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1.
J Surg Res ; 257: 529-536, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32919343

RESUMO

BACKGROUND: Previous investigation has shown that the combined predictive value of white blood cell count and ultrasound (US) findings to be superior to either alone in children with suspected appendicitis. The purpose of this study was to evaluate the impact of a diagnostic clinical pathway (DCP) leveraging the combined predictive value of these tests on computed tomography (CT) utilization and resource utilization. METHODS: Retrospective cohort study comparing 8 mo of data before DCP implementation to 18 mo of data following implementation. The pathway incorporated decision-support for disposition (operative intervention, observation, or further cross-sectional imaging) based on the combined predictive value of laboratory and US data (stratifying patients into low, moderate, and high-risk groups). Study measures included CT and magnetic resonance imaging utilization, imaging-related cost, time to appendectomy, and negative appendectomy rate. RESULTS: Ninety-seven patients in the preintervention period were compared with 319 patients in the postintervention period. Following DCP implementation, CT utilization decreased by 86% (21% versus 3%, P < 0.001). Mean time to appendectomy decreased from 8.5 to 7.2 h (P < 0.001), and the negative appendectomy rate remained unchanged (5% versus 4%, P = 0.54). Magnetic resonance imaging utilization increased following pathway implementation (1% versus 7%, P = 0.02); however, median imaging-related cost was significantly lower in the postimplementation period ($283/case to $270/case, P = 0.002) CONCLUSIONS: In children with suspected appendicitis, implementation of a DCP leveraging the combined predictive value of white blood cell and US data was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/diagnóstico por imagem , Procedimentos Clínicos/estatística & dados numéricos , Exposição à Radiação/prevenção & controle , Ultrassonografia , Adolescente , Apendicite/sangue , Apendicite/cirurgia , Criança , Feminino , Humanos , Contagem de Leucócitos , Imagem por Ressonância Magnética/estatística & dados numéricos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Tempo para o Tratamento , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/estatística & dados numéricos , Adulto Jovem
2.
Clin Dermatol ; 38(2): 254-256, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32513405

RESUMO

With the increasing costs of health care, clinical practice guidelines (CPGs) have gained a crucial role in standardizing care, protecting health resources, and assuring their accurate distribution by improving health outcomes. Influencing the outcome of a guideline (by one of the authors, members of the specialty board, or an influential member of the specialty) could result in inappropriate expense to the health care system and profits to investors of the medications/tests/devices that were recommended. CPGs are statements based on a systematic review of the existing scientific evidence, developed by knowledgeable experts, that have the potential to reduce inappropriate practice variation, enhance research, and improve health care quality and safety.1.


Assuntos
Conflito de Interesses , Guias de Prática Clínica como Assunto , Garantia da Qualidade dos Cuidados de Saúde , Qualidade da Assistência à Saúde , Confiança , Assistência à Saúde/economia , Assistência à Saúde/normas , Custos de Cuidados de Saúde , Recursos em Saúde , Humanos , Avaliação de Resultados em Cuidados de Saúde , Procedimentos Desnecessários/economia
3.
Ann Vasc Surg ; 67: 208-212, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32439530

RESUMO

BACKGROUND: Overtreatment and overuse of resources are leading causes of rising health care costs. Identification and elimination process of low value services is important in reducing such costs. At many institutions it is routine to send excised plaque after carotid endarterectomy (CEA) for pathology evaluation. With more than 140,000 CEAs performed annually in the United States, this represents an opportunity for potential cost savings. We set out to examine the cost and clinical use of pathology evaluation of plaque after CEA. METHODS: We performed a retrospective review of patients undergoing CEA at a single institution from 2016 to 2019. Patients were excluded if they had a prolonged postoperative length of stay or if they had a preoperative stroke. Demographics, perioperative outcomes, and billing costs were recorded. RESULTS: We identified 82 total CEAs, of which 42 were excluded according to the aforementioned exclusion criteria. We reviewed 40 CEAs. Mean age of this cohort was 67.2 (±8.3) years. Most (72.5%) were asymptomatic at the time of admission, whereas 27.5% presented with a transient ischemic attack. Mean postoperative length of stay was 1.8 days. The primary insurers were 39.5% private, 39.5% Medicare, and 21.1% Medicaid. Mean total charges for the hospitalization were $83,367 (±$42,874). Of this total, professional fees were $3,512 (±$980) and facility fees were $80,395 (±$42,886). Mean pathology charges were $285 (±$88). The pathology professional fee was $61 (±$27), which represented 1.82% (±0.88) of the professional costs. Reimbursement for the facility pathology charge was $229 (±$57) and for the professional pathology charge was $25 (±$14). All plaque samples were submitted for gross examination and hematoxylin and eosin staining. The correlation rate for the clinical and pathologic diagnosis was 100%. The pathology reports simply read "atherosclerotic plaque" and "calcific plaque" in 32.5% and 45% of samples. For the remaining plaques, 12.5% and 10% of reports also noted fibrosis and degenerative changes, respectively. There were no clinical implications or decisions made based on the pathology reports. Cost of pathology evaluation was on average $285, with an average reimbursement of $235. With 140,000 CEAs done annually, this represents a potential $32.9-$39.9 million saved to the health care system. CONCLUSIONS: Pathology evaluation of carotid plaque incurs significant costs to the health care system with no clear value for the postoperative care of the patient. Hospital policy regarding mandatory pathologic examination and surgeon preferences regarding plaque analysis should be more closely examined.


Assuntos
Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/economia , Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas/economia , Custos Hospitalares , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Placa Aterosclerótica , Cuidados Pós-Operatórios/economia , Idoso , Biópsia/economia , Artérias Carótidas/patologia , Doenças das Artérias Carótidas/patologia , Redução de Custos , Análise Custo-Benefício , Feminino , Humanos , Reembolso de Seguro de Saúde/economia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Desnecessários/economia
5.
Med Care ; 58(4): 314-319, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32197027

RESUMO

BACKGROUND: Community health worker (CHW) programs take many forms and have been shown to be effective in improving health in several contexts. The extent to which they reduce unnecessary care is not firmly established. OBJECTIVES: This study estimates the number of hospitalizations and emergency department (ED) visits that would need to be avoided to recoup program costs for a CHW program that addressed both medical and social needs. RESEARCH DESIGN: A programmatic cost analysis is conducted using 6 different categories: personnel, training, transportation, equipment, facilities, and administrative costs. First, baseline costs are established for the current program and then estimate the number of avoided ED visits or hospitalizations needed to recoup program costs using national average health care estimates for different patient populations. MEASURES: Data on program costs are taken from administrative program records. Estimates of ED visit and hospitalization costs (or charges in some cases) are taken from the literature. RESULTS: To fully offset program costs, each CHW would need to work with their annual caseload of 150 participants to avoid almost 50 ED visits collectively. If CHW participants also avoided 2 hospitalizations, the number of avoided ED visits needed to offset costs reduces to about 34. CONCLUSIONS: Estimates of avoided visits needed to reach the break-even point are consistent with the literature. The analysis does not take other outcomes of the program from the clients' or workers' perspectives into account, so it is likely an upper bound on the number of avoided visits needed to be cost-effective.


Assuntos
Serviços de Saúde Comunitária/economia , Agentes Comunitários de Saúde/economia , Serviço Hospitalar de Emergência/economia , Hospitalização/economia , Procedimentos Desnecessários/economia , Custos e Análise de Custo , Humanos , Kansas
6.
JAMA Netw Open ; 3(2): e1921202, 2020 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-32058553

RESUMO

Importance: Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. Objective: To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. Design, Setting, and Participants: This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. Main Outcomes and Measures: Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. Results: Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). Conclusions and Relevance: The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.


Assuntos
Redução Fechada , Fraturas do Rádio , Procedimentos Desnecessários , Criança , Pré-Escolar , Redução Fechada/economia , Redução Fechada/estatística & dados numéricos , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Hipnóticos e Sedativos , Masculino , Pais , Aceitação pelo Paciente de Cuidados de Saúde , Fraturas do Rádio/economia , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/cirurgia , Estudos Retrospectivos , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/estatística & dados numéricos
7.
Am J Clin Pathol ; 153(3): 328-332, 2020 02 08.
Artigo em Inglês | MEDLINE | ID: mdl-31665226

RESUMO

OBJECTIVES: To determine the impact of an electronic intervention designed to block duplicate constitutional genetic tests. METHODS: We constructed, implemented, and studied an electronic intervention that stopped duplicate genetic tests. The activation frequency, types of tests affected, and cost savings achieved with this intervention were determined. The frequency and justification of override requests were also studied. RESULTS: This intervention stopped 710 unnecessary duplicate genetic tests over a 3-year period and saved $98,596. The tests with the highest numbers of alerts were those used for screening presurgical or transplant patients and were commonly part of an order set or test panel. Most override requests were justified because of the lack of exclusion codes in the initial programming. CONCLUSIONS: Electronic interventions that stop duplicate genetic testing, if properly constructed, can reduce waste, save health care dollars, and facilitate patient care by directing the provider to a test that has already been performed.


Assuntos
Redução de Custos , Testes Genéticos/economia , Procedimentos Desnecessários/economia , Sistemas de Apoio a Decisões Clínicas , Humanos
8.
BMC Health Serv Res ; 19(1): 983, 2019 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-31864352

RESUMO

BACKGROUND: The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder. METHODS: The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS. RESULTS: The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed. CONCLUSIONS: The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.


Assuntos
Clínicos Gerais , Dor Lombar/diagnóstico por imagem , Programas Nacionais de Saúde/economia , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Austrália , Análise Custo-Benefício , Humanos , Atenção Primária à Saúde , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/economia , Procedimentos Desnecessários/economia
9.
N Z Med J ; 132(1488): 11-20, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31851657

RESUMO

AIM: Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS: The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS: There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION: The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.


Assuntos
Sobremedicalização/prevenção & controle , Procedimentos Desnecessários/estatística & dados numéricos , Urinálise/estatística & dados numéricos , Adulto , Educação em Saúde , Humanos , Sobremedicalização/economia , Sobremedicalização/estatística & dados numéricos , Nova Zelândia , Procedimentos Desnecessários/economia , Urinálise/economia , Urinálise/métodos , Infecções Urinárias/diagnóstico , Infecções Urinárias/microbiologia
10.
Pediatr Emerg Care ; 35(11): 791-798, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31688798

RESUMO

OBJECTIVE: This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. METHODS: We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. RESULTS: For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. CONCLUSION: A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.


Assuntos
Instituições de Assistência Ambulatorial/normas , Bronquiolite/diagnóstico , Prestação Integrada de Cuidados de Saúde/economia , Serviço Hospitalar de Emergência/normas , Instituições de Assistência Ambulatorial/economia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Bronquiolite/economia , Prestação Integrada de Cuidados de Saúde/normas , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Lactente , Estudos Longitudinais , Masculino , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Melhoria de Qualidade , Procedimentos Desnecessários/economia
11.
BMC Health Serv Res ; 19(1): 707, 2019 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-31707993

RESUMO

BACKGROUND: It is unknown to what extent Choosing Wisely recommendations about income-generating treatments apply to members of the society generating the recommendations. The primary aim of this study is to determine the proportion of Choosing Wisely recommendations targeting income-generating treatments, and whether recommendations from professional societies on income-generating treatments are more likely to target members or non-members. The secondary aim is to determine the prevalence of qualified statements, and whether qualified statements are more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members. METHODS: We performed a content analysis of all Choosing Wisely recommendations, with data extracted from Choosing Wisely websites. Two researchers coded recommendations as test or treatment-based, for or against a procedure, containing qualified statements, income-generating and applying to members. Disagreements were resolved by discussion or consultation with a third researcher. A Chi-squared test evaluated whether society recommendations on income-generating treatments were more likely to target members or non-members; and whether qualified statements were more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members. RESULTS: We found 1293 Choosing Wisely recommendations (48.3% tests and 48.6% treatments). Ninety-eight treatment recommendations targeted income-generating treatments (17.8%), and recommendations on income-generating treatments were less likely to target members compared to non-members (15.6% vs. 40.4%, p < 0.001). Nearly half of all recommendations were qualified (41.9%), with a similar proportion of recommendations targeting income-generating and non-income-generating treatments that apply to members containing qualified statements (49.4% vs. 42.0%, p = 0.23). CONCLUSIONS: Many societies provide Choosing Wisely recommendations that minimise impact on their own members. Only 20% of treatment recommendations target income-generating treatments, and of these recommendations mostly target non-members. Many recommendations are also qualified. Increasing the number of recommendations from societies that are unqualified and target member clinicians responsible for de-implementation of low-value and costly treatments should be a priority.


Assuntos
Comportamento de Escolha , Renda , Procedimentos Desnecessários/economia , Saúde Global/economia , Política de Saúde/economia , Humanos , Pobreza , Guias de Prática Clínica como Assunto , Sociedades Médicas/economia
12.
BMJ Open ; 9(10): e029760, 2019 10 07.
Artigo em Inglês | MEDLINE | ID: mdl-31594878

RESUMO

OBJECTIVE: There has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of patients. So far, there is little evidence of effective strategies to reduce this overtesting in general practice. Therefore, the aim of this qualitative study was to explore the barriers and facilitators for reducing the number of (unnecessary) vitamin D and B12 laboratory tests ordered. DESIGN AND SETTING: This qualitative study, based on a grounded theory design, used semistructured interviews among general practitioners (GPs) and patients from two primary care networks (147 GPs, 195 000 patients). These networks participated in the Reducing Vitamin Testing in Primary Care Practice (REVERT) study, a clustered randomized trial comparing two de-implementation strategies to reduce test ordering in primary care in the Netherlands. PARTICIPANTS: Twenty-one GPs, with a maximum of 1 GP per practice who took part in the REVERT study, and 22 patients (who were invited by their GP during vitamin-related consultations) were recruited, from which 20 GPs and 19 patients agreed to participate in this study. RESULTS: The most important factor hampering vitamin-test reduction programmes is the mismatch between patients and medical professionals regarding the presumed appropriate indications for testing for vitamin D and B12. In contrast, the most important facilitator for vitamin-test reduction may be updating GPs' knowledge about test indications and their awareness of their own testing behaviour. CONCLUSION: To achieve a sustainable reduction in vitamin testing, guidelines with clear and uniform recommendations on evidence-based indications for vitamin testing, combined with regular (individual) feedback on test-ordering behaviour, are needed. Moreover, the general public needs access to clear and reliable information on vitamin testing. Further research is required to measure the effect of these strategies on the number of vitamin test requests. TRIAL REGISTRATION NUMBER: WAG/mb/16/039555.


Assuntos
Técnicas de Laboratório Clínico , Medicina Geral , Sobremedicalização/prevenção & controle , Vitamina B 12/sangue , Vitamina D/sangue , Atitude do Pessoal de Saúde , Técnicas de Laboratório Clínico/economia , Técnicas de Laboratório Clínico/métodos , Análise por Conglomerados , Feminino , Medicina Geral/economia , Medicina Geral/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Avaliação de Resultados em Cuidados de Saúde , Padrões de Prática Médica , Pesquisa Qualitativa , Procedimentos Desnecessários/economia
13.
JAMA Netw Open ; 2(10): e1913325, 2019 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-31617925

RESUMO

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.


Assuntos
Achados Incidentais , Medicina Interna/estatística & dados numéricos , Assistência ao Paciente/estatística & dados numéricos , Médicos/estatística & dados numéricos , Adulto , Estudos Transversais , Técnicas de Apoio para a Decisão , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Medicina Interna/métodos , Masculino , Pessoa de Meia-Idade , Estresse Ocupacional/etiologia , Assistência ao Paciente/efeitos adversos , Assistência ao Paciente/psicologia , Médicos/psicologia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/estatística & dados numéricos , Inquéritos e Questionários , Procedimentos Desnecessários/efeitos adversos , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/psicologia
14.
JAMA ; 322(15): 1501-1509, 2019 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-31589283

RESUMO

Importance: The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains. Objectives: To estimate current levels of waste in the US health care system in 6 previously developed domains and to report estimates of potential savings for each domain. Evidence: A search of peer-reviewed and "gray" literature from January 2012 to May 2019 focused on the 6 waste domains previously identified by the Institute of Medicine and Berwick and Hackbarth: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. For each domain, available estimates of waste-related costs and data from interventions shown to reduce waste-related costs were recorded, converted to annual estimates in 2019 dollars for national populations when necessary, and combined into ranges or summed as appropriate. Findings: The review yielded 71 estimates from 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature. Computations yielded the following estimated ranges of total annual cost of waste: failure of care delivery, $102.4 billion to $165.7 billion; failure of care coordination, $27.2 billion to $78.2 billion; overtreatment or low-value care, $75.7 billion to $101.2 billion; pricing failure, $230.7 billion to $240.5 billion; fraud and abuse, $58.5 billion to $83.9 billion; and administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: failure of care delivery, $44.4 billion to $97.3 billion; failure of care coordination, $29.6 billion to $38.2 billion; overtreatment or low-value care, $12.8 billion to $28.6 billion; pricing failure, $81.4 billion to $91.2 billion; and fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion. Conclusions and Relevance: In this review based on 6 previously identified domains of health care waste, the estimated cost of waste in the US health care system ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste, excluding savings from administrative complexity, ranged from $191 billion to $286 billion, representing a potential 25% reduction in the total cost of waste. Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in US health care expenditures.


Assuntos
Redução de Custos/economia , Assistência à Saúde/economia , Gastos em Saúde , Técnicas de Laboratório Clínico/economia , Assistência à Saúde/organização & administração , Custos de Medicamentos , Fraude/economia , Humanos , Sobremedicalização/economia , Sobremedicalização/prevenção & controle , Visita a Consultório Médico/economia , Falha de Tratamento , Estados Unidos , Procedimentos Desnecessários/economia
15.
Intern Med J ; 49(9): 1168-1170, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31507043

RESUMO

Interval laboratory investigations are necessary for monitoring chronic diseases. However, testing too frequently may not be beneficial clinically and can be considered low-value care. We examined the frequency of glycosylated haemoglobin, lipids, iron panels (serum iron, ferritin, transferrin, iron binding) thyroid function (free T4 and thyroid stimulating hormone) and 25-OH vitamin D tests in a 1290-bed tertiary hospital in Singapore. All tests done over a 20-month period (January 2016 to August 2017) were retrieved from the laboratory database. Of the 275 565 tests done for 115 971 patients, 5.2% were repeat tests done at intervals shorter than the minimum retesting interval, as defined by the Royal College of Pathologist and Irish Guidelines on the Use of the Laboratory. Using the Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule, we estimated a cost burden of US$222 096 per year. Strategies to reduce unnecessary repetitive testing can result in significant cost savings.


Assuntos
Doença Crônica/economia , Serviços de Laboratório Clínico , Centros de Atenção Terciária/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Redução de Custos , Humanos , Laboratórios , Estudos Retrospectivos , Singapura , Procedimentos Desnecessários/economia
16.
Injury ; 50(11): 2093-2096, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31383354

RESUMO

INTRODUCTION: Common practice in orthopedic surgery is to obtain postoperative radiographs to evaluate for healing or complications. Images obtained in the post-anesthesia care unit (PACU) have not been shown to positively impact patient care. This study plans to evaluate the clinical utility and cost-effectiveness of PACU postoperative radiographs following tibial plateau open reduction and internal fixation (ORIF). METHODS: Data from 211 patients who underwent a tibial plateau ORIF over a 5-year period at a single institution were retrospectively reviewed to determine if a patient received a postoperative radiograph in the PACU. Radiograph and clinical notes were reviewed to determine if postoperative radiograph resulted in management changes. Radiograph charges were calculated using CPT codes. RESULTS: A total of 142 of 211 patients (67.3%) who underwent tibial plateau ORIF received a postoperative radiograph while in the PACU. The majority of the radiographs had normal findings (88.7%). Of the 142 patients with postoperative imaging, subsequent management changes occurred for only one patient (0.7%). In this case, an incidental foot fracture was found which resulted in further CT imaging to assess the fracture. Other abnormal radiograph readings (11.3%) were generally due to incidental, chronic findings that did not require management changes. The average postoperative radiograph cost was $433.55 per patient, totaling $91,480 for 142 patients over a 5-year period. CONCLUSIONS: Routine postoperative radiographs following tibial plateau ORIF resulted in minimal management change patients in this series. The substantial cost of postoperative radiographs yielding little clinical utility suggests the use of routine PACU imaging following tibial plateau ORIF should be discontinued. Imaging would only be indicated in situations where intraoperative complications are suspected, thus reducing unnecessary imaging and patient cost.


Assuntos
Traumatismos do Joelho/cirurgia , Articulação do Joelho/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Procedimentos Desnecessários , Adulto , Continuidade da Assistência ao Paciente/economia , Feminino , Fixação Interna de Fraturas , Custos de Cuidados de Saúde , Humanos , Traumatismos do Joelho/diagnóstico por imagem , Traumatismos do Joelho/fisiopatologia , Articulação do Joelho/fisiopatologia , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Radiografia/economia , Radiografia/métodos , Estudos Retrospectivos , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/fisiopatologia , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/métodos
17.
Iowa Orthop J ; 39(1): 57-61, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31413675

RESUMO

Background: Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs. Methods: We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was "unnecessary," defined as a Cobb angle <20 degrees. Patient and provider costs were estimated. Patient costs included transportation expenses and parental lost wages. Provider costs included orthopaedic evaluation, diagnostic imaging, and overhead. Transportation costs were based on actual driving distances and the Internal Revenue Service standard mileage rate. Parental lost wages and the cost of evaluation by an orthopaedic surgeon were calculated with time-driven activity-based costing. Diagnostic imaging costs were calculated with a traditional activity-based costing methodology. Results: Three hundred thirty-seven patients were included. The prevalence of unnecessary referrals was 39% (n=131). 17% of patients had a Cobb angle <10 degrees and 22% had a Cobb angle between 10-20 degrees. Males were more likely to be referred unnecessarily than females, 49% to 35% (p=0.02) as were non-Caucasians (54% vs. 37%, p=0.04). No difference was noted related to source of insurance (private or public, p=0.18). The average total cost of an unnecessary referral was $782.13 USD, including $231.07 in patient costs and $551.06 in provider costs. Conclusions: Nearly 40% of all referrals for AIS were deemed unnecessary. The average cost of an unnecessary referral is approximately $780, imposing significant costs on both patients and the healthcare system.Level of Evidence: III.


Assuntos
Custos de Cuidados de Saúde , Radiografia/economia , Encaminhamento e Consulta/economia , Escoliose/diagnóstico por imagem , Procedimentos Desnecessários/economia , Adolescente , Instituições de Assistência Ambulatorial , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Hospitais Universitários , Humanos , Masculino , Radiografia/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Escoliose/cirurgia , Estados Unidos , Procedimentos Desnecessários/estatística & dados numéricos
18.
Health Aff (Millwood) ; 38(8): 1351-1357, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31381388

RESUMO

Low-value care is the provision of procedures and treatments that provide little or no benefit to patients while increasing the cost of health care. This study examined the provision of low-value care in the Military Heath System (MHS), comparing care delivered in civilian health care facilities (purchased care) to care delivered in Department of Defense-controlled health care facilities (direct care). We used 2014 TRICARE claims data to evaluate the provision of nineteen previously developed measures of low-value care, including diagnostic, screening, and monitoring tests and therapeutic procedures. Of these, six measures appeared more frequently in direct care, while eleven measures appeared more frequently in purchased care-which may reflect the outsourcing of specialist services from the former to the latter. Magnetic resonance imaging for low back pain emerged as the most common low-value service in both care environments and could represent a target for future interventions. As the MHS and the United States increasingly focus on value-based care, the identification of low-value services accompanied by efforts to reduce such inefficient practices could provide greater quality of care at a lower cost.


Assuntos
Serviços de Saúde Militar , Garantia da Qualidade dos Cuidados de Saúde , Procedimentos Desnecessários/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Serviços de Saúde Militar/economia , Serviços de Saúde Militar/normas , Militares/estatística & dados numéricos , Qualidade da Assistência à Saúde , Estados Unidos , Procedimentos Desnecessários/economia , Adulto Jovem
19.
Health Econ ; 28(10): 1166-1178, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31309648

RESUMO

Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed-effects specification to address selection, it is estimated that the switch to capitation leads to a short-run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.


Assuntos
Serviços de Laboratório Clínico/normas , Aceitação pelo Paciente de Cuidados de Saúde , Atenção Primária à Saúde , Mecanismo de Reembolso/organização & administração , Capitação/organização & administração , Bases de Dados Factuais , Feminino , Humanos , Masculino , Ontário , Procedimentos Desnecessários/economia
20.
Int J Health Plann Manage ; 34(4): e1437-e1447, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31271228

RESUMO

INTRODUCTION: Back pain is a common global disorder and magnetic resonance imaging (MRI) is one method of assessing its cause. The lack of official and general clinical guidelines is the cause of inadequate supervision of lumbar MRI prescriptions. The goal of this research was to analyze inappropriate lumbar MRI prescriptions and the resulting economic burden on individuals. METHOD: This is a descriptive-analytical study carried out on a sample of 614 patients who visited four hospitals in Tehran. The appropriateness or inappropriateness of the MRI prescriptions was determined using clinical guidelines and a questionnaire based on previous studies. The economic burden created by inappropriate prescriptions for MRIs was determined after calculating the total direct and indirect costs. FINDINGS: The total MRI prescription cost paid by the study sample was $26 071, and the cost of inappropriate prescriptions was $10 310. The MRI prescription rate had a significant relationship with gender, age, education, employment, primary insurance type, and supplemental health insurance. CONCLUSION: The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.


Assuntos
Dor nas Costas/diagnóstico por imagem , Imagem por Ressonância Magnética/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor nas Costas/economia , Efeitos Psicossociais da Doença , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Região Lombossacral/diagnóstico por imagem , Imagem por Ressonância Magnética/economia , Masculino , Pessoa de Meia-Idade , Procedimentos Desnecessários/economia
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