royal Australian and New Zealand College of Radiologists.
KEYWORDS:
CT scan; bone scan; overuse; prostate cancer; staging
Iran Red Crescent Med J. 2014 May;16(5):e13067. doi: 10.5812/ircmj.13067. Epub 2014 May 5.
Indications and overuse of computed tomography in minor head trauma.
Zargar Balaye Jame S1, Majdzadeh R2, Akbari Sari A3, Rashidian A3, Arab M1, Rahmani H4.
Abstract
BACKGROUND:
Computed Tomography (CT) is a useful diagnostic technology, particularly in accident and emergency departments.
OBJECTIVES:
To identify a comprehensive list of indications for application of CT in patients with minor head trauma (MHT) and to determine appropriateness of its use on the basis of this list.
MATERIALS AND METHODS:
A cross-sectional study was conducted in three Imaging centers in Tehran. A panel of experts developed a list of CT indications for MHT by reviewing documents. A pre-structured checklist was designed and incorporated into a structured form. Four hundred consecutive patients referring to three imaging centers for performing CT due to MHT completed the questionnaire.
RESULTS:
Of 400 patients who underwent CT after MHT, 187 (46.8%) patients had Glasgow coma scale (GCS) score of 13 or 14 at two hours post-trauma and 37 (19.8%) of these patients did not have any indication of imaging. In addition, 213 (53.2%) patients had GCS score of 15 out of which 110 (51.6%) patients did not have any indication of imaging. Patients with a GCS score of 15 had a noticeably lower proportion of abnormal CT results in comparison to patients with a GCS score of 13 or 14, (odds ratio, 19.07; 95% confidence interval, 6.74-54.00; and P < 0.001). There was a statistically significant association between abnormal CT results and the presence of indications including vomiting, dangerous mechanism of injury, visible signs of trauma above the clavicles, signs of skull base fracture, and suspected skull fracture (P < 0.001).
CONCLUSIONS:
On average, about 37% of the patients with MHT referring to the emergency departments had no indication of CT and approximately 86.5% of CT results were normal. Improving this situation can result in a significant saving in health care costs.
KEYWORDS:
Abnormal; Craniocerebral Trauma; Indication; Tomography, X-Ray Computed
Am J Med Qual. 2015 Nov-Dec;30(6):566-70. doi: 10.1177/1062860614540982. Epub 2014 Jun 26.
„Choosing wisely“ in an academic department of medicine.
Hines JZ1, Sewell JL2, Sehgal NL2, Moriates C2, Horton CK2, Chen AH2.
Abstract
The „Choosing Wisely“ campaign seeks to reduce unnecessary care in the United States through self-published recommendations by professional societies. The research team sought to identify factors related to low-value care in the Department of Medicine at the University of California San Francisco, using a subset of clinical scenarios published by the American College of Physicians. The team further explored respondents‘ values on cost consciousness. A notable minority disagreed with the identified low-value tests. In 6 of 8 scenarios, faculty were more likely to rate the scenarios as representing low-value testing (P < .05). Level of training was the only predictor of attitudes toward unnecessary care after linear regression analysis (coefficient 3.14, P < .001). Increased postgraduate education about cost of care is recommended.
JACC Cardiovasc Imaging. 2014 Jul;7(7):690-700. doi: 10.1016/j.jcmg.2014.02.008. Epub 2014 Jun 18.
Farmer SA1, Lenzo J2, Magid DJ3, Gurwitz JH4, Smith DH5, Hsu G6, Sung SH6, Go AS7.
Abstract
OBJECTIVES:
This study aimed to characterize the use of cardiovascular testing for patients with incident heart failure (HF) hospitalization who participated in the National Heart, Lung, and Blood Institute sponsored Cardiovascular Research Network (CVRN) Heart Failure study.
BACKGROUND:
HF is a common cause of hospitalization, and testing and treatment patterns may differ substantially between providers. Testing choices have important implications for the cost and quality of care.
METHODS:
Crude and adjusted cardiovascular testing rates were calculated for each participating hospital. Cox proportional hazards regression models were used to examine hospital testing rates after adjustment for hospital-level patient case mix.
RESULTS:
Of the 37,099 patients in the CVRN Heart Failure study, 5,878 patients were hospitalized with incident HF between 2005 and 2008. Of these, evidence of cardiovascular testing was available for 4,650 (79.1%) patients between 14 days before the incident HF admission and ending 6 months after the incident discharge. We compared crude and adjusted cardiovascular testing rates at the hospital level because the majority of testing occurred during the incident HF hospitalization. Of patients who underwent testing, 4,085 (87.9%) had an echocardiogram, 4,345 (93.4%) had a systolic function assessment, and 1,714 (36.9%) had a coronary artery disease assessment. Crude and adjusted testing rates varied markedly across the profiled hospitals, for individual testing modalities (e.g., echocardiography, stress echocardiography, nuclear stress testing, and left heart catheterization) and for specific clinical indications (e.g., systolic function assessment and coronary artery disease assessment).
CONCLUSIONS:
For patients with newly diagnosed HF, we did not observe widespread overuse of cardiovascular testing in the 6 months following incident HF hospitalization relative to existing HF guidelines. Variations in testing were greatest for assessment of ischemia, in which testing guidelines are less certain.
Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
cardiovascular testing; geographic variations; heart failure
Comment in
- Cardiovascular imaging utilization: boom or bust?[JACC Cardiovasc Imaging. 2014]
G Ital Cardiol (Rome). 2014 Apr;15(4):244-52. doi: 10.1714/1497.16505.
[Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)].
[Article in Italian]
Bobbio M, Abrignani MG, Caldarola P, Casolo G, Fattirolli F, Gabrielli D, Grimaldi M, Mazzotta G, Roncon L, Tozzi Q, Vallebona A.
Abstract
In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA’s Less Is More and BMJ’s Too Much Medicine series, and the American College of Physicians‘ High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody’s proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation’s Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.
JAMA Intern Med. 2014 Jul;174(7):1067-76. doi: 10.1001/jamainternmed.2014.1541.
Measuring low-value care in Medicare.
Schwartz AL1, Landon BE2, Elshaug AG3, Chernew ME1, McWilliams JM4.
Abstract
IMPORTANCE:
Despite the importance of identifying and reducing wasteful health care use, few direct measures of overuse have been developed. Direct measures are appealing because they identify specific services to limit and can characterize low-value care even among the most efficient providers.
OBJECTIVES:
To develop claims-based measures of low-value services, examine service use (and associated spending) detected by these measures in Medicare, and determine whether patterns of use are related across different types of low-value services.
DESIGN, SETTING, AND PARTICIPANTS:
Drawing from evidence-based lists of services that provide minimal clinical benefit, we developed 26 claims-based measures of low-value services. Using 2009 claims for 1,360,908 Medicare beneficiaries, we assessed the proportion of beneficiaries receiving these services, mean per-beneficiary service use, and the proportion of total spending devoted to these services. We compared the amount of use and spending detected by versions of these measures with different sensitivity and specificity. We also estimated correlations between use of different services within geographic areas, adjusting for beneficiaries‘ sociodemographic and clinical characteristics.
MAIN OUTCOMES AND MEASURES:
Use and spending detected by 26 measures of low-value services in 6 categories: low-value cancer screening, low-value diagnostic and preventive testing, low-value preoperative testing, low-value imaging, low-value cardiovascular testing and procedures, and other low-value surgical procedures.
RESULTS:
Services detected by more sensitive versions of measures affected 42% of beneficiaries and constituted 2.7% of overall annual spending. Services detected by more specific versions of measures affected 25% of beneficiaries and constituted 0.6% of overall spending. In adjusted analyses, low-value spending detected in geographic regions at the 5th percentile of the regional distribution of low-value spending ($227 per beneficiary) exceeded the difference in detected low-value spending between regions at the 5th and 95th percentiles ($189 per beneficiary). Adjusted regional use was positively correlated among 5 of 6 categories of low-value services (mean r for pairwise, between-category correlations, 0.33; range, 0.14-0.54; P ≤ .01).
CONCLUSIONS AND RELEVANCE:
Services detected by a limited number of measures of low-value care constituted modest proportions of overall spending but affected substantial proportions of beneficiaries and may be reflective of overuse more broadly. Performance of claims-based measures in supporting targeted payment or coverage policies to reduce overuse may depend heavily on how the measures are defined.
Comment in
- Developing methods for less is more.[JAMA Intern Med. 2014]
- Re: Measuring low-value care in medicare.[J Urol. 2015]
Osteoporos Int. 2014 Sep;25(9):2307-11. doi: 10.1007/s00198-014-2725-2. Epub 2014 May 9.
Overuse of short-interval bone densitometry: assessing rates of low-value care.
Morden NE1, Schpero WL, Zaha R, Sequist TD, Colla CH.
Abstract
We evaluated the prevalence and geographic variation of short-interval (repeated in under 2 years) dual-energy X-ray absorptiometry tests (DXAs) among Medicare beneficiaries. Short-interval DXA use varied across regions (coefficient of variation = 0.64), and unlike other DXAs, rates decreased with payment cuts.
INTRODUCTION:
The American College of Rheumatology, through the Choosing Wisely initiative, identified measuring bone density more often than every 2 years as care „physicians and patients should question.“ We measured the prevalence and described the geographic variation of short-interval (repeated in under 2 years) DXAs among Medicare beneficiaries and estimated the cost of this testing and its responsiveness to payment change.
METHODS:
Using 100 % Medicare claims data, 2006-2011, we identified DXAs and short-interval DXAs for female Medicare beneficiaries over age 66. We determined the population rate of DXAs and short-interval DXAs, as well as Medicare spending on short-interval DXAs, nationally and by hospital referral region (HRR).
RESULTS:
DXA use was stable 2008-2011 (12.4 to 11.5 DXAs per 100 women). DXA use varied across HRRs: in 2011, overall DXA use ranged from 6.3 to 23.0 per 100 women (coefficient of variation = 0.18), and short-interval DXAs ranged from 0.3 to 8.0 per 100 women (coefficient of variation = 0.64). Short-interval DXA use fluctuated substantially with payment changes; other DXAs did not. Short-interval DXAs, which represented 10.1 % of all DXAs, cost Medicare approximately US$16 million in 2011.
CONCLUSIONS:
One out of ten DXAs was administered in a time frame shorter than recommended and at a substantial cost to Medicare. DXA use varied across regions. Short-interval DXA use was responsive to reimbursement changes, suggesting carefully designed policy and payment reform may reduce this care identified by rheumatologists as low value.
BMJ. 2014 May 6;348:g2975. doi: 10.1136/bmj.g2975.
J Am Coll Radiol. 2014 Aug;11(8):788-90. doi: 10.1016/j.jacr.2013.12.010. Epub 2014 Apr 24.
Are combined CT scans of the thorax being overused?
Levin DC1, Parker L2, Halpern EJ2, Rao VM2.
Abstract
PURPOSE:
A news article in June 2011 reported that Medicare claims showed considerable overuse of „double“ CT scans of the thorax (ie, combined scans without contrast followed by with contrast) at a number of hospitals. Most radiologists agree that they should be done only on rare occasions. The aim of this study was to determine what proportion of all thoracic CT scans are combined scans in the Medicare population.
METHODS:
The data sources were the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2001 to 2011. The 3 Current Procedural Terminology codes for thoracic CT (with contrast, without contrast, and without plus with contrast) were selected. Utilization rates per 1,000 beneficiaries and the percentage that were combined scans were calculated.
RESULTS:
The utilization rate of combined scans increased from 2001 through 2006, remained steady in 2007, but then decreased sharply thereafter. The compound annual rate of change from 2007 to 2011 was -10.4%. From 2001 through 2006, combined thoracic CT scans constituted 6.0% to 6.1% of all thoracic CT scans. However, from 2006 to 2011, this percentage progressively declined, reaching a low of 4.2% in 2011.
CONCLUSIONS:
Despite the 2011 news report, only a very small percentage of thoracic CT scans nationwide are done both without and with contrast. Moreover, that percentage dropped by almost one-third from 2006 to 2011, suggesting that the practice is declining. The figure of 4.2% can be used as a benchmark against which to judge radiology facilities in the future.
Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
CT with contrast; Medical economics; radiology and radiologists; socioeconomic issues; thoracic CT; utilization of imaging
Z Gerontol Geriatr. 2014 Jan;47(1):17-22. doi: 10.1007/s00391-013-0590-9.
[Article in German]
Strech D1.
Abstract
BACKGROUND:
The topics of rationing and priority setting have been increasingly discussed over the past 5 years in Germany by physicians together with other health care stakeholders. The topic of overuse, however, has not been discussed with similar intensity and publicity.
OBJECTIVES:
This analysis paper outlines the relationships and differences between efficiency, priority setting, and rationing. Furthermore, it argues why and how German physicians should address the topic of overuse with more transparency and intensity.
DISCUSSION:
Efforts of physicians to rationalize health care mainly comprise efforts to decrease overuse. The identification of important areas of overuse includes the prioritization of indications and medical interventions. Rationing health care can be unavoidable, for example, because other strategies such as rationalization, price regulation or disinvestments are not sufficient to avoid scarcity of financial resources. In such a case, rationing health care is unavoidable and, therefore, cannot be unethical per se. However, the debate on rationing becomes more legitimate if physicians demonstrate sufficient efforts to reduce overuse sufficiently. The Choosing Wisely initiative in the USA is outlined as one interesting option of how physicians could demonstrate and prove such efforts. Additional and more effective strategies to decrease overuse might be possible.
CONCLUSION:
German physicians demand a more explicit communication within their communities and together with other stakeholders on the appropriateness of existing and potential future activities to decrease overuse. Such initiatives to avoid and decrease overuse should primarily be motivated through the ethical principle of beneficence, while the effect of cost containment should be considered as a welcomed side effect.
Pharmacoeconomics. 2014 Jan;32(1):5-13. doi: 10.1007/s40273-013-0119-5.
Abstract
The provision of stress ulcer prophylaxis (SUP) for the prevention of clinically significant bleeding is widely recognized as a crucial component of care in critically ill patients. Nevertheless, SUP is often provided to non-critically ill patients despite a risk for clinically significant bleeding of roughly 0.1 %. The overuse of SUP therefore introduces added risks for adverse drug events and cost, with minimal expected benefit in clinical outcome. Historically, histamine-2-receptor antagonists (H2RAs) have been the preferred agent for SUP; however, recent data have revealed proton pump inhibitors (PPIs) as the most common modality (76 %). There are no high quality randomized controlled trials demonstrating superiority with PPIs compared with H2RAs for the prevention of clinically significant bleeding associated with stress ulcers. In contrast, PPIs have recently been linked to several adverse effects including Clostridium difficile diarrhea and pneumonia. These complications have substantial economic consequences and have a marked impact on the overall cost effectiveness of PPI therapy. Nevertheless, PPI use remains widespread in patients who are at both high and low risk for clinically significant bleeding. This article will describe the utilization of PPIs for SUP and present the clinical and economic consequences linked to their use/overuse.
J Comp Eff Res. 2013 May;2(3):235-47. doi: 10.2217/cer.13.26.
Rich EC1, Lake TK, Valenzano CS, Maxfield MM.
Abstract
This article develops a framework for understanding how financial and nonfinancial incentives can complicate point-of-care decision-making by physicians, leading to the overuse or underuse of healthcare services. By examining the types of decisions that clinicians and patients make at the point-of-care, the framework clarifies how incentives can distort physicians‘ decisions about testing, diagnosis and treatment, as well as efforts to enhance patient adherence. The analysis highlights contributing factors that promote and impede evidence-based decision-making, using examples from the ‚Choosing Wisely‘ program. It concludes with a summary of how the existing fee-for-service payment system in the USA may contribute to the problems of over- and under-testing, diagnosis and treatment, highlighted through the efforts of Choosing Wisely.
Spine J. 2014 Jun 1;14(6):1036-48. doi: 10.1016/j.spinee.2013.10.031. Epub 2013 Nov 8.
A systematic review of diagnostic imaging use for low back pain in the United States.
Dagenais S1, Galloway EK2, Roffey DM3.
Abstract
BACKGROUND CONTEXT:
Various studies have reported on the increasing use and costs of diagnostic imaging for low back pain (LBP) in the United States. However, it is unclear whether the methods used in these studies allowed for meaningful comparisons or whether the reported use data can be used to develop evidence-based use benchmarks.
PURPOSE:
The primary purpose of this study was to review previous estimates of the use of diagnostic imaging for LBP in the United States.
STUDY DESIGN/SETTING:
The study design is a systematic review of published literature.
METHODS:
A search through May 2012 was conducted using keywords and free text terms related to health services and LBP in Medline and Health Policy Reference; results were screened for relevance independently, and full-text studies were assessed for eligibility. Only studies published in English since the year 2000 reporting on use of diagnostic imaging for LBP using claims data from the United States were included. Reporting quality was assessed using a modified Downs and Black tool for observational studies.
RESULTS:
The search strategy yielded 1,102 citations, seven of which met the criteria for eligibility. Studies reported use from commercial health plans (N=4) and Medicare (N=3), with sample sizes ranging from 13,760 to 740,467 members with LBP from specific states or across the United States. The number of diagnostic codes used to identify nonspecific LBP ranged from 2 to 66; other heterogeneity was noted in the methods used across these studies. In commercial health plans, use of radiography occurred in 12.0% to 32.2% of patients with LBP, magnetic resonance imaging (MRI) was used in 16.0% to 21.0%, computed tomography (CT) was used in 1.4% to 3.0%, and MRI and/or CT was used in 10.9% to 16.1%. Findings in Medicare populations were 22.9% to 48.2% for radiography, 11.6% for MRI, and 10.4% to 16.3% for MRI and/or CT.
CONCLUSIONS:
The reported use of diagnostic imaging for LBP varied across the studies reviewed; differences in methodology made meaningful comparisons difficult. Standardizing methods for performing and reporting analyses of claims data related to use could facilitate efforts by third-party payers, health care providers, and researchers to identify and address the perceived overuse of diagnostic imaging for LBP.
Copyright © 2014 Elsevier Inc. All rights reserved.
KEYWORDS:
Claims data; Computed tomography; Diagnostic imaging; Low back pain; Magnetic resonance imaging; Utilization; X-rays
PLoS One. 2013 Oct 23;8(10):e75221. doi: 10.1371/journal.pone.0075221. eCollection 2013.
White P1, Thornton H, Pinnock H, Georgopoulou S, Booth HP.
Abstract
INTRODUCTION:
Combined inhaled long-acting beta-agonists and corticosteroids (LABA+ICS) are costly. They are recommended in severe or very severe chronic obstructive pulmonary disease (COPD). They should not be prescribed in mild or moderate disease. In COPD ICS are associated with side-effects including risk of pneumonia. We quantified appropriateness of prescribing and examined the risks and costs associated with overuse.
METHODS:
Data were extracted from the electronic and paper records of 41 London general practices (population 310,775) including spirometry, medications and exacerbations. We classified severity, assessed appropriateness of prescribing using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for 2009, and performed a sensitivity analysis using the broader recommendations of the 2011 revision.
RESULTS:
3537 patients had a diagnosis of COPD. Spirometry was recorded for 2458(69%). 709(29%) did not meet GOLD criteria. 1749(49%) with confirmed COPD were analysed: 8.6% under-treated, 38% over-treated. Over-prescription of ICS in GOLD stage I or II (n=403, 38%) and in GOLD III or IV without exacerbations (n=231, 33.6%) was common. An estimated 12 cases (95%CI 7-19) annually of serious pneumonia were likely among 897 inappropriately treated. 535 cases of overtreatment involved LABA+ICS with a mean per patient cost of £553.56/year (€650.03). Using the broader indications for ICS in the 2011 revised GOLD guideline 25% were still classified as over-treated. The estimated risk of 15 cases of pneumonia (95%CI 8-22) in 1074 patients currently receiving ICS would rise by 20% to 18 (95%CI 9.8-26.7) in 1305 patients prescribed ICS if all with GOLD grade 3 and 4 received LABA+ICS.
CONCLUSION:
Over-prescription of ICS in confirmed COPD was widespread with considerable potential for harm. In COPD where treatment is often escalated in the hope of easing the burden of disease clinicians should consider both the risks and benefits of treatment and the costs where the benefits are unproven.
JAMA Intern Med. 2013 Sep 23;173(17):1573-81. doi: 10.1001/jamainternmed.2013.8992.
Worsening trends in the management and treatment of back pain.
Mafi JN1, McCarthy EP, Davis RB, Landon BE.
Erratum in
- Error in text.[JAMA Intern Med. 2015]
Abstract
IMPORTANCE:
Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.
OBJECTIVE:
To characterize the treatment of back pain from January 1, 1999, through December 26, 2010.
DESIGN, SETTING, AND PATIENTS:
Using nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we studied outpatient visits with a chief symptom and/or primary diagnosis of back or neck pain, as well as those with secondary symptoms and diagnoses of back or neck pain. We excluded visits with concomitant „red flags,“ including fever, neurologic symptoms, or cancer. Results were analyzed using logistic regression adjusted for patient and health care professional characteristics and weighted to reflect national estimates. We also present adjusted results stratified by symptom duration and whether the health care professional was the primary care physician (PCP).
MAIN OUTCOMES AND MEASURES:
We assessed imaging, narcotics, and referrals to physicians (guideline discordant indicators). In addition, we evaluated use of nonsteroidal anti-inflammatory drugs or acetaminophen and referrals to physical therapy (guideline concordant indicators).
RESULTS:
We identified 23,918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P< .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P< .001). In contrast, narcotic use increased from 19.3% to 29.1% (P< .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P< .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P< .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.
CONCLUSIONS AND RELEVANCE:
Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.
Comment in
- Assessment and management of back pain.[JAMA Intern Med. 2014]
- Assessment and management of back pain.[JAMA Intern Med. 2014]
- Assessment and management of back pain–reply.[JAMA Intern Med. 2014]
- Why don’t physicians (and patients) consistently follow clinical practice guidelines?[JAMA Intern Med. 2013]
Int J Cardiol. 2013 Oct;168(4):4516-7. doi: 10.1016/j.ijcard.2013.06.109. Epub 2013 Jul 17.
Dominguez-Rodriguez A1, Gomez MA, Del Carmen Garcia-Baute M, Abreu-Gonzalez P, Gonzalez-Diaz A, Laynez-Cerdeña I.
KEYWORDS:
Appropriate use criteria; Cardiac SPECT; Coronary heart disease
Pharmacoeconomics. 2014 Mar;32(3):245-55. doi: 10.1007/s40273-013-0068-z.
Chen M1, Wang L, Chen W, Zhang L, Jiang H, Mao W.
Abstract
BACKGROUND:
Before the new round of healthcare reform in China, primary healthcare providers could obtain a fixed 15 % or greater mark-up of profits by prescribing and selling medicines. There were concerns that this perverse incentive was a key cause of irrational medicine use. China’s new Essential Medicines Program (EMP) was launched in 2009 as part of the national health sector reform initiatives. One of its core policies was to eliminate primary care providers‘ economic incentives to overprescribe or prescribe unnecessarily expensive drugs, which were regarded as consequences of China’s traditional financing system for health institutions.
OBJECTIVES:
The objective of the study was to measure changes in prescribing patterns in primary healthcare facilities after the removal of the economic incentives for physicians to overprescribe as a result of the implementation of the EMP.
METHODS:
A comparison design was applied to 8,258 prescriptions in 2007 and 8,278 prescriptions in 2010, from 83 primary healthcare facilities nationwide. Indicators were adopted to evaluate medicine utilization, which included overall number of medicines, average number of Western and traditional Chinese medicines, pharmaceutical expenditure per outpatient prescription, and proportion of prescriptions that contained two or more antibiotics. We further assessed the use of medicines (antibiotics, infusion, hormones, and intravenous injection) per disease-specific prescription for hypertension, diabetes, coronary artery heart disease, bronchitis, upper respiratory tract infection, and gastritis. A difference-in-difference analysis was employed to evaluate the net policy effect.
RESULTS:
Overall changes in indicators were not found to be statistically significant between the 2 years. The results varied for different diseases. The number of Western drugs per outpatient prescription decreased while that of traditional Chinese medicines increased. Overuse of antibiotics remained an extensive problem in the treatment of many diseases, though there was some significant improvement in certain diseases, like diabetes in rural areas. Medicine expenditure per prescription also decreased.
CONCLUSIONS:
It seems that the removal of a perverse economic incentive alone would not lead to improvement of healthcare providers‘ prescribing patterns. The rationality of the Essential Medicines List and the lack of payers‘ and providers‘ meaningful involvement in the development of the policy possibly contribute to the lack of significant changes in prescribing behaviors. It is suggested that China should adopt more comprehensive policies for healthcare facilities, physicians, patients, and payers, rather than just relying on economic incentives to improve rational use of medicines.
JAMA Intern Med. 2013 Jul 22;173(14):1277-8. doi: 10.1001/jamainternmed.2013.6181.
Overuse of health care services: when less is more … more or less.
Rev Med Suisse. 2013 Apr 10;9(381):770, 772-4.
[Article in French]
Regard S1, Gaspoz JM, Kherad O.
Abstract
After decades of remarkable development, medicine is facing a tough economic reality and new challenges. These challenges include defining the values, objectives and tasks of sustainable medicine. In this context, the concept of „less is more“ emerged in North America. „Less is more“ is an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health. It is therefore necessary to drive unnecessary and costly practices by streamlining care without rationing.
Ir J Med Sci. 2013 Dec;182(4):669-72. doi: 10.1007/s11845-013-0951-9. Epub 2013 Apr 19.
Slattery E1, Clancy KX, Harewood GC, Murray FE, Patchett S.
Abstract
INTRODUCTION:
There is growing evidence to demonstrate overuse of medical resources in fee for service (FFS) payment models (in which physicians are reimbursed according to volume of care provided) compared to capitation payment models (in which physicians receive a fixed salary regardless of level of care provided). In this medical centre, patients with and without insurance are admitted through the same access point (emergency room) and cared for by the same physicians. Therefore, apart from insurance status, all other variables influencing delivery of care are similar for both patient groups. However, physician reimbursement differs for both groups: FFS for patients with private insurance (i.e. the admitting physician’s reimbursement escalates progressively with each day that the patient spends in hospital) and base salary irrespective of care provided for patients with universal insurance (capitation payment model). All admitting physicians are aware of the patient’s insurance status and the duration of hospitalization is at the discretion of the admitting physician. This study aimed to compare cost of care of patients with and without insurance admitted to a teaching hospital with a primary gastroenterology or hepatology (GIH) diagnosis.
METHODS:
All hospital inpatients admitted between January 2008 and December 2009 with a primary GI-related diagnosis related group (DRG) were identified. Patients were classified as uninsured (state-funded) or privately insured. Only DRGs with at least five patients in both the insured and uninsured patient groups were analyzed to ensure a precise estimate of inpatient costs. Patient level costing (PLC) was used to express the total cost of hospital care for each patient; PLC comprised a weighted daily bed cost plus cost of all medical services provided (e.g. radiology, pathology tests) calculated according to an activity-based costing approach, cost of medications were excluded. An overall mean cost of care per patient was calculated for both groups. All costs were discounted to 2009 values.
RESULTS:
In total, 630 patients were admitted with one of 11 GIH DRGs, 181 (29 %) with private insurance. Pooled mean cost of care was higher for uninsured (6,781 euros/patient) compared to insured patients (6,128 euros/patient). Apart from patients with ’non-cirrhotic non-alcoholic liver disease (non-complex)‘ in whom mean cost was higher for insured patients, there were no significant differences in mean cost of care nor mean patient age for insured and uninsured groups for any other diagnoses.
CONCLUSION:
Inpatient hospital costs were equivalent for patients with and without private health insurance when care was provided in a single hospital. Provision of care for all patients in a common hospital setting regardless of health insurance status may reduce disparities in healthcare utilization.
Eur J Gen Pract. 2013 Jun;19(2):106-10. doi: 10.3109/13814788.2013.766713. Epub 2013 Apr 5.
Dalbak LG1, Rognstad S, Melbye H, Straand J.
Abstract
BACKGROUND:
Inhaled glucocorticosteroids (ICS) are first-line anti-inflammatory treatment in asthma, but not in chronic obstructive pulmonary disease (COPD). To restrict ICS use in COPD to cases of severe disease, new terms for reimbursement of drug costs were introduced in Norway in 2006, requiring a diagnosis of COPD to be verified by spirometry.
OBJECTIVES:
To describe how GPs‘ diagnoses and treatment of patients who used ICS before 2006 changed after a reassessment of the patients that included spirometry.
METHODS:
From the shared electronic patient record system in one group practice, patients ≥ 50 years prescribed ICS (including in combination with long-acting beta2-agonists) during the previous year were identified and invited to a tailored consultation including spirometry to assure the quality of diagnosis and treatment. GPs‘ diagnoses and ICS prescribing patterns after this reassessment were recorded, retrospectively.
RESULTS:
Of 164 patients identified, 112 were included. Post-bronchodilator spirometry showed airflow limitation indicating COPD in 55 patients. Of the 57 remaining patients, five had a positive reversibility test. The number of patients diagnosed with asthma increased (from 25 to 62) after the reassessment. A diagnosis of COPD was also more frequently used, whereas fewer patients had other pulmonary diagnoses. ICS was discontinued in 31 patients; 20 with mild to moderate COPD and 11 with normal spirometry.
CONCLUSION:
Altered reimbursement terms for ICS changed GPs‘ diagnostic practice in a way that made the diagnoses better fit with the treatment given, but over-diagnosis of asthma could not be excluded. Spirometry was useful for identifying ICS overuse.
JAMA Intern Med. 2013 May 13;173(9):823-5. doi: 10.1001/jamainternmed.2013.3804.
Overuse of magnetic resonance imaging.
Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE.
Erratum in
- JAMA Intern Med. 2013 Aug 12;173(15):1477.
Comment in
- Inappropriate use of lumbar magnetic resonance imaging: limitations and potential solutions.[JAMA Intern Med. 2013]
- Inappropriate use of lumbar magnetic resonance imaging: limitations and potential solutions–reply.[JAMA Intern Med. 2013]
Health Aff (Millwood). 2013 Mar;32(3):527-35. doi: 10.1377/hlthaff.2012.1030.
Kozhimannil KB1, Law MR, Virnig BA.
Abstract
Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.
Comment in
- Midwives and cesarean sections.[Health Aff (Millwood). 2013]
- Cesarean sections: the authors reply.[Health Aff (Millwood). 2013]
Circ Cardiovasc Imaging. 2013 Jan 1;6(1):2-5. doi: 10.1161/CIRCIMAGING.112.982165.
Torosoff MT, Fein SA, Boden WE.
Comment on
- Patterns of stress testing and diagnostic catheterization after coronary stenting in 250 350 medicare beneficiaries.[Circ Cardiovasc Imaging. 2013]
JAMA Intern Med. 2013 Jan 28;173(2):142-8. doi: 10.1001/2013.jamainternmed.1022.
Trends in the overuse of ambulatory health care services in the United States.
Kale MS1, Bishop TF, Federman AD, Keyhani S.
Abstract
BACKGROUND:
Given the rising costs of health care, policymakers are increasingly interested in identifying the inefficiencies in our health care system. The objective of this study was to determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade.
METHODS:
Cross-sectional analysis of the 1999 and 2009 National Ambulatory Medical Care Survey and the outpatient department component of the National Hospital Ambulatory Medical Care Survey, which are nationally representative annual surveys of visits to non-federally funded ambulatory care practices. We applied 22 quality indicators using a combination of current quality measures and guideline recommendations. The main outcome measures were the rates of underuse, overuse, and misuse and their 95% CIs.
RESULTS:
We observed a statistically significant improvement in 6 of 9 underuse quality indicators. There was an improvement in the use of antithrombotic therapy for atrial fibrillation; the use of aspirin, β-blockers, and statins in coronary artery disease; the use of β-blockers in congestive heart failure; and the use of statins in diabetes mellitus. We observed an improvement in only 2 of 11 overuse quality indicators, 1 indicator became worse, and 8 did not change. There was a statistically significant decrease in the overuse of cervical cancer screening in visits for women older than 65 years and in the overuse of antibiotics in asthma exacerbations. However, there was an increase in the overuse of prostate cancer screening in men older than 74 years. Of the 2 misuse indicators, there was a decrease in the proportion of patients with a urinary tract infection who were prescribed an inappropriate antibiotic.
CONCLUSIONS:
We found significant improvement in the delivery of underused care but more limited changes in the reduction of inappropriate care. With the high cost of health care, these results are concerning.
Comment in
- Accurately estimating cervical cancer screeningoveruse among older women–reply. [JAMA Intern Med. 2013]
- Accurately estimating cervical cancer screeningoveruse among older women. [JAMA Intern Med. 2013]
- Undertreatment improves, but overtreatment does not.[JAMA Intern Med. 2013]
J Interv Card Electrophysiol. 2013 Mar;36(2):137-44. doi: 10.1007/s10840-012-9747-5. Epub 2012 Dec 15.
Abstract
Cardiac implantable electronic devices (CIEDs), despite their proven effectiveness in large clinical trials for a wide range of patients with arrhythmia and heart failure, are frequent targets for criticism regarding cost-efficiency and alleged overuse. Newer indications, such as sinus node dysfunction for pacemakers and primary prevention for implantable cardioverter-defibrillators, increased eligible patient population significantly. This lead to heightened scrutiny from payors and legislative agencies, such as prior authorization and mandatory registry participation. Despite the significant administrative burden, the efficiency of these measures to decrease abuse is not clear. In addition, professional societies, regulatory agencies, and payors may not always agree whether use of a device is appropriate for a given patient. The review focuses on past and current issues related to utilization of CIEDs, which lead to increased regulatory oversight, and the effort of professional societies, payors, and governmental agencies to improve access to these life-saving therapeutical modalities while maintaining a just and cost-efficient healthcare system.
Health Aff (Millwood). 2012 Dec;31(12):2830. doi: 10.1377/hlthaff.2012.1236.
Prior authorization and overuse of imaging.
Hunter G, Schneider J, Pinkard S.
Popul Health Manag. 2013 Jun;16(3):164-8. doi: 10.1089/pop.2012.0019. Epub 2012 Oct 31.
Behnke LM1, Solis A, Shulman SA, Skoufalos A.
Abstract
Overutilization, defined as use of unnecessary care when alternatives may produce similar outcomes, results in higher cost without increased value. Overutilization can be understood by focusing on settings where overuse is obvious. One example is percutaneous coronary intervention (PCI) in chronic stable angina. PCI is a potentially lifesaving procedure in an acute setting, but current practice guidelines indicate low-risk patients with chronic stable angina should be treated initially with optimal medical therapy (OMT) and lifestyle modification. A decision to move from this approach to PCI should be based on severity of symptoms and degree of risk. Over the last 30 years, advances in equipment, adjunctive medical treatments, and safety have made PCI more common. Recent evidence questions the benefit of PCI in stable coronary artery disease demonstrating no reduction in overall mortality or major cardiac events compared to OMT. Despite these findings, some continue to favor aggressive PCI interventions over conservative management in low-risk situations. Patients who undergo PCI without understanding the evidence may be inappropriately reassured that PCI will reduce the need for OMT and the risk of heart attack and death. Research shows shared decision-making can result in more conservative care, particularly when patients are assessed for health literacy and counseled on clinical evidence. Overutilization of PCI can be addressed by promoting active participation in an evidence-based decision-making process, allowing the opportunity to understand the expected value of invasive procedures over OMT alone through processes that encourage physicians to incorporate shared decision making prior to PCI in non-acute situations.
Johns Hopkins Med Lett Health After 50. 2012 Aug;24(7):4-5.
Do you really need that test? Experts point to overuse of screening and diagnostic tests.
[No authors listed]
Clin J Am Soc Nephrol. 2012 Oct;7(10):1664-72. doi: 10.2215/CJN.04970512. Epub 2012 Sep 13.
Williams AW1, Dwyer AC, Eddy AA, Fink JC, Jaber BL, Linas SL, Michael B, O’Hare AM, Schaefer HM, Shaffer RN, Trachtman H, Weiner DE, Falk AR; American Society of Nephrology Quality, and Patient Safety Task Force.
Abstract
Estimates suggest that one third of United States health care spending results from overuse or misuse of tests, procedures, and therapies. The American Board of Internal Medicine Foundation, in partnership with Consumer Reports, initiated the „Choosing Wisely“ campaign to identify areas in patient care and resource use most open to improvement. Nine subspecialty organizations joined the campaign; each organization identified five tests, procedures, or therapies that are overused, are misused, or could potentially lead to harm or unnecessary health care spending. Each of the American Society of Nephrology’s (ASN’s) 10 advisory groups submitted recommendations for inclusion. The ASN Quality and Patient Safety Task Force selected five recommendations based on relevance and importance to individuals with kidney disease.Recommendations selected were: (1) Do not perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms; (2) do not administer erythropoiesis-stimulating agents to CKD patients with hemoglobin levels ≥10 g/dl without symptoms of anemia; (3) avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension, heart failure, or CKD of all causes, including diabetes; (4) do not place peripherally inserted central catheters in stage 3-5 CKD patients without consulting nephrology; (5) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.These five recommendations and supporting evidence give providers information to facilitate prudent care decisions and empower patients to actively participate in critical, honest conversations about their care, potentially reducing unnecessary health care spending and preventing harm.
Ann Intern Med. 2012 Oct 16;157(8):574-6.
The overuse of diagnostic imaging and the Choosing Wisely initiative.
Radiol Clin North Am. 2012 Jul;50(4):569-85. doi: 10.1016/j.rcl.2012.04.005.
Appropriate use of lumbar imaging for evaluation of low back pain.
Abstract
Use of lumbar spine imaging, particularly advanced imaging, continues to grow rapidly in the United States. Many lumbar spine imaging tests are obtained in patients who have no clinical symptoms or risk factors suggesting a serious underlying condition, yet evidence shows that this routine imaging is not associated with benefits, exposes patients to unnecessary harms, and increases costs. This article reviews current trends and practice patterns in lumbar spine imaging, direct and downstream costs, benefits and harms, current recommendations, and potential strategies for reducing imaging overuse.
Copyright © 2012 Elsevier Inc. All rights reserved.
Curr Opin Neurol. 2012 Jun;25(3):290-5. doi: 10.1097/WCO.0b013e328352c431.
Prevention and management of medication overuse headache.
Abstract
PURPOSE OF REVIEW:
This review provides an update on our knowledge regarding prevention and management of medication overuse headache (MOH).
RECENT FINDINGS:
The prevalence of MOH is 1-2% in the general population worldwide, and because of the tremendous socio-economic cost, it is likely to be the most costly neurological disorder known. MOH has similarities with traditional drug addiction. Use of a brochure on medication overuse can prevent MOH. The Severity of Dependence Scale (SDS) score is a significant predictor of medication overuse among headache patients. Withdrawal of medication is essential in the management of MOH, and simultaneous initiation of prophylactic medication may alleviate this process. Short advice on medication overuse by a physician reduced mean medication days from 22 to 6 days; 76% no longer had medication overuse and 42% no longer had chronic headache.
SUMMARY:
A brochure and/or the SDS should be used to prevent MOH. Withdrawal is the cornerstone of MOH management. Short advice on MOH is the current most cost effective management method, a method that can be applied anywhere including third world countries.
Health Aff (Millwood). 2012 Apr;31(4):750-9. doi: 10.1377/hlthaff.2011.1062.
Jacobs BL1, Zhang Y, Skolarus TA, Hollenbeck BK.
Abstract
To study the impact of new, expensive, and unproven therapies to treat prostate cancer, we investigated the dissemination of intensity-modulated radiotherapy (IMRT). IMRT is an innovative treatment for prostate cancer that delivers higher doses of radiation with improved precision compared to alternative radiotherapies. We observed rapid adoption of this new treatment among men diagnosed with prostate cancer from 2001 through 2007, despite uncertainty about its relative effectiveness. We compared patient and disease characteristics of those receiving IMRT and the previous radiation standard of care, three-dimensional conformal therapy; assessed intermediate-term outcomes; and examined potential factors associated with the increased use of IMRT. We found that in the early period of IMRT adoption (2001-03) men with high-risk disease were more likely to receive IMRT, whereas after IMRT’s initial dissemination (2004-07) men with low-risk disease had fairly similar likelihoods of receiving IMRT as men with high-risk disease. This raises concerns about overtreatment, as well as considerable health care costs, because treatment with IMRT costs $15,000-$20,000 more than other standard therapies. As health care delivery reforms gain traction, policy makers must balance the promotion of new, yet unproven, technology with the risk of overuse.
Comment in
- Intensity-modulated radiation therapy for prostate cancer iscost effective and improves therapeutic ratio.[Expert Rev Pharmacoecon Outcomes Res. 2012]
- The right therapy for prostate cancer.[Health Aff (Millwood). 2012]
J Nucl Med. 2012 Mar;53(3):14N.
BMD rescreening and procedure overuse.
[No authors listed]
Med Care. 2012 Mar;50(3):257-61. doi: 10.1097/MLR.0b013e3182422b0f.
Keyhani S1, Falk R, Bishop T, Howell E, Korenstein D.
Abstract
OBJECTIVE:
To examine the relationship between overuse of healthcare services and geographic variations in medical care.
DESIGN:
Systematic Review.
DATA SOURCES:
Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009.
STUDY SELECTION:
Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data.
DATA EXTRACTION:
We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured.
RESULTS:
Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%).
CONCLUSIONS:
The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.
Europace. 2012 Jun;14(6):787-94. doi: 10.1093/europace/eus001. Epub 2012 Feb 2.
Sudden cardiac death and implantable cardioverter defibrillators: two modern epidemics?
Abstract
Critical analysis of the existing evidence indicates that: In patients with documented sustained ventricular arrhythmias and/or cardiac arrest, implantable cardioverter defibrillators (ICDs) confer a survival benefit. In several clinical settings this is rather transient, and might be lost when modern medical therapy including β-blockers is implemented. In patients without sustained ventricular arrhythmias or cardiac arrest, ICDs confer a significant survival benefit only in high-risk patients with ischaemic cardiomyopathy and left ventricular ejection fraction of ≤ 35% due to a remote myocardial infarction. Left ventricular ejection fraction alone is rather unlikely to be sufficient for effective sudden cardiac death risk prediction, due to low sensitivity and specificity. The benefits of ICDs in the elderly as well as in women are not established. With current prices, ICDs are probably cost-effective only when used in high-risk patients without associated comorbidities that limit the life expectancy to <10 years. Recommendations by current guidelines may result in unnecessary overuse of ICD.
Ann Intern Med. 2012 Jan 17;156(2):147-9. doi: 10.7326/0003-4819-156-2-201201170-00011.
Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care.
Qaseem A1, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese JG, Weinberger S.
Abstract
Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.
Comment in
- Re: Appropriate use of screening and diagnostic tests to foster high-value,cost-conscious care. [Ann Intern Med. 2012]
- Re: Appropriate use of screening and diagnostic tests to foster high-value,cost-conscious care. [Ann Intern Med. 2012]
- Fostering high-value,cost-conscious care. [Ann Intern Med. 2012]
- Re: Appropriate use of screening and diagnostic tests to foster high-value,cost-conscious care. [Ann Intern Med. 2012]
- High-value testing begins with a few simple questions.[Ann Intern Med. 2012]
Int J Health Plann Manage. 2011 Oct-Dec;26(4):449-70. doi: 10.1002/hpm.1112.
Abstract
Treatment by injection or infusion is widespread in China. Using the common cold as a tracer condition, we explored the reasons for over-prescription of injections and infusions in Guizhou, China. Interviews with prescribers, patients and key informants were supplemented by focus groups. These revealed how historical ideas encourage unnecessary use of percutaneous treatment: faith in the healing power of needles is locally attributed to association with acupuncture. Many patients and some staff believe that injections per se are therapeutic. However, the structure of health service financing and remuneration now reinforces this irrational faith. Market-based reforms have attempted to control costs and increase productivity with an incentive scheme which rewards prescribers financially for over-prescription in general and for use of injections and infusions in particular. Aggressive marketing has displaced oral treatment from health facilities into independent pharmacies, leaving doctors functioning mainly as injection providers. There is a need for a multi-faceted response encompassing education and reform of financial incentives to reduce the use of unnecessary treatment.
Copyright © 2011 John Wiley & Sons, Ltd.
Authors
Source
Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006-.
2006 Feb.
Excerpt
In 2003, over 16 million patients entered the hospital through the emergency department—roughly 44 percent of all hospital stays or 55 percent of hospital stays excluding pregnancy and childbirth. Policymakers and health care professionals are concerned about potential overuse and inappropriate use of emergency rooms (EDs). There is also concern that emergency departments care for patients with chronic conditions who may not be receiving adequate outpatient follow-up to control their conditions. This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) on the most common reasons in 2003 for all hospitalizations that began in the ED.
Sections
BMC Palliat Care. 2011 Sep 21;10:14. doi: 10.1186/1472-684X-10-14.
The effect on survival of continuing chemotherapy to near death.
Saito AM1, Landrum MB, Neville BA, Ayanian JZ, Earle CC.
Abstract
BACKGROUND:
Overuse of anti-cancer therapy is an important quality-of-care issue. An aggressive approach to treatment can have negative effects on quality of life and cost, but its effect on survival is not well-defined.
METHODS:
Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 7,879 Medicare-enrolled patients aged 65 or older who died after having survived at least 3 months after diagnosis of advanced non-small cell lung cancer (NSCLC) between 1991 and 1999. We used Cox proportional hazards regression analysis, propensity scores, and instrumental variable analysis (IVA) to compare survival among patients who never received chemotherapy (n = 4,345), those who received standard chemotherapy but not within two weeks prior to death (n = 3,235), and those who were still receiving chemotherapy within 14 days of death (n = 299). Geographic variation in the application of chemotherapy was used as the instrument for IVA.
RESULTS:
Receipt of chemotherapy was associated with a 2-month improvement in overall survival. However, based on three different statistical approaches, no additional survival benefit was evident from continuing chemotherapy within 14 days of death. Moreover, patients receiving chemotherapy near the end of life were much less likely to enter hospice (81% versus 51% with no chemotherapy and 52% with standard chemotherapy, P < 0.001), or were more likely to be admitted within only 3 days of death.
CONCLUSIONS:
Continuing chemotherapy for advanced NSCLC until very near death is associated with a decreased likelihood of receiving hospice care but not prolonged survival. Oncologists should strive to discontinue chemotherapy as death approaches and encourage patients to enroll in hospice for better end-of-life palliative care.
Milbank Q. 2011 Sep;89(3):343-80. doi: 10.1111/j.1468-0009.2011.00632.x.
Meier DE1.
Abstract
CONTEXT:
A small proportion of patients with serious illness or multiple chronic conditions account for the majority of health care spending. Despite the high cost, evidence demonstrates that these patients receive health care of inadequate quality, characterized by fragmentation, overuse, medical errors, and poor quality of life.
METHODS:
This article examines data demonstrating the impact of the U.S. health care system on clinical care outcomes and costs for the sickest and most vulnerable patients. It also defines palliative care and hospice, synthesizes studies of the outcomes of palliative care and hospice services, reviews variables predicting access to palliative care and hospice services, and identifies those policy priorities necessary to strengthen access to high-quality palliative care.
FINDINGS:
Palliative care and hospice services improve patient-centered outcomes such as pain, depression, and other symptoms; patient and family satisfaction; and the receipt of care in the place that the patient chooses. Some data suggest that, compared with the usual care, palliative care prolongs life. By helping patients get the care they need to avoid unnecessary emergency department and hospital stays and shifting the locus of care to the home or community, palliative care and hospice reduce health care spending for America’s sickest and most costly patient populations.
CONCLUSIONS:
Policies focused on enhancing the palliative care workforce, investing in the field’s science base, and increasing the availability of services in U.S. hospitals and nursing homes are needed to ensure equitable access to optimal care for seriously ill patients and those with multiple chronic conditions.
© 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.
Arch Intern Med. 2011 Aug 8;171(15):1335-43. doi: 10.1001/archinternmed.2011.212. Epub 2011 May 9.
Overuse of screening colonoscopy in the Medicare population.
Goodwin JS1, Singh A, Reddy N, Riall TS, Kuo YF.
Abstract
BACKGROUND:
All relevant authorities recommend an interval of 10 years between normal screening colonoscopies. We assessed the timing of repeated colonoscopies after a negative screening colonoscopy finding in a population-based sample of Medicare patients.
METHODS:
A 5% national sample of Medicare enrollees from 2000 through 2008 was used to identify average-risk patients undergoing screening colonoscopy between 2001 and 2003. Colonoscopy was classified as a negative screening examination finding if no indication other than screening were in the claims and if no biopsy, fulguration, or polypectomy was performed. Time to repeated colonoscopy was calculated.
RESULTS:
Among 24,071 Medicare patients who had a negative screening colonoscopy finding in 2001 through 2003, 46.2% underwent a repeated examination in fewer than 7 years. In 42.5% of these patients (23.5% of the overall sample), there was no clear indication for the early repeated examination. In patients aged 75 to 79 years or 80 years or older at the time of the initial negative screening colonoscopy result, 45.6% and 32.9%, respectively, received a repeated examination within 7 years. In multivariable analyses, male sex, more comorbidities, and colonoscopy by a high-volume colonoscopist or in an office setting were associated with higher rates of early repeated colonoscopy without clear indication, while those 80 years or older had a reduced risk. There were also marked geographic variations, from less than 5% in some health referral regions to greater than 50% in others.
CONCLUSIONS:
A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.
Comment in
- Colorectal cancer screening protocols and procedures: comment on „Overuse of screening colonoscopy in the Medicare population“ and „Long-term outcomes following positive fecal occult blood test results in older adults“.[Arch Intern Med. 2011]
- Screening for colorectal cancer in the elderly population: how much is enough?[Arch Intern Med. 2011]
GMS Health Technol Assess. 2011 Apr 19;7:Doc03. doi: 10.3205/hta000094.
Over-, under- and misuse of pain treatment in Germany.
Abstract
BACKGROUND:
The HTA-report (Health Technology Assessment) deals with over- and undertreatment of pain therapy. Especially in Germany chronic pain is a common reason for the loss of working hours and early retirement. In addition to a reduction in quality of life for the affected persons, chronic pain is therefore also an enormous economic burden for society.
OBJECTIVES:
Which diseases are in particular relevant regarding pain therapy?What is the social-medical care situation regarding pain facilities in Germany?What is the social-medical care situation in pain therapy when comparing on international level?Which effects, costs or cost-effects can be seen on the micro-, meso- and macro level with regard to pain therapy?Among which social-medical services in pain therapy is there is an over- or undertreatment with regard to the micro-, meso- and macro level?Which medical and organisational aspects that have an effect on the costs and/or cost-effectiveness have to be particularly taken into account with regard to pain treatment/chronic pain?What is the influence of the individual patient’s needs (micro level) in different situations of pain (e. g. palliative situation) on the meso- and macro level?Which social-medical and ethical aspects for an adequate treatment of chronic pain on each level have to be specially taken into account?Is the consideration of these aspects appropriate to avoid over- or undertreatment?Are juridical questions included in every day care of chronic pain patients, mainly in palliative care?On which level can appropriate interventions prevent over- or undertreatment?
METHODS:
A systematic literature research is done in 35 databases. In the HTA, reviews, epidemiological and clinical studies and economic evaluations are included which report about pain therapy and in particular palliative care in the years 2005 till 2010.
RESULTS:
47 studies meet the inclusion criteria. An undertreatment of acupuncture, over- and misuse with regard to opiate prescription and an overuse regarding unspecific chest pain and chronic low back pain (LBP) can be observed. The results show the benefit and the cost-effectiveness of interdisciplinary as well as multi-professional approaches, multimodal pain therapy and cross-sectoral integrated medical care. Only rough values can be determined about the care situation regarding the supply of pain therapeutic and palliative medical facilities as the data are completely insufficient.
DISCUSSION:
Due to the broad research question the HTA-report contains inevitably different outcomes and study designs which partially differ qualitatively very strong from each other. In the field of palliative care hospices for in-patients and palliative wards as well as hospices for out-patients are becoming more and more important. Palliative care is a basic right of all terminally ill persons.
CONCLUSION:
Despite the relatively high number of studies in Germany the HTA-report shows a massive lack in health care research. Based on the studies a further expansion of out-patient pain and palliative care is recommended. Further training for all involved professional groups must be improved. An independent empirical analysis is necessary to determine over or undertreatment in pain care.
KEYWORDS:
EBM; HTA; HTA report; HTA-report; RCT; accident; analgesia; back pain; biomedical technology assessment; blinded; blinding; care; chronic; chronic pain; clinical study; clinical trial; controlled clinical study; controlled clinical trial; controlled clinical trials as topic; cost analysis; cost control; cost effectiveness; cost reduction; cost-benefit analyses; cost-benefit analysis; cost-cutting; cost-effectiveness; costs; costs and cost analysis; cross over; crossover; cross-over; cross-over studies; cross-over trials; decision making; delivery of health care; diagnosis; doctor’s note; double blind; double-blind; double-blind method; doubleblind; early retirement; economic aspect; economics; economics, medical; effectiveness; efficacy; efficiency; ethics; evaluation studies as topic; evidence based medicine; evidence-based medicine; headache; health; health care; health care costs; health economic studies; health economics; health policy; health technology assessment; healthcare needs; hospice; humans; integrated care; ischialgia; judgment; juricical; lack of work; life qualities; low back pain; lumbar pain; medical assessment; medical care; medical costs; medical evaluation; meta analysis; meta-analysis; methods; migraine; misuse; models, economic; multicenter; multicenter trial; multicentre; multimodal supply; neck pain; overuse; pain; pain care; pain clinic; pain clinics; pain disorder; pain management; pain measurement; pain patient; pain reduction; pain situation; pain therapy; palliative; palliative care; palliative medicine; palliative therapy; palliative treatment; palliative treatments; peer review; pharmaeconomics; placebo; placebo effect; placebos; prevention; program effectiveness; prospective studies; psychotherapy; quality of life; random; random allocation; randomisation; randomised clinical study; randomised clinical trial; randomised controlled study; randomised controlled trial; randomised study; randomised trial; randomization; randomized clinical study; randomized clinical trial; randomized controlled study; randomized controlled trial; randomized study; randomized trial; rehabilitation; report; research article; research-article; review; review literature; rights; risk assessment; sensitivity; shoulder pain; sick certificate; sick note; sickness costs; single blind; single blind method; single-blind; singleblind; social economic factors; socioeconomic factors; socioeconomics; somatoform disorders; specifity; spinal column; spondylosis; stoppage; supply shortage; systematic review; technical report; technology; technology assessment; technology assessment, biomedical; technology evaluation; technology, medical; therapy; thoracic spine; thoracic vertebral column; treatment; trial, cross-over; trial, crossover; triple blind; triple-blind; tripleblind; underuse; validation studies; vertebral column
Phys Ther. 2011 Apr;91(4):484-95. doi: 10.2522/ptj.20100281. Epub 2011 Feb 17.
Physical therapy for chronic low back pain in North Carolina: overuse, underuse, or misuse?
Freburger JK1, Carey TS, Holmes GM.
Abstract
BACKGROUND:
There are limited population-based studies of determinants of physical therapy use for chronic low back pain (LBP) and of the types of treatments received by individuals who see a physical therapist.
OBJECTIVE:
The purposes of this study were: (1) to identify determinants of physical therapy use for chronic LBP, (2) to describe physical therapy treatments for chronic LBP, and (3) to compare use of treatments with current best evidence on care for this condition.
DESIGN:
This study was a cross-sectional, population-based telephone survey of North Carolinians.
METHODS:
Five hundred eighty-eight individuals with chronic LBP who had sought care in the previous year were surveyed on their health and health care use. Bivariate and multivariable analyses were conducted to identify predisposing, enabling, and need characteristics associated with physical therapy use. Descriptive analyses were conducted to determine the use of physical treatments for individuals who saw a physical therapist. Use of treatments was compared with evidence from systematic reviews.
RESULTS:
Of our sample, 29.7% had seen a physical therapist in the previous year, with a mean of 15.6 visits. In multivariable analyses, receiving workers‘ compensation, seeing physician specialists, and higher Medical Outcomes Study 12-Item Short-Form Health Survey questionnaire (SF-12) physical component scores were positively associated with physical therapy use. Having no health insurance was negatively associated with physical therapy use. Exercise was the most frequent treatment received (75% of sample), and traction was the least frequent treatment received (7%). Some effective treatments were underutilized, whereas some ineffective treatments were overutilized.
LIMITATIONS:
Only one state was examined, and findings were based on patient report.
CONCLUSIONS:
Fewer than one third of individuals with chronic LBP saw a physical therapist. Health-related and non-health-related factors were associated with physical therapy use. Individuals who saw a physical therapist did not always receive evidence-based treatments. There are potential opportunities for improving access to and quality of physical therapy for chronic LBP.