Definition of low-value care in a low-risk preoperative population: A scoping review.

RATIONALE: Preoperative care is one of the main areas in which to address low-value care. A detailed definition of what low-value care is in this period of the surgical care journey paves the way for new scientific research, clinical improvements, and reduction of unnecessary costs in this field. AIMS AND OBJECTIVE: To identify how low-value care in low-risk preoperative population has been defined in the scientific literature and propose a low-value care framework with potential consequences in this setting. METHODS: Scoping review of theoretical studies and peer-reviewed papers, including reviews, commentaries, or expert opinions, were considered eligible for inclusion. The following databases were consulted: MEDLINE (via PubMed), EMBASE, and SCOPUS (from inception to July 24, 2021), using a structured search with the keywords "low value care", "clinical waste", "preoperative", and "elective procedures." Two independent reviewers performed study selection and data extraction. The definition of low-value care in the preoperative period and their consequences were described after extracting previous low-value care concepts and summarising the contents. Also, a visual framework was built with this information. RESULTS: From 1519 publications identified in the initial searches, 22 underwent full-text assessment, and 11 conceptual studies were included in the review. A total of four studies (36%) presented a general low-value care definition, and all studies report some situations considered low-value care in the preoperative field of low-risk surgeries. The most common example of preoperative low-value care, listed in nine studies (81%), was having asymptomatic patients undergo screening tests before surgery. The main clinical and nonclinical consequences of low-value care in the preoperative phase included false-positive results from exams as well as psychological distress, increased costs, and delay in surgery. CONCLUSIONS: Revisiting and integrating previous definitions of low-value care in low-risk surgery into a scoping review is a starting point for de-implementing unnecessary care and promoting improvements in surgical pathways.

Using Patient-Reported Outcome Measures to Evaluate Care for Patients With Inflammatory Chronic Rheumatic Disease.

OBJECTIVES: Few countries integrate patient-reported outcome measures (PROMs) in routine performance assessment and those that do focus on elective surgery. This study addresses the challenges of using PROMs to evaluate care in chronic conditions. We set out a modeling strategy to assess the extent to which changes over time in self-reported health status by patients with inflammatory chronic rheumatic disease are related to their biological drug therapy and rheumatology center primarily responsible for their care. METHODS: Using data from the Portuguese Register of Rheumatic Diseases, we assess health status using the Health Assessment Questionnaire-Disability Index for rheumatic patients receiving biological drugs between 2000 and 2017. We specify a fixed-effects model using the least squares dummy variables estimator. RESULTS: Patients receiving infliximab or rituximab report lower health status than those on etanercept (the most common therapy) and patients in 4 of the 26 rheumatology centers report higher health status than those at other centers. CONCLUSIONS: PROMs can be used for those with chronic conditions to provide the patient's perspective about the impact on their health status of the choice of drug therapy and care provider. Care for chronic patients might be improved if healthcare organizations monitor PROMs and engage in performance assessment initiatives on a routine basis.

Development of the HIV360 international core set of outcome measures for adults living with HIV: A consensus process.

OBJECTIVES: HIV outcomes centre primarily around clinical markers with limited focus on patient-reported outcomes. With a global trend towards capturing the outcomes that matter most to patients, there is agreement that standardizing the definition of value in HIV care is key to their incorporation. This study aims to address the lack of routine, standardized data in HIV care. METHODS: An international working group (WG) of 37 experts and patients, and a steering group (SG) of 18 experts were convened from 14 countries. The project team (PT) identified outcomes by conducting a literature review, screening 1979 articles and reviewing the full texts of 547 of these articles. Semi-structured interviews and advisory groups were performed with the WG, SG and people living with HIV to add to the list of potentially relevant outcomes. The WG voted via a modified Delphi process - informed by six Zoom calls - to establish a core set of outcomes for use in clinical practice. RESULTS: From 156 identified outcomes, consensus was reached to include three patient-reported outcomes, four clinician-reported measures and one administratively reported outcome; standardized measures were included. The WG also reached agreement to measure 22 risk-adjustment variables. This outcome set can be applied to any person living with HIV aged > 18 years. CONCLUSIONS: Adoption of the HIV360 outcome set will enable healthcare providers to record, compare and integrate standardized metrics across treatment sites to drive quality improvement in HIV care.

Inhaler Review in Older Adults with Asthma or COPD: A Cost-Effectiveness Study and a Perspective in Portugal.

OBJECTIVES: Older patients with asthma or chronic obstructive pulmonary disease are particularly susceptible to exacerbations that may be associated with incorrect use of inhalers. Educational programs with inhaler technique review seem to be effective, but no studies have addressed their cost-effectiveness in older adult patients. The objective was to perform a cost-effectiveness analysis of education programs in older patients and estimate the cost benefit of applying such a program in Portugal. DESIGN: We developed a decision tree analysis from a healthcare perspective, according to intervention costs and the exacerbation rates and costs described in a previous meta-analysis. A sensitivity analysis of worst and best case scenarios was performed to estimate thresholds for intervention affordable limits, as well as cost-saving estimations and incremental cost-effectiveness ratios (ICERs) for a Portuguese scenario. SETTING AND PARTICIPANTS: We estimated cost-effectiveness thresholds applicable in all settings and performed a sensitivity analysis of a theoretical intervention model in all patients including an inhaler technique review at an annual appointment with a doctor and a nurse. RESULTS: In the best case scenario, the intervention affordable budget could be up to almost 1800€ (US $1585.24) per patient per year. Mean intervention-associated savings in Portugal would be 311.88€ (US $274.68) per patient per year, representing annual savings up to €131 million (US $150 million) for the whole health system, already including intervention costs. ICERs for Portugal vary between 93.73€ (US $82.55) and 437.43€ (US $385.25) per exacerbation avoided. CONCLUSION: A model of an intervention program with an inhaler technique review in older adult patients suggests that this intervention is cost-effective and can generate significant savings. J Am Geriatr Soc 1-7, 2019.