Overordering of tumor marker for outpatients revealed by performance indicators and the impact of a health policy intervention: An observational study using administrative records.

PURPOSE: The overuse of laboratory tests contributes to impair health systems effectiveness, tumor markers (TMs) being a paradigmatic example. In the present study we applied indicators of TMs appropriateness developed from administrative datasets to appraise regionwide overordering in the clinical practice. PATIENTS AND METHODS: TMs ordered to outpatients in the Veneto Region over 6 years were obtained from the eletronic Outpatients' Records of Diagnostic and Therapeutic Procedures. TMs orders were examined as aggregated data or stratified according to disease codes, gender, age, and requests per patient. TMs recommended only for specific malignancies were examined using epidemiological data obtained from Veneto Tumor Registry. RESULTS: A total of 5,821,251 TMs were ordered in 4,382,159 patients over 6 years. Overall, 3,252,389 (55.9%) TMs were ordered without appropriate disease codes (ranging from 77.0% for PSA to 17.5% for CA15.3). TM orders declined over 6 years (-13.4%), with a noticeable reduction of orders without appropriate disease codes (-21.3%). Orders decreased sharply from 2015 to 2016, after the enactment of a national Decree-Law aimed at improving appropriateness, and remained stable thereafter. However, the rate of inappropriate TMs requests still remained elevated (44.4%) in the last year of observation, with orders of TMs being much higher than expected on the basis of prevalence and incidence figures of specific malignancies. CONCLUSIONS: Indicators developed from administrative datasets were effective in assessing the overordering of TMs and the impact of interventions to improve appropriateness. The developed indicators could be considered for other diagnostic tests.

Use of Routine Health Datasets to Assess the Appropriateness of Diagnostic Tests in the Follow-Up of Breast Cancer Patients: A Population-Based Study on 3930 Patients.

Purpose: Clinical practice guidelines (CPGs) recommend against intensive follow-up in asymptomatic women with breast cancer (BC). The present study assessed the adherence to CPGs of diagnostic tests ordering during BC follow-up by exploring routinely collected health data through an algorithm developed to distinguish patients according to their status at follow-up. Patients and Methods: A retrospective population-based cohort study was performed monitoring the diagnostic tests ordered during 5 years of follow-up in all BC cases incident in 2013 in the Veneto Region, Italy. Data were extracted from the Veneto Tumour Registry, the Hospital Discharge Records and the Outpatients' Records of Diagnostic and Therapeutic Procedures. The algorithm was developed using information on infusion of anticancer agents, imaging exams ordered, and death. Results: The algorithm classified patients by status at follow-up in four groups: (i) probably no-evidence-of-disease (NED), (ii) suspicious signs of relapse not confirmed, (iii) increased risk of relapse and (iv) advanced disease at presentation or progressive disease. A total of 3930 consecutive incident cases were followed-up for 5 years, corresponding to 17,184 person-years, 15,345 of which pertaining to NED cases. In NED cases, 32,900 tumour markers and 15,858 imaging exams were ordered. Liver ultrasonography and chest radiography were most frequently ordered. Conclusion: In contrast with recommendations of CPGs, a substantial overordering of tumour markers and imaging exams occurred in NED BC patients. The developed algorithm can be repeatedly applied to routine health datasets for regular monitoring of the adherence to CPGs and of the impact of interventions to improve appropriateness.

Indicators of inappropriate tumour marker use through the mining of electronic health records.

RATIONALE, AIMS, AND OBJECTIVES: Although the issue of monitoring appropriateness of tumour markers (TMs) request in outpatients remains crucial, proper indicators are still demanding. The present study developed and explored indicators of inappropriate TM ordering in outpatients through the data mining of electronic health records (EHRs). METHODS: Carcinoembryonic antigen (CEA), alfa-fetoprotein (AFP), carbohydrate antigen (CA)125, CA15.3, CA19.9, and prostate-specific antigen (PSA) ordered in outpatients during a year were examined by mining EHRs of a Local Health Authority in Italy. Evidence-based criteria were used to develop performance indicators. Demographic and clinical information associated with TM orders were examined. RESULTS: A total of 80 813 TMs were ordered in 52 536 outpatients (1.54 markers/patient). Indicators related to disease codes, gender, age, and TM repetitions were developed, and their application showed that (1) CA15.3 and CEA are prevalently requested in patients with cancer (79.2% and 65.6%) whereas the other TMs are largely requested also in patients without cancer; (2) requests of PSA in women and of CA125 or CA15.3 in men are negligible; (3) although requests in people older than 80 years are relevant (16.4% of total), the highest rate of request of all markers occurs in patients aged 40 to 79 years; (4) CA15.3 and CEA are mainly requested in cancer cases between 50 and 79 years and AFP, CA19.9, and CA125 in those between 60 and 69 years; (5) <50% of PSA orders are associated with cancer code for all age intervals; and (6) multiple repetitions of AFP, CA125, CA15.3, CA19.9, and CEA are prevalent in cancer patients or benign diseases to which TMs are appropriate, whereas PSA repetitions occur mainly in patients without cancer. CONCLUSIONS: The developed indicators resulted suitable to monitor TM overordering in outpatients through the mining of EHRs. The present study is a first approach towards the use of big-data mining for TM appropriateness evaluation purposes.

White matter lesions and the risk of incident hip fracture in older persons: results from the progetto veneto anziani study.

BACKGROUND: White matter lesions (WMLs) are associated with hypertension, an increased risk of falling, and impaired physical and cognitive performance that may affect the mechanical effect of falls. METHODS: We hypothesized that WMLs are a risk factor for hip fracture (HF). We studied a sample of 820 community-dwelling Italian persons 65 years and older from the cohort of the Progetto Veneto Anziani Study who underwent brain magnetic resonance imaging at baseline. Subjects were classified as having no lesions, focal lesions, or diffuse WMLs. RESULTS: Compared with those with no lesions, participants with diffuse WMLs were older, reported more falls, and had worse physical and cognitive performance, all factors implicated in the causal pathway to HF. During 9 years of follow-up, 51 HFs occurred. Hip fracture risk associated with diffuse WMLs markedly differed between participants younger than 80 years vs those 80 years and older. After adjustment among participants younger than 80 years, diffuse WMLs compared with no lesions were associated with a 2.7-fold (95% confidence interval, 1.1-7.1) increase in the risk of HF. Focal lesions were not statistically significantly associated with an increased risk of HF in the same age group (hazard ratio, 2.0; 95% confidence interval, 0.6-7.6). No associations between diffuse WMLs, focal lesions, and HF were evident among participants 80 years and older, possibly because of the limited sample size. CONCLUSIONS: White matter lesions represent an independent risk factor for HF in persons younger than 80 years. Older persons with diffuse WMLs should be considered candidates for multifactorial interventions aimed at reducing the risk of falling and fractures.