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1.
J Gen Intern Med ; 33(8): 1268-1275, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29845468

RESUMO

BACKGROUND: Physicians "purchase" many health care services on behalf of patients yet remain largely unaware of the costs of these services. Electronic health record (EHR) cost displays may facilitate cost-conscious ordering of health services. OBJECTIVE: To determine whether displaying hospital lab and imaging order costs is associated with changes in the number and costs of orders placed. DESIGN: Quasi-experimental study. PARTICIPANTS: All patients with inpatient or observation encounters across a multi-site health system from April 2013 to October 2015. INTERVENTION: Display of order costs, based on Medicare fee schedules, in the EHR for 1032 lab tests and 1329 imaging tests. MAIN MEASURES: Outcomes for both lab and imaging orders were (1) whether an order was placed during a hospital encounter, (2) whether an order was placed on a given patient-day, (3) number of orders placed per patient-day, and (4) cost of orders placed per patient-day. KEY RESULTS: During the lab and imaging study periods, there were 248,214 and 258,267 encounters, respectively. Cost display implementation was associated with a decreased odds of any lab or imaging being ordered during the encounter (lab adjusted odds ratio [AOR] = 0.97, p = .01; imaging AOR = 0.97, p < .001), a decreased odds of any lab or imaging being ordered on a given patient-day (lab AOR = 0.95, p < .001; imaging AOR = 0.97, p < .001), a decreased number of lab or imaging orders on patient-days with orders (lab adjusted count ratio = 0.93, p < .001; imaging adjusted count ratio = 0.98, p < .001), and a decreased cost of lab orders and increased cost of imaging orders on patient-days with orders (lab adjusted cost ratio = 0.93, p < .001; imaging adjusted cost ratio = 1.02, p = .003). Overall, the intervention was associated with an 8.5 and 1.7% reduction in lab and imaging costs per patient-day, respectively. CONCLUSIONS: Displaying costs within EHR ordering screens was associated with decreases in the number and costs of lab and imaging orders.


Assuntos
Técnicas de Laboratório Clínico/economia , Diagnóstico por Imagem/economia , Honorários e Preços , Padrões de Prática Médica/economia , Centros Médicos Acadêmicos/economia , Centros Médicos Acadêmicos/estatística & dados numéricos , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino
2.
Postgrad Med J ; 92(1092): 592-6, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27033861

RESUMO

AIM: Cost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have had mixed results. We sought to assess resident physician cost awareness following sustained visual display of costs into electronic health record (EHR) order entry screens. STUDY DESIGN: We completed a preintervention and postintervention web-based survey. Participants were physicians in internal medicine, paediatrics, combined medicine and paediatrics, obstetrics and gynaecology, emergency medicine, and orthopaedic surgery at one tertiary co are academic medical centre. Costs were displayed in the EHR for 1032 unique laboratory orders. We measured attitudes towards costs and estimates of Medicare reimbursement rates for 11 common laboratory and imaging tests. RESULTS: We received 209 survey responses during the preintervention period (response rate 71.1%) and 194 responses during the postintervention period (response rate 66.0%). The proportion of residents that agreed/strongly agreed that they knew the costs of tests they ordered increased after the cost display (8.6% vs 38.2%; p<0.001). Cost estimation accuracy among residents increased after the cost display from 24.0% to 52.4% for laboratory orders (p<0.001) and from 37.7% to 49.6% for imaging orders (p<0.001). CONCLUSIONS: Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.


Assuntos
Atitude do Pessoal de Saúde , Técnicas de Laboratório Clínico/economia , Custos de Cuidados de Saúde , Internato e Residência , Conhecimento , Corpo Clínico Hospitalar/educação , Registros Eletrônicos de Saúde , Medicina de Emergência/educação , Ginecologia/educação , Humanos , Medicina Interna/educação , Medicare , Obstetrícia/educação , Ortopedia/educação , Pediatria/educação , Mecanismo de Reembolso , Estados Unidos
3.
J Ultrasound Med ; 35(12): 2665-2673, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27821652

RESUMO

OBJECTIVES: To determine (1) how often routine screening fetal anatomic sonography fails to completely visualize fetal anatomy; (2) the proportion of women with incomplete ultrasound examinations who are recommended for repeat screening and then undergo repeat sonography; and (3) how often abnormal fetal anatomy is detected on repeat sonography. METHODS: We conducted a retrospective cohort study at a high-volume academic obstetric ultrasound center. Participants were 16,300 women at 17 through 21 weeks' gestation with a singleton pregnancy presenting for screening anatomic sonography between January 2009 and December 2013. Main outcome measures were (1) incomplete visualization of anatomy at initial screening sonography; (2) among women with incomplete but otherwise normal initial screening ultrasound examinations, recommendation for and performance of repeat sonography; and (3) among women undergoing repeat sonography, discovery of abnormal fetal anatomy within anatomic components that were previously incompletely visualized. RESULTS: The mean maternal age ± SD was 30.8 ± 6.3 years, and the mean gestational age was 18.8 ± 1.0 weeks. Among 16,300 initial screening ultrasound examinations, 2157 (13.2%) had incomplete visualization of fetal anatomy. Of those women eligible for follow-up, 91.5% were recommended for repeat screening, of whom 92.8% had a subsequent examination. Of 1560 repeat screening ultrasound examinations, 8 (0.5%) showed an abnormality in the components of anatomy that were previously visualized incompletely. CONCLUSIONS: In this large single-center study, incomplete visualization was common in screening fetal anatomic ultrasound examinations. Recommendations for repeat imaging were nearly universal, but abnormal fetal anatomy was infrequently discovered on repeat screening.


Assuntos
Anormalidades Congênitas/diagnóstico por imagem , Ultrassonografia Pré-Natal/métodos , Ultrassonografia Pré-Natal/estatística & dados numéricos , Adulto , Estudos de Coortes , Feminino , Humanos , Gravidez , Reprodutibilidade dos Testes , Estudos Retrospectivos
4.
JAMA ; 319(24): 2558, 2018 06 26.
Artigo em Inglês | MEDLINE | ID: mdl-29946715
5.
BMJ Open ; 9(4): e024143, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-31048427

RESUMO

OBJECTIVE: To determine if preterm birth, defined as gestational age <37 weeks, is lower for women living in counties with higher well-being, after accounting for known individual risk factors. DESIGN: Cross-sectional study of all US births in 2011. PARTICIPANTS: We obtained birth data from the National Center for Health Statistics which included 3 938 985 individuals. MAIN OUTCOMES MEASURES: Primary outcome measure was maternal risk of preterm delivery by county; primary independent variable was county-level well-being as measured by the Gallup-Sharecare Well-Being Index (WBI). RESULTS: Women living in counties with higher population well-being had a lower rate of preterm delivery. The rate of preterm birth in counties in the lowest WBI quintile was 13.1%, while the rate of preterm birth in counties in the highest WBI quintile was 10.9%. In the model adjusted for maternal risk factors (age, race, Hispanic ethnicity, smoking status, timing of initiation of prenatal visits, multiparity, maternal insurance payer), the association was slightly attenuated with an absolute difference of 1.9% (95% CI 1.7% to 2.1%; p<0.001). CONCLUSIONS: Pregnant women who live in areas with higher population well-being have lower risk of preterm birth, even after accounting for individual risk factors.


Assuntos
Nascimento Prematuro/epidemiologia , Fatores Socioeconômicos , Adulto , Estudos Transversais , Feminino , Idade Gestacional , Humanos , Gravidez , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
6.
J Gastrointest Surg ; 11(12): 1647-52; discussion 1652-3, 2007 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17906906

RESUMO

INTRODUCTION: The anal transition zone (ATZ) after ileal pouch anal anastomosis (IPAA) for ulcerative colitis is considered at risk for dysplasia and persistent or recurrent disease activity. The long-term fate of the ATZ and the effects of histologic changes on defecatory function are not well-known. METHODS: To evaluate the inflammatory and preneoplastic changes of the ATZ in patients without preoperative dysplasia, yearly biopsies of the ATZ were obtained and functional results recorded on a questionnaire/diary. Histologic changes were correlated with simultaneous assessment of defecatory function. RESULTS: Between 1992 and 2006, 225 patients underwent a stapled IPAA. A total of 238 successful biopsies of the ATZ were performed. There was no dysplasia found. Acute inflammation was noted in 4.6%, chronic inflammation in 84.9%, and normal mucosa in 10.5% of cases. Patients with chronic inflammation reported an average of 6.2+/-1.7 bowel movements/day and 93.2% of them were able to delay a bowel movement for at least 30 min. The presence of chronic ATZ inflammation did not seem to have a negative impact on function, with 96.1% of patients reporting perfect continence, and only 5.3% using protective pads. CONCLUSIONS: Preservation of the ATZ in selected patients is safe and offers excellent long-term functional results. New onset dysplasia was not noted. Chronic inflammation had limited clinical impact. Presence of ATZ inflammation in a total of 89.5% of patients warrants life-long surveillance with biopsies.


Assuntos
Canal Anal/patologia , Colite Ulcerativa/patologia , Defecação/fisiologia , Adolescente , Adulto , Idoso , Anastomose Cirúrgica , Colite Ulcerativa/cirurgia , Bolsas Cólicas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Grampeamento Cirúrgico , Técnicas de Sutura
7.
J Grad Med Educ ; 8(2): 248-51, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27168897

RESUMO

Background Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness. Objective We sought to assess senior resident self-perceived cost awareness and cost knowledge. Methods In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale-New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price. Results We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%. Conclusions In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.


Assuntos
Atitude do Pessoal de Saúde , Conscientização , Testes Diagnósticos de Rotina/economia , Internato e Residência , Connecticut , Estudos Transversais , Educação de Pós-Graduação em Medicina , Hospitais de Ensino , Humanos , Inquéritos e Questionários
8.
J Hosp Med ; 11(1): 65-76, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26498736

RESUMO

BACKGROUND: Displaying order prices to physicians is 1 potential strategy to reduce unnecessary health expenditures, but its impact on patterns of care is unclear. OBJECTIVE: To review characteristics of previous price display interventions, impact on order costs and volume, effects on patient safety, acceptability to physicians, and the quality of this evidence. DESIGN: Systematic review of studies that showed numeric prices of laboratory tests, imaging studies, or medications to providers in real time during the ordering process and evaluated the impact on provider ordering. Two investigators independently extracted data for each study and evaluated study quality using a modified Downs and Black checklist. RESULTS: Of 1494 studies reviewed, 19 met inclusion criteria, including 5 randomized trials, 13 pre-post intervention studies, and 1 time series analysis. Studies were published between 1983 and 2014. Of 15 studies reporting the quantitative impact of price display on aggregate order costs or volume, 10 demonstrated a statistically significant decrease in the intervention group. Price display was found to decrease aggregate order costs (9 of 13 studies) more frequently than order volume (3 of 8 studies). Patient safety was evaluated in 5 studies and was unaffected by price display. Provider acceptability tended to be positive, although evidence was limited. Study quality was mixed, with checklist scores ranging from 5/21 to 20/21. CONCLUSIONS: Provider price display likely reduces order costs to a modest degree. Patient safety appeared unchanged, though evidence was limited. More high-quality evidence is needed to confirm these findings within a modern context.


Assuntos
Honorários e Preços , Custos de Cuidados de Saúde , Padrões de Prática Médica/economia , Comércio , Custos e Análise de Custo , Humanos , Sistemas de Registro de Ordens Médicas , Segurança do Paciente
9.
Obstet Gynecol ; 118(6): 1261-1270, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22105255

RESUMO

OBJECTIVE: To use the data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program to estimate major postoperative morbidity after 1) appendectomy in pregnant compared with nonpregnant women; and 2) cholecystectomy in pregnant compared with nonpregnant women. METHODS: We selected a cohort of reproductive-aged women undergoing appendectomy and cholecystectomy between 2005 and 2009 from the data files of the ACS National Surgical Quality Improvement Program. Outcomes in pregnant women were compared with those in nonpregnant women. The primary outcome was composite 30-day major postoperative complications. Pregnancy-specific complications were not assessed and thus not addressed. RESULTS: Pregnant and nonpregnant women had similar composite 30-day major morbidity after appendectomy (3.9% [33 of 857] compared with 3.1% [593 of 19,172], P=.212) and cholecystectomy (1.8% [eight of 436] compared with 1.8% [584 of 32,479], P=.954). Pregnant women were more likely to have preoperative systemic infections before each procedure. In logistic regression analysis, pregnancy status was not predictive of increased postoperative morbidity for appendectomy (adjusted odds ratio 1.26, 95% confidence interval 0.87-1.82). CONCLUSION: Pregnancy does not increase the occurrence of postoperative maternal morbidity related to appendectomy and cholecystectomy. LEVEL OF EVIDENCE: II.


Assuntos
Apendicectomia , Colecistectomia , Complicações Pós-Operatórias/epidemiologia , Complicações na Gravidez/cirurgia , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Estudos Retrospectivos , Adulto Jovem
10.
J Gastrointest Surg ; 13(3): 526-32, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-19015927

RESUMO

PURPOSE: Long-term results after laparoscopic ileal pouch anal anastomosis (IPAA) have not been thoroughly evaluated. Our study prospectively compares short- and long-term outcomes of laparoscopic and open IPAA. METHODS: Between October 2002 and November 2007, 73 laparoscopic and 106 open IPAA patients were enrolled. Patient- and disease-specific characteristics and short- and long-term outcomes were prospectively collected. RESULTS: There were no differences in demographics, treatment, indication, duration of surgery, and diversion between groups. Laparoscopic patients had faster return of flatus (p = 0.008), faster assumption of a liquid diet (p < 0.001), and less blood loss (p = 0.026). While complications were similar, the incidence of incisional hernias was lower in the laparoscopic group (p = 0.011). Mean follow-up was 24.8 months. Average number of bowel movements was 6.8 +/- 2.8/day for laparoscopy and 6.3 +/- 1.7 for open (p = 0.058). Overall, 68.4% of patients were fully continent at 1 year, up to 83.7% long term without differences between groups. Other indicators of defecatory function and quality of life remain similar overtime. CONCLUSIONS: Laparoscopic IPAA confers excellent functional results. Most patients are fully continent and have an average of six bowel movements/day. When present, minor incontinence improves over time. Laparoscopy mirrors the results of open IPAA and is a valuable alternative to open surgery.


Assuntos
Colite Ulcerativa/cirurgia , Bolsas Cólicas , Laparoscopia , Proctocolectomia Restauradora/métodos , Adulto , Defecação , Feminino , Seguimentos , Humanos , Masculino , Qualidade de Vida , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento
11.
Surgery ; 144(4): 533-7; discussion 537-9, 2008 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18847636

RESUMO

BACKGROUND: Chronic inflammation (CI) is commonly found in the anal transition zone (ATZ) after stapled ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Yet, its impact on defecatory function and the need for a complete mucosectomy has not been completely elucidated. This study aims to evaluate the long-term functional outcomes of patients with CI of the ATZ after stapled IPAA in comparison with mucosectomy patients. METHODS: Between June 1987 and November 2007, 66 UC patients were found to have CI of the ATZ after stapled IPAA and were compared with 228 UC patients who underwent mucosectomy with hand-sewn (HS) IPAA. Patients were mailed a questionnaire to assess defecatory function and quality of life. Data were analyzed prospectively. RESULTS: No differences were observed in age, sex, number, or consistency of bowel movements (BMs) between groups. Complete continence was reported by 90.3% of CI and 66.8% of HS patients (P < .001). The CI group also had a significantly lower rate of major incontinence (P < .001). Functional parameters in favor of the CI group included the ability to discriminate between gas and stool (P < .001), the use of protective pads during both the day and the night (P < .001), dietary modifications in the timing of meals (P < .001) and type of food (P = .005), and the presence of perianal rash (P = .019). In the CI group, more patients rated their quality of life as improved from before the operation (P < .001). CONCLUSIONS: Preservation of the ATZ, even in presence of persistent inflammation, confers improved continence, better functional outcomes, and superior quality of life.


Assuntos
Canal Anal/patologia , Colite Ulcerativa/cirurgia , Pouchite/patologia , Qualidade de Vida , Grampeamento Cirúrgico/efeitos adversos , Adulto , Distribuição por Idade , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Doença Crônica , Estudos de Coortes , Colectomia/efeitos adversos , Colectomia/métodos , Colite Ulcerativa/patologia , Bolsas Cólicas/patologia , Incontinência Fecal/epidemiologia , Incontinência Fecal/etiologia , Feminino , Seguimentos , Humanos , Incidência , Mucosa Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Pouchite/epidemiologia , Probabilidade , Estudos Prospectivos , Medição de Risco , Distribuição por Sexo , Técnicas de Sutura , Fatores de Tempo
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