RESUMO
This update on pediatric medical overuse identifies and provides concise summaries of 10 impactful articles related to pediatric medical overuse from the years 2019 to 2020.
Assuntos
Antibacterianos/uso terapêutico , Transfusão de Sangue/tendências , Mau Uso de Serviços de Saúde/tendências , Uso Excessivo dos Serviços de Saúde/tendências , Antibacterianos/efeitos adversos , Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Transtorno do Deficit de Atenção com Hiperatividade/terapia , Criança , Mau Uso de Serviços de Saúde/prevenção & controle , Humanos , Uso Excessivo dos Serviços de Saúde/prevenção & controle , Pneumotórax/diagnóstico , Pneumotórax/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Tonsilectomia/métodos , Tonsilectomia/tendênciasRESUMO
BACKGROUND AND AIM: During this COVID-19 pandemic, Taiwan is one of the few countries where fecal immunochemical test and endoscopic activity for colorectal cancer screening keeps ongoing. We aimed to investigate how screening uptake and colonoscopy rate were affected in one of the biggest screening hubs in Northern Taiwan. METHODS: We conducted a prospective observational study tracing and analyzing the screening uptake and the trend of compliance to diagnostic colonoscopy in fecal immunochemical test-positive subjects in the National Taiwan University Hospital screening hub since the outbreak of COVID-19 and compared it with that of the corresponding periods in the past 3 years. Cancellation and rescheduling rates of colonoscopy and related reasons were also explored. RESULTS: Screening uptake during December 2019 to April 2020 was 88.8%, which was significantly lower than that in the corresponding period of the past 3 years (91.2-92.7%, P for trend < 0.0001). Colonoscopy rate in this period was 66.1%, which was also significantly lower than that in the past 3 years (70.2-77.5%, P for trend = 0.017). Rescheduling or cancellation rate was up to 10.9%, which was significantly higher than that in the past 3 years (P for trend = 0.023), and half of them was due to the fear of being infected. CONCLUSION: Fecal immunochemical test screening was significantly affected by COVID-19 pandemic. In order to resume the practice in COVID-19 era, screening organizers should consider various approaches to secure timely diagnosis of colorectal cancer.
Assuntos
COVID-19 , Colonoscopia/métodos , Neoplasias Colorretais , Detecção Precoce de Câncer , Mau Uso de Serviços de Saúde , Sangue Oculto , Idoso , COVID-19/epidemiologia , COVID-19/prevenção & controle , COVID-19/psicologia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia , Controle de Doenças Transmissíveis/métodos , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/estatística & dados numéricos , Mau Uso de Serviços de Saúde/prevenção & controle , Mau Uso de Serviços de Saúde/tendências , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Prospectivos , SARS-CoV-2 , Taiwan/epidemiologiaRESUMO
BACKGROUND: Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens. METHODS: A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups. RESULTS: 698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD. CONCLUSION: Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.
Assuntos
Amputação Cirúrgica/tendências , Procedimentos Endovasculares/tendências , Disparidades em Assistência à Saúde/tendências , Hospitais Comunitários/tendências , Hospitais Rurais/tendências , Extremidade Inferior/irrigação sanguínea , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Doença Arterial Periférica/cirurgia , Padrões de Prática Médica/tendências , Procedimentos Cirúrgicos Vasculares/tendências , Idoso , Índice Tornozelo-Braço/tendências , Angiografia por Tomografia Computadorizada/tendências , Feminino , Mau Uso de Serviços de Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/patologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla/tendênciasRESUMO
BACKGROUND: Concerns have been raised about the accessibility and quality of cancer-related care for people with intellectual disabilities (ID). However, there is limited insight into cancer incidence and the utilization of cancer care at the ID population level to inform targeted cancer control strategies. Therefore, we aimed to examine differences in the utilization of cancer-related care between people with and without ID, identified through diagnostic codes on health insurance claims. METHODS: In a population-based cohort study, Dutch individuals of all ages who received residential care through the Chronic Care Act due to an ID (n = 65 183) and an age and sex-matched sample of persons without ID (1:2 ratio), who were cancer-free at enrollment in 2013 were followed through 2015. Incidence rates (IRs) of newly started cancer care and IR ratios (IRRs) with 95% CIs were used to compare groups. Separate analyses were performed per cancer type. RESULTS: Individuals with ID received less cancer-related care than individuals without (IRR = 0.64, 95% CI 0.62-0.66). Differences increased with age and were larger for females than for males. Utilization of care for cancers within the national screening program (female breast, cervical, and colon cancer) was lower for people with ID compared to people without ID. CONCLUSION: Cancer may be underdiagnosed and/or undertreated in people with ID, or cancer is truly less prevalent in this population. In particular, the differences detected between males and females with ID, and the potential underutilization of national screening programs, require urgent follow-up investigations.
Assuntos
Acessibilidade aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Oncologia/tendências , Neoplasias/terapia , Pessoas com Deficiência Mental , Demandas Administrativas em Assistência à Saúde , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Criança , Pré-Escolar , Bases de Dados Factuais , Detecção Precoce de Câncer/tendências , Feminino , Mau Uso de Serviços de Saúde/tendências , Humanos , Lactente , Recém-Nascido , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Países Baixos/epidemiologia , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Adulto JovemAssuntos
Infecções por Coronavirus/epidemiologia , Serviço Hospitalar de Emergência/tendências , Mau Uso de Serviços de Saúde/tendências , Pneumonia Viral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Betacoronavirus , COVID-19 , Surtos de Doenças , Fibrinolíticos/uso terapêutico , Humanos , Pandemias , SARS-CoV-2 , Acidente Vascular Cerebral/terapia , Trombectomia/tendências , Terapia Trombolítica/tendências , Ativador de Plasminogênio Tecidual/uso terapêutico , Estados Unidos/epidemiologiaAssuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Transtornos Mentais/epidemiologia , Transtornos Mentais/reabilitação , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Design Centrado no Usuário , Estudos Transversais , Previsões , Implementação de Plano de Saúde/estatística & dados numéricos , Implementação de Plano de Saúde/tendências , Política de Saúde/tendências , Acessibilidade aos Serviços de Saúde/tendências , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Mau Uso de Serviços de Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Vida Independente/estatística & dados numéricos , Transtornos Mentais/psicologia , Modelos Teóricos , Transtornos Relacionados ao Uso de Substâncias/psicologia , Estados UnidosRESUMO
BACKGROUND: Little is known about patients discharged to hospice following hospitalization for complications of cirrhosis. AIM: We sought to understand the current pattern of hospice utilization in patients with cirrhosis by evaluating the North American Consortium for the Study of End-stage Liver Disease (NACSELD) cohort. METHODS: Patients with cirrhosis from 14 tertiary-care hepatology centers across North America non-electively hospitalized and prospectively enrolled were evaluated. Exclusion criteria included HIV infection, transplantation or non-hepatic malignancy. Random computer-based propensity score matching was undertaken in a 1:2 ratio based on admission MELD score ± 3 points. RESULTS: Totally, 2718 patients were enrolled, 5% (N = 132) were discharged to hospice, 6% (N = 171) died, and the rest were discharged alive. Patients discharged to hospice were older (60 vs. 57 years, p = 0.04), less likely to have had SBP (13% vs. 28%, p = 0.002) and be listed for liver transplantation (11% vs. 26%, p = 0.0007). Features, on multivariable modeling, associated with increased probability of discharge to hospice as opposed to being discharged alive: grade-3-4 hepatic encephalopathy, a higher Child-Turcotte-Pugh (CTP) score, and a higher discharge serum creatinine; however, a higher serum sodium, being listed for transplant and being prescribed rifaximin or a statin were protective from hospice discharge. CONCLUSION: Patients with more advanced liver disease, hepatic encephalopathy, renal dysfunction, and those not candidates for liver transplantation were more likely to be discharged to hospice. However, in this sick multinational cohort of cirrhotic inpatients, it seems that hospice is markedly underutilized (5%) since 25% of patients not discharged to hospice died within 6 months.
Assuntos
Mau Uso de Serviços de Saúde/tendências , Cuidados Paliativos na Terminalidade da Vida/tendências , Pacientes Internados , Cirrose Hepática/terapia , Cuidados Paliativos/tendências , Alta do Paciente/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Idoso , Feminino , Nível de Saúde , Mortalidade Hospitalar/tendências , Humanos , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , América do Norte , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Medical care overuse is a significant source of patient harm and wasteful spending. Understanding the drivers of overuse is essential to the design of effective interventions. OBJECTIVE: We tested the association between structural factors of the health care delivery system and regional differences systemic overuse. RESEARCH DESIGN: We conducted a retrospective analysis of deidentified claims for 18- to 64-year-old adults from the IBM MarketScan Commercial Claims and Encounters Database. We calculated a semiannual Johns Hopkins Overuse Index for each of the 375 Metropolitan Statistical Areas in the United States, from January 2011 to June 2015. We fit an ordinary least squares regression to model the Johns Hopkins Overuse Index as a function of regional characteristics of the health care system, adjusted for confounders and time. RESULTS: The supply of regional health care resources was associated with systemic overuse in commercially insured beneficiaries. Regional characteristics associated with systemic overuse included number of physicians per 1000 residents (P=0.001) and higher Medicare malpractice geographic price cost index (P<0.001). Regions with a higher density of primary care physicians (P=0.008) and a higher proportion of hospital-based providers (P=0.016) had less systemic overuse. Differences in hospital and insurer market power were inversely associated with systemic overuse. CONCLUSIONS: Systemic overuse is associated with observable, structural characteristics of the regional health care system. These findings suggest that interventions that aim to improve care efficiency via reductions in overuse should focus on the structural drivers of this phenomenon, rather than on the eradication of individual overused procedures.
Assuntos
Geografia , Mau Uso de Serviços de Saúde , Benefícios do Seguro , Setor Privado , Adulto , Atenção à Saúde/economia , Atenção à Saúde/tendências , Feminino , Mau Uso de Serviços de Saúde/economia , Mau Uso de Serviços de Saúde/tendências , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/tendências , Masculino , Medicare/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
Harmful and hazardous alcohol consumption is one of the most significant public health problems in Italy and Europe. Habitual excessive consumption and occasional excessive consumption, known as binge drinking, are the two main risk behaviours related to alcohol. Harmful drinking and alcohol dependence have strong social repercussions in terms of their social and economic impact and contribution to productivity losses. In addition, the terms alcohol abuse and alcohol dependence have been recently substituted by the only term of alcohol use disorder (AUD). The issues presented in this review demonstrate that excessive alcohol consumption is a growing public health concern and an appropriate national action plan is needed to increase the prevention of harmful and hazardous consumption and encourage patients to seek healthcare. To date, the main problem is the under-treatment of the population at risk, manifested as the time-lag between the onset of AUD and the first clinical detection. In order to address this, the Screening, Brief Intervention, and Referral to Treatment (SBIRT) strategy has been shared across countries in Europe and is supported by a Systematic Review of Reviews on SBIRT in primary healthcare. Unfortunately, there are still obstacles in the implementation of this approach. The main problem would appear to be general practitioners' difficulty in carrying out accurate and widespread screening, because they may minimize the problem. A more concerted effort in the training of healthcare professionals could address this by enabling the creation of renewed networks for the early identification of harmful and hazardous drinkers. These networks could prevent the occurrence of avoidable alcohol-related conditions, such as alcohol-related liver disease (ALD), while allowing for the timely implementation of evidence-based brief interventions.
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Alcoolismo/epidemiologia , Alcoolismo/terapia , Mau Uso de Serviços de Saúde/prevenção & controle , Hepatopatias Alcoólicas/epidemiologia , Hepatopatias Alcoólicas/terapia , Tempo para o Tratamento , Alcoolismo/diagnóstico , Mau Uso de Serviços de Saúde/tendências , Humanos , Hepatopatias Alcoólicas/diagnóstico , Tempo para o Tratamento/tendências , Resultado do TratamentoRESUMO
Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.
Assuntos
Serviço Hospitalar de Emergência , Mau Uso de Serviços de Saúde/tendências , Bases de Dados Factuais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Acessibilidade aos Serviços de Saúde , Habitação , Humanos , Masculino , Medicaid , Pessoa de Meia-Idade , São Francisco , Estados UnidosRESUMO
BACKGROUND: Women comprise approximately one-third of the advanced heart failure population but may receive fewer advanced heart failure therapies including left ventricular assist devices (LVADs). During the early pulsatile-flow device era, women had higher post-LVAD mortality and increased complications. However, knowledge about these differences in the continuous-flow device era is limited. Therefore, we sought to explore temporal trends in LVAD utilization and post-LVAD mortality by sex. METHODS AND RESULTS: Patients with LVAD implantation from 2004 to 2016 were identified using the Nationwide Inpatient Sample. Trends in LVAD utilization and post-LVAD inpatient mortality were compared by sex and device era. Although LVADs are being increasingly utilized for patients with advanced systolic heart failure, women continue to represent a smaller proportion of LVAD recipients-25.8% in 2004 to 21.9% in 2016 (P for trend, 0.91). Women had increased inpatient mortality after LVAD implantation compared with men in the pulsatile-flow era (46.9% versus 31.1%, P<0.0001) but not in the continuous-flow era (13.3% versus 12.1%, P=0.27; P for interaction=0.0002). Inpatient mortality decreased for both sexes over time after LVAD, with a sharp fall in 2008 to 2009. Female sex was independently associated with increased post-LVAD inpatient mortality beyond adjustment for demographics and risk factors during the pulsatile-flow era (odds ratio, 2.13; 95% CI, 1.45-3.10; P<0.0001) but not during the continuous-flow era (1.18; 0.93-1.48; P=0.16). CONCLUSIONS: Although utilization of LVAD therapy increased over time for both sexes, LVAD implantation remains stably lower in women, which may suggest a potential underutilization of this potentially life-saving therapy. Prospective studies are needed to confirm these findings.
Assuntos
Mau Uso de Serviços de Saúde/tendências , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/tendências , Mortalidade Hospitalar/tendências , Implantação de Prótese/estatística & dados numéricos , Adulto , Idoso , Bases de Dados Factuais , Feminino , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Coração Auxiliar/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Implantação de Prótese/mortalidade , Implantação de Prótese/tendências , Fatores Sexuais , Estados Unidos/epidemiologiaRESUMO
Objective To investigate the association between hypothyroidism and cardiovascular disease (CVD) in both treated and untreated hypothyroid patients, and the consequences of over- and under-treatment with respect to cardiovascular risk. Design A registry-based case-control study nested within a population-based cohort of 275 467 individuals with at least one serum thyroid stimulating hormone (TSH) measurement in the period of 1995-2011. Methods Incident cases of CVD were matched with controls according to gender, age and year of birth. Conditional logistic regression analyses were performed to calculate CVD risks associated with exposure to hypothyroidism, with adjustment for 19 pre-existing comorbidities, including cardiovascular disease and diabetes, using the Charlson Comorbidity Index. Results Overall, 20 487 individuals experienced CVD (9.4%, incidence rate 13.1 per 1000 person-years, 95% confidence interval (CI), 13.0-13.3). Risk of CVD was increased in untreated hypothyroidism compared to euthyroidism (odds ratio (OR): 1.83 (95% CI: 1.43-2.35; P < 0.001)). Cardiovascular risk was increased in both treated and untreated hypothyroid individuals per half year of elevated TSH (OR: 1.11 (95% CI: 1.06-1.16; P < 0.001) and OR: 1.15 (95% CI: 1.09-1.23; P = 0.001), respectively). In patients treated with levothyroxine, OR for CVD was 1.12 (95% CI: 1.06-1.18; P < 0.001) for each 6 months of decreased TSH. Conclusion Cardiovascular risk is increased in untreated, but not in treated hypothyroid patients. Among those with treated hypothyroidism, duration of decreased TSH (overtreatment) had a similar impact on cardiovascular risk as duration of elevated TSH (under-treatment), highlighting the importance of initiating treatment and maintaining biochemical euthyroidism in hypothyroid patients in order to reduce the risk of CVD and death.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Hipotireoidismo/epidemiologia , Hipotireoidismo/terapia , Uso Excessivo dos Serviços de Saúde/tendências , Adulto , Idoso , Doenças Cardiovasculares/diagnóstico , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Mau Uso de Serviços de Saúde/tendências , Humanos , Hipotireoidismo/diagnóstico , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Fatores de TempoRESUMO
During college and medical school, the author's summer employment acquainted him with members of organized crime families. After a full career as a primary care clinician and geriatrician with research on improving health care delivery, the author opines that several insights from organized crime should be of interest to health care professionals: (1) don't damage the host; (2) protect the brand; and (3) lead necessary adaption. From these insights, the author presents symptoms of failure evidenced by the US health care system, followed by several adaptations that would reduce the system's costs, improve its image, and address future challenges.
Assuntos
Crime , Fraude/economia , Custos de Cuidados de Saúde/tendências , Setor de Assistência à Saúde/economia , Mau Uso de Serviços de Saúde/economia , Fraude/tendências , Setor de Assistência à Saúde/tendências , Mau Uso de Serviços de Saúde/tendências , Humanos , Estados UnidosAssuntos
Angina Instável/terapia , Mau Uso de Serviços de Saúde/tendências , Seguro Saúde/tendências , Intervenção Coronária Percutânea/tendências , Idoso , Angina Instável/epidemiologia , Angiografia Coronária/tendências , Feminino , Florida , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , New York , Pacientes Ambulatoriais/estatística & dados numéricos , Resultado do TratamentoRESUMO
Importance: Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse. Observations: A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits). Conclusions and Relevance: Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.
Assuntos
Atenção à Saúde/tendências , Mau Uso de Serviços de Saúde/tendências , Medicina Baseada em Evidências/tendências , Humanos , Uso Excessivo dos Serviços de Saúde/tendências , Uso Excessivo de Medicamentos Prescritos/tendências , Qualidade da Assistência à Saúde/tendências , Procedimentos Desnecessários/tendênciasRESUMO
BACKGROUND: Overuse of health care resources has been identified as the leading contributor to waste in the US health care system. OBJECTIVE: To explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services. DESIGN: Using Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas. KEY RESULTS: Regions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P < 0.001). Regional characteristics associated with higher JHOI scores, indicating more systemic overuse, included number per 1000 residents of acute care hospital beds (P = 0.002) and of hospital-based anesthesiologists, pathologists, and radiologists (P = 0.02). CONCLUSIONS: Regional variations in health care resources including the clinician workforce are associated with the intensity of systemic overuse of health care. The role of primary care doctors in reducing health care overuse deserves further attention.
Assuntos
Atenção à Saúde/tendências , Recursos em Saúde/provisão & distribuição , Recursos em Saúde/tendências , Mau Uso de Serviços de Saúde/tendências , Benefícios do Seguro/tendências , Medicare/tendências , Idoso , Idoso de 80 Anos ou mais , Atenção à Saúde/economia , Feminino , Recursos em Saúde/economia , Mau Uso de Serviços de Saúde/economia , Humanos , Benefícios do Seguro/economia , Masculino , Medicare/economia , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/tendências , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: To evaluate real-world patient characteristics, medication use, and health care utilization patterns in patients with type 2 diabetes with established cardiovascular disease (CVD). METHODS: Cross-sectional analysis of patients with type 2 diabetes seen at Cleveland Clinic from 2005 to 2016, divided into two cohorts: with-CVD and without-CVD. Patient demographics and antidiabetic medications were recorded in December 2016; department encounters included all visits from 1/1/2016 to 12/31/2016. Comorbidity burden was assessed by the diabetes complications severity index (DCSI) score. RESULTS: Of 95,569 patients with type 2 diabetes, 40,910 (42.8%) were identified as having established CVD. Patients with CVD vs. those without were older (median age 69.1 vs. 58.2 years), predominantly male (53.8% vs. 42.6%), and more likely to have Medicare insurance (69.4% vs. 35.3%). The with-CVD cohort had a higher proportion of patients with a DCSI score ≥ 3 than the without-CVD cohort (65.0% vs. 10.3%). Utilization rates of glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors were low in both with-CVD (4.1 and 2.5%) and without-CVD cohorts (5.4 and 4.1%), respectively. The majority of patient visits (75%) were seen by a primary care provider. During the 1-year observation period, 81.9 and 62.0% of patients with type 2 diabetes and CVD were not seen by endocrinology or cardiology, respectively. CONCLUSIONS: These data indicated underutilization of specialists and antidiabetic medications reported to confer CV benefit in patients with type 2 diabetes and CVD. The impact of recently updated guidelines and cardiovascular outcome trial results on management patterns in such patients remains to be seen.
Assuntos
Doenças Cardiovasculares/terapia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Recursos em Saúde/tendências , Mau Uso de Serviços de Saúde/tendências , Hipoglicemiantes/uso terapêutico , Padrões de Prática Médica/tendências , Idoso , Cardiologia/tendências , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Comorbidade , Estudos Transversais , Bases de Dados Factuais , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Registros Eletrônicos de Saúde , Endocrinologia/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Atenção Primária à Saúde/tendências , Encaminhamento e Consulta/tendências , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Atrial fibrillation (AF) is a leading cause of stroke. Oral anticoagulant (OAC) therapy can significantly reduce the risk of stroke in patients with AF, but underuse of OACs for stroke prevention continues to be a serious clinical problem, with significant deleterious impact on outcomes. We review the studies demonstrating OAC underutilization and evaluating strategies for promoting the increased use of OAC therapy for stroke prevention in nonvalvular AF (NVAF) patients, including in special patient populations.
Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Mau Uso de Serviços de Saúde/tendências , Padrões de Prática Médica/tendências , Acidente Vascular Cerebral/prevenção & controle , Vitamina K/antagonistas & inibidores , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Prescrições de Medicamentos , Humanos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Resultado do TratamentoRESUMO
Medical actions that have been shown to be beneficial in individual studies may be associated with a negative benefit-harm balance at the population level due to oversupply or undersupply. Therefore, structured dialogues among basic researchers, clinicians and public health researchers are needed to generate relevant public health questions in relation to medical actions and to undertake research projects that answer these questions. For this purpose, more structured PhD programs in public health are required. Implementation barriers for evidence-based medical actions in the population need to be identified and tailored interventions to reduce these barriers need to be developed and evaluated.
Assuntos
Tecnologia Biomédica/tendências , Programas Nacionais de Saúde/tendências , Saúde Pública/tendências , Berlim , Medicina Baseada em Evidências/tendências , Previsões , Alemanha , Acessibilidade aos Serviços de Saúde/tendências , Mau Uso de Serviços de Saúde/tendências , Pesquisa sobre Serviços de Saúde/tendências , Humanos , Programas de Rastreamento/tendênciasRESUMO
INTRODUCTION: Underutilisation of radiotherapy has been observed worldwide. To evaluate the current situation in Belgium, optimal utilisation proportions (OUPs) adopted from the European SocieTy for Radiotherapy and Oncology - Health Economics in Radiation Oncology (ESTRO-HERO) project were compared to actual utilisation proportions (AUPs) and with radiotherapy advised during the multidisciplinary cancer team (MDT) meetings. In addition, the impact of independent variables was analysed. MATERIALS AND METHODS: AUPs and advised radiotherapy were calculated overall and by cancer type for 110,810 unique cancer diagnoses in 2009-2010. Radiotherapy utilisation was derived from reimbursement data and distinguished between palliative and curative intent external beam radiotherapy (EBRT) and/or brachytherapy (BT). Sensitivity analyses regarding the influence of the follow-up period, the survival length and patient's age were performed. Advised radiotherapy was calculated based on broad treatment categories as reported at MDT meetings. RESULTS: The overall AUP of 37% (39% including BT) was lower than the OUP of 53%, but in line with advised radiotherapy (35%). Large variations by tumour type were observed: in some tumours (e.g. lung and prostate cancer) AUP was considerably lower than OUP, whereas in others there was reasonable concordance (e.g. breast and rectal cancer). Overall, 84% of treatments started within 9 months following diagnosis. Survival time influenced AUP in a cancer type-dependent way. Elderly patients received less radiotherapy. CONCLUSION: Although the actually delivered radiotherapy in Belgium aligns well to MDT advices, it is lower than the evidence-based optimum. Further analysis of potential barriers is needed for radiotherapy forecasting and planning, and in order to promote adequate access to radiotherapy.