Sobreuso de ecografía transvaginal en un hospital universitario privado de Argentina: estudio de corte transversal / Transvaginal ultrasound overuse in a private university hospital in Argentina: a cross-sectional study

Introducción. Si bien contamos con recomendaciones basadas en la evidencia en contra de realizar tamizaje de cáncer ovárico con ecografía transvaginal debido a que aumenta el riesgo de resultados falsamente positivos y de cascadas diagnósticas, sin disminuir la mortalidad por esta enfermedad, su solicitud en mujeres sanas es frecuente. Sin embargo, no conocemos la magnitud de la implementación de esta práctica, que constituye un cuidado de bajo valor. Objetivo. Documentar el sobreuso de ecografías transvaginales realizadas en forma ambulatoria en un hospital universitario privado de Argentina. Métodos. Estudio de corte transversal de una muestra aleatoria de ecografías realizadas en forma ambulatoria durante 2017 y 2018. Mediante revisión manual de las historias clínicas, la solicitud de cada ecografía fue clasificada como apropiada cuando algún problema clínico justificaba su realización, o inapropiada cuando había sido realizada con fines de control de salud o por una condición clínica sin indicación de seguimiento ecográfico. Resultados. De un total de 1.997 ecografías analizadas, realizadas a 1.954 mujeres adultas (edad promedio 50 años),1.345 (67,4 %; intervalo de confianza [IC] 95 % 65,2 a 69,4) habían sido solicitadas en el contexto de un control de saludo sin un problema asociado en la historia clínica y otras 54 (8,3 %; IC 95 % 6,3 a 10,7), por condiciones de salud para las que no hay recomendaciones de realizar seguimiento ecográfico. Conclusiones. Esta investigación documentó una alta proporción de sobre utilización de la ecografías transvaginales en nuestra institución. Futuras investigaciones permitirán comprender los motivos que impulsan esta práctica y ayudarán a diseñar intervenciones para disminuir estos cuidados de bajo valor. (AU)

Background. Although we have evidence-based recommendations against screening for ovarian cancer with transvaginalultrasound because it increases the risk of false positive results and diagnostic cascades without reducing mortality from this disease, its request in healthy women is frequent. However, we do not know the magnitude of the implementation of this practice, which constitutes low-value care. Objective. To document the overuse of transvaginal ultrasounds performed on an outpatient basis in a private university hospital in Argentina. Methods. Cross-sectional study of a random sample of outpatient ultrasounds performed during 2017 and 2018. Through a manual review of the medical records, the request for each ultrasound was classified as appropriate when a clinical problem justified its performance or inappropriate when it was carried out for health control purposes or for a clinical condition that had no indication for ultrasound follow-up. Results. Of a total of 1997 ultrasounds analyzed, performed on 1954 adult women (average age 50 years), 1,345 (67.4 %;95 % confidence interval [CI] 65.2 to 69.4) had been requested in the context of a health check-up or without a documented problem in the medical history that would support its performance, and another 54 (8.3 %; 95 % CI 6.3 to 10.7), for health conditions for which there are no treatment recommendations to perform ultrasound follow-up. Conclusions. This research documented a high proportion of overuse of transvaginal ultrasound in our institution. Future research will allow us to understand the reasons that drive this practice and will help design interventions to reduce thislow-value care. (AU)

Construção e evidência de validade do Instrumento de Avaliação do Conhecimento sobre Prevenção Quaternária / Construction and evidence of validity of the knowledge assessment instrument on quaternary prevention / Construcción y pruebas de validez del instrumento de evaluación de los conocimientos sobre prevención cuaternaria

Objetivo: desenvolver e estimar a evidência de validade de um instrumento para avaliar a percepção dos acadêmicos de medicina sobre a prevenção quaternária. Método: Trata-se de um estudo metodológico desenvolvido em três etapas: 1) construção do instrumento para avaliação do conhecimento sobre Prevenção Quaternária a partir de referenciais teóricos; 2) evidência de validade baseada no conteúdo, realizada por 13 juízes; 3) evidência de validade baseada na estrutura interna, realizada por 180 acadêmicos de medicina. Análises fatoriais foram realizadas para verificar a estrutura hierárquica do modelo a partir das duas dimensões inicialmente construídas: Domínio Conhecimento e Domínio Prático. Resultados: O coeficiente de evidência de validade de conteúdo da escala total (CVCt) foi de 0,98, demonstrando uma alta concordância entre os avaliadores com a conceituação teórica subjacente. Quanto à precisão do instrumento, todos os itens apresentaram valores de Alfa de Cronbach acima de 0,7, indicando boa precisão. Verificou-se bons indicadores de precisão para a escala com dois fatores (Domínio Conhecimento e Domínio Prático) ƛ2= 109.746, gl= 103; p<0,001; ƛ2/gl= 0,30; CFI= 0,98 e RMSEA 0,019. Conclusão: o instrumento IP4-15 apresentou as evidências de validade de conteúdo, estrutura interna, precisão e propriedades dos itens adequadas para avaliar o conhecimento e a prática da prevenção quaternária de acadêmicos do curso de medicina. Serão necessários estudos futuros para investigar a aplicabilidade do IP4-15 para outras populações.(AU)

Objective: to develop and estimate the evidence of validity of an instrument to assess the perception of medical students about Quaternary Prevention. Method: this is a methodological study carried out in three steps: 1) construction of the instrument to assess knowledge about Quaternary Prevention based on theoretical references; 2) content-based evidence of validity, performed by 13 judges; 3) internal structure-based evidence of validity, performed by 180 medical students. Factor analyzes were performed to verify the hierarchical structure of the model based on the two dimensions initially constructed: Knowledge Domain and Practical Domain. Results: The total scale content validity evidence coefficient (CVCt) was 0.98, demonstrating a high inter-rater agreement with the underlying theoretical conceptualization. As for instrument precision, all items had Cronbach's Alpha values above 0.7, indicating good precision. Good precision indicators were found for the scale with two factors (Knowledge Domain and Practical Domain) ƛ2= 109,746, gl= 103; p<0.001; ƛ2/gl=0.30; CFI=0.98 and RMSEA 0.019. Conclusion: the IP4-15 instrument presented adequate evidence of content validity, internal structure, precision, and properties of the items to assess the knowledge and practice of Quaternary Prevention of medical students. Future studies will be needed to investigate the applicability of IP4-15 to other populations.(AU)

la percepción de los estudiantes de medicina sobre la Prevención Cuaternaria. Método:se trata de un estudio metodológico desarrollado en tres etapas: 1) construcción de un instrumento para evaluar el conocimiento sobre Prevención Cuaternaria basado en referencias teóricas; 2) prueba de validez basada en el contenido, realizada por 13 jueces; 3) prueba de validez basada en la estructura interna, realizada por 180 estudiantes de Medicina. Se realizaron análisis factoriales para verificar la estructura jerárquica del modelo a partir de las dos dimensiones construidas inicialmente: Dominio del conocimiento y dominio práctico. Resultados: el coeficiente de evidencia de validez de contenido de la escala total (CVCt) fue de 0,98, lo que demuestra...(AU)

Too Much Healthcare: The Harmful Combination of Overdiagnosis and Medical Overuse, Told and Untold Stories.

BACKGROUND: Too much healthcare is prevalent, wasteful, and harmful. It consists of two separate phenomena: overdiagnosis and overuse. Overdiagnosis is the labeling of a person with a disease or abnormal condition that would not have caused the person harm if left undiscovered. Individuals derive no clinical benefit from overdiagnosis, although they may experience physical, psychological, or financial harm. It has been found that 15-30%, 20-50%, 0-67%, and 50-90% of people with screen detected breast, prostate, lung, and thyroid cancer, respectively, are overdiagnosed. Since many screening tests have trade-off between benefit and harm, a shared decision-making approach is essential. Incidental findings are very common and may also cause overdiagnosis. Overdiagnosis is recognizable in populations and not at the individual level. However, overuse is recognizable at the level of the individual practitioner. Choosing Wisely, an intervention directed at reducing low value care, now faces the challenge of developing interventions that go beyond recommendations. While some of the drivers of overdiagnosis and overuse are similar, different and parallel strategies are needed in order to reduce them. This is one of the major challenges to our health care system.

Fitoterapia e desmedicalização na Atenção Primária à Saúde: um caminho possível? / Phytotherapy and dismedicalization in Primary Health Care: a possible way? / Fitoterapia y desmedicalización en Atención Primaria de Salud: ¿Un posible camino?

Introdução: O uso da fitoterapia no cuidado em saúde é acessível, confiável e culturalmente aceito, reconhecendo-se que cerca de 80% da população mundial faz uso das plantas medicinais. No Sistema Único de Saúde (SUS), com o movimento da Reforma Sanitária e os interesses popular e institucional, foi construída a Política Nacional de Plantas Medicinais e Fitoterápicos, que incentivou a implantação de diversos programas de fitoterapia no Brasil. Apesar dessa ascensão da fitoterapia no SUS, a medicalização segue influenciando a prática clínica e tornando os indivíduos cada vez mais suscetíveis a intervenções desnecessárias, que muitas vezes acabam causando danos. Objetivo: Debater possibilidades de uso da fitoterapia no enfrentamento da sobremedicalização para promover a prevenção quaternária na Atenção Primária à Saúde. Métodos: Trata-se de um ensaio teórico elaborado com base na contextualização da possibilidade de enfrentamento da medicalização no âmbito do SUS, com o uso da fitoterapia. Resultados: O referencial teórico partiu de uma breve revisão do avanço da medicalização no SUS, considerando em seguida a fitoterapia como prática acessível e difundida entre a população brasileira como possibilidade para reduzir a medicalização ao ser correlacionada com o método clínico centrado na pessoa. Conclusões: A fitoterapia pode ser uma aliada da prática da prevenção quaternária ao tornar possível o encontro do saber tradicional com o técnico-científico, viabilizando um modo de cuidado alternativo à lógica medicalizadora.

Introduction: The use of phytotherapy in health care is accessible, reliable, and culturally accepted, and it is recognized that about 80% of the world population makes use of medicinal plants. In the Unified Health System (Sistema Único de Saúde ­ SUS), based on the Sanitary Reform movement and popular and institutional interests, the National Policy on Medicinal Plants and Phytotherapeutics was created, which encouraged the implementation of several phytotherapy programs in Brazil. Despite this rise of phytotherapy in the SUS, medicalization continues to influence clinical practice and make individuals increasingly susceptible to unnecessary interventions that often end up causing damage. Objective: To discuss possibilities of using phytotherapy to face overmedicalization to promote quaternary prevention in Primary Health Care. Methods: This is a theoretical essay based on the contextualization of the possibility of facing medicalization within the SUS from the perspective of Phytotherapy. Results: The theoretical framework started with a brief review of the advance of medicalization in the SUS, then considering phytotherapy as an accessible and widespread practice among the Brazilian population as a possibility to reduce medicalization when correlated with the Person-Centered Clinical Method. Conclusions: Phytotherapy can be an ally of the practice of quaternary prevention by making it possible to meet traditional and technical-scientific knowledge, enabling an alternative care method to the medicalizing logic.

Introducción: El uso de la fitoterapia en el cuidado de la salud es accesible, confiable y culturalmente aceptado, y se reconoce que cerca del 80% de la población mundial hace uso de plantas medicinales. En el SUS, con base en el movimiento de Reforma Sanitaria y los intereses populares e institucionales, fue creada la Política Nacional de Plantas Medicinales y Fitoterapéuticos, que incentivó la implementación de varios programas de fitoterapia en Brasil. A pesar de este auge de la fitoterapia en el SUS, la medicalización continúa influyendo en la práctica clínica y hace que los individuos sean cada vez más susceptibles a intervenciones innecesarias que muchas veces terminan causando daños. Objetivo: Discutir las posibilidades del uso de la fitoterapia para enfrentar la sobremedicalización para promover la prevención cuaternaria en la Atención Primaria de Salud. Métodos: Se trata de un ensayo teórico basado en la contextualización de la posibilidad de enfrentar la medicalización en el SUS desde la perspectiva de la Fitoterapia. Resultados: El referencial teórico partió de una breve revisión del avance de la medicalización en el Sistema Único de Salud, considerando luego la fitoterapia como práctica accesible y difundida entre la población brasileña como posibilidad de reducción de la medicalización cuando se correlaciona con el Método Clínico Centrado en la Persona. Conclusiones: La fitoterapia puede ser un aliado de la práctica de la prevención cuaternaria al posibilitar el encuentro con los saberes tradicionales y técnico-científicos, posibilitando un método de atención alternativo a la lógica medicalizante.

Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults.

Importance: Metrics that detect low-value care in common forms of health care data, such as administrative claims or electronic health records, primarily focus on tests and procedures but not on medications, representing a major gap in the ability to systematically measure low-value prescribing. Objective: To develop a scalable and broadly applicable metric that contains a set of quality indicators (EVOLV-Rx) for use in health care data to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders' perspectives. Design, Setting, and Participants: This qualitative study used an online modified-Delphi method to convene an expert panel of 15 physicians and pharmacists. This panel, comprising clinicians, health system leaders, and researchers, was tasked with rating and discussing candidate low-value prescribing practices that were derived from medication safety criteria; peer-reviewed literature; and qualitative studies of patient, caregiver, and physician perspectives. The RAND ExpertLens online platform was used to conduct the activities of the panel. The panelists were engaged for 3 rounds between January 1 and March 31, 2021. Main Outcomes and Measures: Panelists used a 9-point Likert scale to rate and then discuss the scientific validity and clinical usefulness of the criteria to detect low-value prescribing practices. Candidate low-value prescribing practices were rated as follows: 1 to 3, indicating low validity or usefulness; 3.5 to 6, uncertain validity or usefulness; and 6.5 to 9, high validity or usefulness. Agreement among panelists and the degree of scientific validity and clinical usefulness were assessed using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method. Results: Of the 527 low-value prescribing recommendations identified, 27 discrete candidate low-value prescribing practices were considered for inclusion in EVOLV-Rx. After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥6.5). After round 2 panel deliberations, the criteria to detect 19 candidate practices were revised. After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for both scientific validity and clinical usefulness. Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥6.5) but uncertain clinical usefulness (scores <6.5) ratings, whereas 6 received uncertain scientific validity rating (scores <6.5). Conclusions and Relevance: This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults. Applying EVOLV-Rx may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care across the full spectrum of health services.

Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature.

BACKGROUND: Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed. METHODS: A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020. RESULTS: Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs. CONCLUSIONS: An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Use of the prostate-specific antigen test in the U.S. for men age 30 to 64 in 2011 to 2017 using a large commercial claims database: Implications for practice interventions.

BACKGROUND: Given the public health relevance of PSA-based screening, various professional organizations have issued recommendations on the use of the PSA test to screen for prostate cancer in different age groups. AIM: Using a large commercial claims database, we aimed to determine the most recent rates of PSA testing for privately insured men age 30 to 64 in the context of screening recommendations. METHODS AND RESULTS: Data from employer plans were from MarketScan commercial claims database. Annual PSA testing rate was the proportion of men with ≥1 paid test(s) per 12 months of continuous enrollment. Men with diagnosis of any prostate-related condition were excluded. Annual percent change (APC) in PSA test use was estimated using joinpoint regression analysis. In 2011 to 2017, annual testing rate encompassing 5.02 to 5.53 million men was approximately 1.4%, age 30 to 34; 3.4% to 4.1%, age 35 to 39; 11% to 13%, age 40 to 44; 18% to 21%, age 45 to 49; 31% to 33%, age 50 to 54; 35% to 37%, age 55 to 59; and 38% to 41%, age 60 to 64. APC for 2011 to 2017 was -0.5% (P = .11), age 30 to 34; -3.0% (P = .001), age 35-39; -3.1% (P < .001), age 40 to 44; -2.4% (P = .001), age 45 to 49; -0.2% (P = .66), age 50 to 54; 0.0% (P = .997), age 55 to 59; and -3.3% (P = .054) from 2011 to 2013 and 1.2% (P = .045) from 2013 to 2017, age 60 to 64. PSA testing rate decreased from 2011 to 2017 for age groups between 35 and 49 by 13.4% to 16.9%. CONCLUSIONS: Based on these data, PSA testing rate has modestly decreased from 2011 to 2017. These results, however, should be considered in view of the limitation that MarketScan claims data may not be equated to actual PSA testing practices in the entire U.S. population age 30 to 64. Future research should be directed to understand why clinicians continue ordering PSA test for men younger than 50.

DeImplementing Ineffective and Low-Value Clinical Practices: Research and Practice Opportunities in Community Oncology Settings.

Patients, practitioners, and policy makers are increasingly concerned about the delivery of ineffective or low-value clinical practices in cancer care settings. Research is needed on how to effectively deimplement these types of practices from cancer care. In this commentary, we spotlight the National Cancer Institute Community Oncology Research Program (NCORP), a national network of community oncology practices, and elaborate on how it is an ideal infrastructure for conducting rigorous, real-world research on deimplementation. We describe key multilevel issues that affect deimplementation and also serve as a guidepost for developing strategies to drive deimplementation. We describe optimal study designs for testing deimplementation strategies and elaborate on how and why the NCORP network is uniquely positioned to conduct rigorous and impactful deimplementation trials. The number and diversity of affiliated community oncology care sites, coupled with the overall objective of improving cancer care delivery, make the NCORP an opportune infrastructure for advancing deimplementation research while simultaneously improving the care of millions of cancer patients nationwide.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System.

BACKGROUND: We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC. MATERIALS AND METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge. RESULTS: A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT. CONCLUSIONS: POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT. LEVEL OF EVIDENCE: Epidemiologic study, level III.

A 4K score/MRI-based nomogram for predicting prostate cancer, clinically significant prostate cancer, and unfavorable prostate cancer.

BACKGROUND: The detection of prostate cancer requires histological confirmation in biopsy core. Currently, number of unnecessary prostate biopsies are being performed in the United States. This is due to the absence of appropriate biopsy decision-making protocol. AIM: To develop and validate a 4K score/multiparametric magnetic resonance imaging (mpMRI)-based nomogram to predict prostate cancer (PCa), clinically significant prostate cancer (csPCa), and unfavorable prostate cancer (uPCa). METHODS AND RESULTS: Retrospective, single-center study evaluating a cohort of 574 men with 4K score test >7% or suspicious digital rectal examination (DRE) or Prostate Imaging Reporting and Data System (PI-RADS) scores 3, 4, or 5 on mpMRI that underwent systematic and/or mpMRI/ultrasound fusion-targeted prostate biopsy between 2016 and 2020. External cohort included 622 men. csPCa and uPCa were defined as Gleason score ≥3 + 4 and ≥4 + 3 on biopsy, respectively. Multivariable logistic regression analysis was performed to build nomogram for predicting PCa, csPCa, and uPCa. Validation was performed by plotting the area under the curve (AUC) and comparing nomogram-predicted probabilities with actual rates of PCa, csPCa, and uPCa probabilities in the external cohort. 4K score, a PI-RADS ≥4, prostate volume and prior negative biopsy were significant predictors of PCa, csPCa, and uPCa. AUCs were 0.84, 0.88, and 0.86 for the prediction of PCa, csPCa, and uPCa, respectively. The predicted and actual rates of PCa, csPCa, and uPCa showed agreement across all percentage probability ranges in the validation cohort. Using the prediction model at threshold of 30, 30% of overall biopsies, 41% of benign biopsies, and 19% of diagnosed indolent PCa could be avoided, while missing 9% of csPCa. CONCLUSION: This novel nomogram would reduce unnecessary prostate biopsies and decrease detection of clinically insignificant PCa.