Survey study of anesthesiologists' and surgeons' ordering of unnecessary preoperative laboratory tests.

BACKGROUND: Nearly 20 years ago it was shown that patients are exposed to unnecessary preoperative testing that is both costly and has associated morbidity. To determine whether such unnecessary testing persists, we performed internal and external surveys to quantify the incidence of unnecessary preoperative testing and to identify strategies for reduction. METHODS: The medical records of 1000 consecutive patients scheduled for surgery at our institution were examined for testing outside of our approved guidelines. Subsequently, 4 scenarios were constructed to solicit physician views of appropriate testing: a 45-year-old woman for a laparoscopic ovarian cystectomy, a 23-year-old woman for right inguinal herniorrhaphy, a 50-year-old man for a hemithyroidectomy, and a 50-year-old man for a total hip replacement. One or more of these scenarios were sent to directors of preoperative clinics (all), United States anesthesiologists (all), gynecologists (cystectomy), general surgeons (herniorrhaphy), otolaryngologists (thyroidectomy), and orthopedists (hip replacement). Potential predictors of ordering and demographic information were collected. RESULTS: More than half of our patients had at least 1 unnecessary test based on our testing guidelines (95% lower confidence limit = 52%). The 17 responding preoperative directors were unanimous for 36 of the 72 combinations of test or consult (henceforth "test") and scenario as being unnecessary. Among the 175 anesthesiologists responding to the survey, 46% ordered 1 or more of the tests unanimously considered unnecessary by the preoperative directors for the given scenario. Among 17 potential predictors of anesthesiologists' unnecessary ordering, only training completed before 1980 significantly increased the risk of ordering at least 1 unnecessary test (by 48%, 95% confidence limits >29%). Anesthesiologists were 53% less likely to order at least 1 unnecessary test relative to gynecologists for the cystectomy scenario, 64% less likely than general surgeons for the herniorrhaphy scenario, 66% less likely than otolaryngologists for the thyroidectomy scenario, and 67% less likely than orthopedists for the hip replacement scenario. The 95% lower confidence limits were all >40%. CONCLUSIONS: The percentage of patients with at least 1 unnecessary test is a suitable end point for monitoring providers' ordering. The incidence can be high despite efforts at improvement, but may be reduced if anesthesiologists rather than surgeons order presurgical tests and consults. However, anesthesia groups should be cognizant of potential heterogeneity among them based on time since training.

Promoting knowledge of cancer prevention and screening in an underserved Hispanic women population: a culturally sensitive education program.

This article aims to measure the baseline knowledge of cancer prevention, screening, and early detection practices, to understand the barriers to cancer screening and sources of health information; and to evaluate the effectiveness of a culturally sensitive education program in an underserved Hispanic women population. A total of 180 women participated. Pre- and postsurveys were administered. Multivariate analysis was used to analyze the impact of program on knowledge and to determine factors affecting learning. Results showed Significant overall improvement in knowledge of cancer symptoms (1.85 baseline vs. 3.67 postintervention, p < .001), knowledge of risk-reducing behaviors (2.71 vs. 4.81, p < .001); and effect on planned behavior (89% planned to follow screening guidelines). Higher incomes and younger age are associated with better learning. Major barriers to cancer screening were financial limitations and lack of knowledge. The intervention was effective in promoting awareness and knowledge of cancer screening and prevention. Programs aimed at reducing cancer incidence and mortality should recognize the importance of cultural sensitivity and facilitating access to screening tests.

Inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD.

BACKGROUND: Prescriber disagreement is among the reasons for poor adherence to COPD treatment guidelines; it is yet not clear whether this leads to adverse outcomes. We tested whether undertreatment according to the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines led to increased exacerbations. METHODS: Records of 878 patients with spirometrically confirmed COPD who were followed from 2005 to 2010 at one Veterans Administration (VA) Medical Center were analyzed. Analysis of variance was performed to assess differences in exacerbation rates between severity groups. Logistic regression analysis was performed to assess the relationship between noncompliance with guidelines and exacerbation rates. FINDINGS: About 19% were appropriately treated by guidelines; 14% overtreated, 44% under-treated, and in 23% treatment did not follow any guideline. Logistic regression revealed a strong inverse relationship between undertreatment and exacerbation rate when severity of obstruction was held constant. Exacerbations per year by GOLD stage were significantly different from each other: mild 0.15, moderate 0.27, severe 0.38, very severe 0.72, and substantially fewer than previously reported. INTERPRETATION: The guidelines were largely not followed. Undertreatment predominated but, contrary to expectations, was associated with fewer exacerbations. Thus, clinicians were likely advancing therapy primarily based upon exacerbation rates as was subsequently recommended in revised GOLD and other more recent guidelines. In retrospect, a substantial lack of prescriber adherence to treatment guidelines may have been a signal that they required re-evaluation. This is likely to be a general principle regarding therapeutic guidelines. The identification of fewer exacerbations in this cohort than has been generally reported probably reflects the comprehensive nature of the VA system, which is more likely to identify relatively asymptomatic (ie, nonexacerbating) COPD patients. Accordingly, these rates may better reflect those in the general population. In addition, the lower rates may reflect the more complete preventive care provided by the VA.

Telephone service interruption weighting adjustments for state health insurance surveys.

Many states rely on telephone surveys to produce estimates of uninsurance. To the extent that people in households without telephones differ from those living in households with telephones, estimates will be biased due to lack of coverage of those in households without telephones. We find the disparity in estimates of uninsurance in the Current Population Survey (all people vs. those living in households without telephones) shows a similar association to the disparity found in the state surveys (all people vs. those living in households with telephone service interruptions). We adjust the state survey weights of those people living in households that experienced telephone interruptions to account for people living in households without telephones and evaluate whether the weighting adjustment for telephone service interruptions is advisable.

Institutions with accredited residencies in New York State with an interest in developing new residencies or expanding existing ones.

PURPOSE: In view of the looming physician shortage, especially in primary care specialties, there have been calls for increasing graduate medical education (GME). However, the capacity for increases of GME in institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME) has not been determined. METHOD: In 2009, the authors surveyed the 48 designated institutional officials supervising ACGME-accredited residencies in New York State that were eligible for their study, to determine interest in and capacity for development of new core residencies and expansion of existing ones if additional funds were made available at current Medicare rates. RESULTS: Thirty-six (75%) responded; 39% would add new programs and 47% would expand current programs with additional funding. The major interest in adding new programs was in emergency medicine (35%). Notably, only 11% would add family medicine. The major interest in program expansion was internal medicine (48%), urology (42%), diagnostic radiology (35%), obstetrics-gynecology (26%), and emergency medicine (25%). CONCLUSIONS: Fewer than 50% of current training institutions are interested in or have the capacity for expansion of core residencies. The interest in establishing or expanding primary care is especially problematic. Because 70% of internal medicine residents become subspecialists, additional funds for GME at current rates would largely encourage the training of additional hospital-based and hospital-intensive specialists, with little impact on those who would practice adult primary care medicine. Significantly increasing the physician training for adult primary care medicine will require more substantial institutional incentives.

An investigation into support for restrictions on HIV carriers in the Chicago metropolitan area

Säo discutidas possíveis explicaçöes para as restriçöes impostas a pacientes aidéticos e indivíduos HIV positivos nas várias esferas da vida social. A diversidade de interesses e valores que permeiam as atitudes em relaçäo a este grupo da populaçäo foram analisados através da técnica de LISREL. Coletaram-se informaçöes de 200 adultos (idade entre 18 e 65 anos) residentes em Chicago, Illinois, USA, através de entrevistas telefônicas. Conclui-se que os dados apontam como explicaçäo a observada discriminaçäo, a intolerância a homossexualidade e a falta de credibilidade nas intervençöes originárias das políticas de saúde do processo para controle da epidemia de AIDS. Säo discutidas as conseqüências destes achados para o estabelecimento de prioridades e de possíveis programas

The engine of the caboose: health policy in developing countries

É discutida a política de saúde em países em desenvolvimento. Defende-se a proposta de que esses países devem adotar uma abordagem progressista quanto a sua política de saúde, rejeitando o sistema que se apóia em dois pilares - o da saúde pública e privada. Salienta-se que a ideologia näo pode ser seu único sustentáculo. Um sistema de saúde progressista deve utilizar as ciências administrativas, sociais e comportamentais na formulaçäo e implementaçäo do conjunto de seus programas e propostas, para que possa servir à populaçäo de nidi eficaz. O sistema de saúde näo pode se eximir em relaçäo a meta da eficácia