Article

From Waste to Value in Health Care

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Abstract

The United States ranks among the worst of industrialized countries for indicators of health such as infant mortality and life expectancy,1 despite spending $2 trillion annually on health care,2 more than any other nation per capita. However, higher health care spending does not correlate with higher quality of care or better patient outcomes.3- 5 These sobering indicators suggest that an opportunity exists to close the value gap in the day-to-day delivery of health care by eliminating actions that impede optimal systematic performance, which result in less than perfect outcomes, extra work, or corrective work, otherwise described as waste.

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... 4 5 Intervention and treatment options for TBI are multiple, but many lack robust evidence of their effectiveness. 6 7 Low-value clinical practices, defined as a test or procedure that is not supported by evidence and/or could expose patients to unnecessary harm [8][9][10][11][12][13][14][15] consume up to 30% of healthcare budgets. 9 16 In the past decade, the medical community has turned towards the deimplementation of low-value practices as a promising means to reduce the strain on healthcare budgets, free-up resources and reduce harm to patients. ...
... Two reviewers (PAT, LM) will independently critically appraise the quality of systematic reviews using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR-2) tool. 37 Methodological quality will be categorised as low (0-3), medium (4-7) and high (8)(9)(10)(11). ...
Article
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Introduction Traumatic brain injury (TBI) leads to 50 000 deaths, 85 000 disabilities and costs $60 billion each year in the USA. Despite numerous interventions and treatment options, the outcomes of TBI have improved little over the last three decades. In a previous scoping review and expert consultation survey, we identified 13 potentially low-value clinical practices in acute TBI. The objective of this umbrella review is to synthesise the evidence on potentially low-value clinical practices in the care of acute TBI. Methods and analysis Using umbrella review methodology, we will search Cochrane Central Register of Controlled Trials, Embase, Epistemonikos, International Prospective Register of Systematic Reviews (PROSPERO) and PubMed to identify systematic reviews evaluating the effect of potential intrahospital low-value practices using tailored population, intervention, comparator, outcome and study design questions based on the results of a previous scoping review. We will present data on the methodological quality of these reviews (Assessing the Methodological Quality of Systematic Reviews-2), reported effect sizes and strength of evidence (Grading of Recommendations, Assessment, Development and Evaluation). Ethics and dissemination Ethics approval is not required as original data will not be collected. Knowledge users from five healthcare quality organisations and clinical associations are involved in the design and conduct of the study. Results will be disseminated in a peer-reviewed journal, at international scientific meetings and to clinical, healthcare quality and patient–partner associations. This work will support the development of metrics to measure the use of low-value practices, inform policy makers on potential targets for deimplementation and in the long term reduce the use of low-value clinical practices in acute TBI care. PROSPERO registration number CRD42019132428.
... They argue that since chemotherapy medications can cost up to e1800 per treatment, it is prudent to be sure they will be used before preparing them. Unused medicine may contribute considerably into the operational waste of a hospital [25]. ...
Article
In this thesis we address a number of challenging problems related to health care logistics. These problems are motivated by hospital managers who collaborated in the research, and the results are applied at their hospitals. The general results and solution approaches presented in this thesis are also valid in other hospital settings.
... Furthermore the presence of publication bias could not be excluded statistically. Considering the under-reporting of QI research 43 and that 88% of studies here presented a statistically significant improvement, its presence needs to be considered. ...
Article
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Background Lean and Six Sigma are improvement methodologies developed in the manufacturing industry and have been applied to healthcare settings since the 1990s. They use a systematic and reproducible approach to provide Quality Improvement (QI), with a flexible process that can be applied to a range of outcomes across different patient groups. This review assesses the literature with regard to the use and utility of Lean and Six Sigma methodologies in surgery. Methods MEDLINE, Embase, PsycINFO, Allied and Complementary Medicine Database, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Health Business Elite and the Health Management Information Consortium were searched in January 2014. Experimental studies were included if they assessed the use of Lean or Six Sigma on the ability to improve specified outcomes in surgical patients. Results Of the 124 studies returned, 23 were suitable for inclusion with 11 assessing Lean, 6 Six Sigma and 6 Lean Six Sigma. The broad range of outcomes can be collated into six common aims: to optimise outpatient efficiency, to improve operating theatre efficiency, to decrease operative complications, to reduce ward-based harms, to reduce mortality and to limit unnecessary cost and length of stay. The majority of studies (88%) demonstrate improvement; however high levels of systematic bias and imprecision were evident. Conclusion Lean and Six Sigma QI methodologies have the potential to produce clinically significant improvement for surgical patients. However there is a need to conduct high-quality studies with low risk of systematic bias in order to further understand their role.
... They argue that since chemotherapy medications can cost up to 1800 euros per treatment, it is prudent to be sure they will be used before preparing them. Indeed, unused medicine may contribute considerably into the operational waste of a hospital [1]. Management of the CDU on the other hand, is concerned that to prepare the medicines 'on-demand' adds an extra process step that leads to unnecessary waiting for the patients. ...
Article
This study investigates the impact of pharmacy policies on patient waiting time in the Chemotherapy Day Unit of the Netherlands Cancer Institute--Antoni van Leeuwenhoek hospital. The project evaluated whether a reduction in waiting time resulting from medication orders being prepared in advance of patient appointments was justified, given that medications prepared in advance are wasted when patients arrive too sick for treatment. Within this context, we derive analytic expressions to approximate patient waiting times and wastage costs, allowing management to see the tradeoff between these two metrics for different policies. Using a case study and a simulation model, the approximations are evaluated. The use of analytic expressions allows the analysis to be easily repeated when medication costs change or when new medications/protocols are introduced. In the same vein, other hospitals with different patient case mixes can easily complete the analysis in their settings. Finally, the outcome from this study resulted in a new policy at the cancer center which is expected to decrease the waiting time by half, while only increasing pharmacy's costs by 1-2%.
... Emphasis on adherence to recommended processes of care and rapid innovation in imaging and therapeutic techniques has led to an exponential rise in the use of tests and treatments that are not supported by evidence and/or could expose patients to unnecessary harm, 5 referred to here as low-value clinical practices. [6][7][8][9][10][11][12][13] Examples include whole body CT for minor or single-system injury and steroid administration following severe traumatic brain injury. 5 Overall, unnecessary clinical processes have been estimated to consume up to 30% of healthcare resources 8 10 12 14 but little is known about healthcare overuse in the context of injury care. ...
Article
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Introduction Preventable injuries lead to 200 000 hospital stays, 60 000 disabilities, and 13 000 deaths per year in Canada with direct costs of $20 billion. Overall, potentially unnecessary medical interventions are estimated to consume up to 30% of healthcare resources and may expose patients to avoidable harm. However, little is known about overuse for acute injury care. We aim to identify low-value clinical practices in injury care. Methods and analysis We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify research articles, reviews, recommendations and guidelines that identify at least one low-value clinical practice specific to injury populations. We will search Medline, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, websites of government agencies, professional societies and patient advocacy organisations, thesis holdings and conference proceedings. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles using a prepiloted and standardised electronic data abstraction form. Low-value clinical practices will be categorised using an extension of the Agency for Healthcare Research and Quality conceptual framework and data will be presented using narrative synthesis. Ethics and dissemination Ethics approval is not required as original data will not be collected. This study will be disseminated in a peer-reviewed journal, international scientific meetings, and to knowledge users through clinical and healthcare quality associations. This review will contribute new knowledge on low-value clinical practices in acute injury care. Our results will support the development indicators to measure resource overuse and inform policy makers on potential targets for deadoption in injury care.
... An effective QI method in health care is characterized by 2 key strategies: directly engaging front-line workers 25 and eliminating wasteful work processes. 26 As suggested by Fischer et al 27 over 15 years ago, and illustrated by Sinksy 28 in a provider office practice, health care workers are able to efficiently and successfully redesign key office systems and processes. ...
Article
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Background: Primary care offices are integrating behavioral health (BH) clinicians into their practices. Implementing such a change is complex, difficult, and time consuming. Lean workflow analysis may be an efficient, effective, and acceptable method for use during integration. The objectives of this study were to observe BH integration into primary care and to measure its impact. Methods: This was a prospective, mixed-methods case study in a primary care practice that served 8,426 patients over a 17-month period, with 652 patients referred to BH services. Secondary measures included primary care visits resulting in BH referrals, referrals resulting in scheduled appointments, time from referral to the scheduled appointment, and time from the referral to the first visit. Providers and staff were surveyed on the Lean method. Results: Referrals increased from 23 to 37 per 1000 visits (P < .001). Referrals resulted in more scheduled (60% to 74%; P < .001) and arrived visits (44% to 53%; P = .025). Time from referral to the first scheduled visit decreased (hazard ratio, 1.60; 95% confidence interval, 1.37-1.88) as did time to first arrived visit (hazard ratio, 1.36; 95% confidence interval, 1.14-1.62). Survey responses and comments were positive. Conclusions: This pilot integration of BH showed significant improvements in treatment initiation and other measures. Strengths of Lean analysis included workflow improvement, system perspective, and project success. Further evaluation is indicated.
... 5 Low-value practices are defined as 'the common use of a particular intervention when the benefits don't justify the potential harm or cost' 6 and comprise unnecessary hospitalisations, transfers, consultations, diagnostic and therapeutic procedures. [5][6][7][8][9][10][11][12] Best practice guidelines to optimise outcomes in adult patients with orthopaedic injuries have been published by recognised orthopaedic and trauma organisations (American Academy of Orthopaedic Surgeons, 13 Orthopaedic Trauma Association, 14 American College of Surgeons-Committee on Trauma 15 ...
Article
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Introduction: Orthopaedic injuries affect almost 90% of trauma patients. A previous scoping review and expert consultation survey identified 15 potential low-value intra-hospital practices in the adult orthopaedic trauma population. Limiting the frequency of such practices could reduce adverse events, improve clinical outcomes and free up resources. The aim of this study is to synthesize the evidence on intra-hospital practices for orthopaedic injuries, previously identified as potentially low-value. Methods and analysis: We will search MEDLINE, EMBASE, Cochrane Central and Epistemonikos to identify systematic reviews, randomized controlled trials (RCTs), quasi-RCTs, cohort studies and case-control studies that evaluate selected practices according to a priori PICOS statements (Population-Intervention-Comparator-Outcome-Study design). We will evaluate the methodological quality for systematic reviews using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2). Risk of bias in original studies will be evaluated with the Cochrane revised tool for RCTs (RoB2) and with the Risk of Bias in Non-randomized Studies – of Interventions (ROBINS-I) tool. If for a given practice, more than two original studies on our primary outcome are identified, we will conduct meta-analysis using a random effects model and assess heterogeneity using the I2 index. We will assess credibility of evidence (I to IV) based on statistical significance, sample size, heterogeneity and bias as per published criteria. Ethics and dissemination: Ethics approval is not required as original data will not be collected. Knowledge users from three level I trauma centers are involved in the design and conduct of the study in accordance with an integrated knowledge translation approach. Findings related to the rapid review will be available in May 2020. They will be presented to key stakeholders to inform discussions and raise awareness on low-value injury care. In addition, results will be disseminated in a peer-reviewed journal, at national and international scientific meetings and to healthcare associations.
... [4,5] Treatment options for TBI are multiple, but many lack robust evidence of their effectiveness. [6,7] Low-value clinical practices, defined as 'a test or procedure that is not supported by evidence and/or could expose patients to unnecessary harm' [8][9][10][11][12][13][14][15] consume up to 30% of healthcare resources. [16,9] In the past decade, the medical community has turned towards the de-adoption of low-value practices as a promising means to reduce the strain on healthcare budgets, free-up resources and reduce harm to patients. ...
Preprint
Full-text available
Background Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last three decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Methods Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (AMSTAR-2), reported effect sizes and credibility of evidence (I to IV). Results The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: CT in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. Conclusions We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality and most included studies had a high risk of bias. Protocol registration PROSPERO: CRD42019132428
... Yet here we are, yet, still battered as a people by a medical industry in which a third to a half of what is done is waste. 10 That's roughly a trillion dollars per year, give-or-take. It's an industry that a Johns Hopkins researcher recently assessed as killing an estimated 250 000 people annually. ...
... The ability to improve healthcare is now an essential part of the training for all health professionals, 1 and patients increasingly expect a commitment to improvement as a part of our professional work. 2 Not only will accelerating the systematic development of such an academic cadre serve to expand the abilities of new health professionals, but also this expanded faculty should advance the scholarship of improvement of patient care and health systems. ...
Article
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It’s time to focus on teaching the teachers for healthcare improvement. The ability to improve healthcare is now an essential part of the training for all health professionals,1 and patients increasingly expect a commitment to improvement as a part of our professional work.2 Not only will accelerating the systematic development of such an academic cadre serve to expand the abilities of new health professionals, but also this expanded faculty should advance the scholarship of improvement of patient care and health systems. Healthcare improvement competencies have become an integral part of professional development and are driven by changes both in healthcare and in the disciplines that specifically address improvement. First, ever more scarce resources demand greater efficiency and reduction of waste in both education and clinical care. Second, emerging professional competencies for all physicians include healthcare improvement and knowledge of effective systems. A prominent example is the development of the Six General Competencies for accreditation and certification of all physicians in the US3 with two of the six competencies being Practice-Based Learning and Improvement, and Systems-Based Practice. All specialties of medicine in the US are now required to define these competencies for their respective trainees. Third, increasing attention to clarity of theory that underlies rigorous improvement research,4 the epistemology and guidelines for scholarly publication,5 and typologies for formal research in improvement science6 are all developing at an accelerating pace (see page 403) . We argue that these changes both facilitate the development of an expert teaching faculty and make its development …
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We know that every improvement is a change—but how do we know that a change is an improvement?1 Improvement experts and patients, each in their own terms, ask this question with appropriate impatience.23 For example, how can valid conclusions be drawn when an improvement initiative employs no control population, or if the study employs predominantly qualitative measures? Indeed, some argue that if the RCT is the gold standard, how can improvement scientists settle for less?4 Others counter that this frame actually constrains the options for knowing.56 Flyvbjerg describes these debates in the larger scientific community—at their most vehement—as the Science Wars.7 That goes far beyond where I intend to take this modest essay. Increasingly there are calls for a rich discussion and appraisal of new ways of knowing while striving to improve existing methodologies in healthcare improvement and patient safety.23 I propose that this journal, given its unique subject matter, provides an appropriate test bed to assess the rigour and utility of scholarly reports in these fields. While doing so, we must also be mindful that there are emerging media that …
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Almost 50 years ago, John F. Kennedy told Yale's graduating class that "what is needed today is a new, difficult but essential confrontation with reality, for the great enemy of truth is very often not the lie-deliberate, contrived and dishonest-but the myth-persistent, persuasive and unrealistic." Today's myth is the belief that 30% of health care spending is due to supplier-induced demand and that this amount could be saved if high-spending regions could more closely resemble low-spending regions. The reality is that, while quality and efficiency remain important goals, the major factors driving geographic differences are related to income inequality. Yet, following the road map of the Dartmouth Atlas, the Affordable Care Act includes penalties for hospitals with excess preventable readmissions (which are mainly of the poor), incentive payments for providers in counties that have the lowest Medicare expenditures (where there tends to be less poverty), incentives for physicians and hospitals that attain new "efficiency standards" (ie, costs similar to the lowest), and a call for the Institute of Medicine to recommend additional incentive strategies based on geographic variation. This scenario iscoupled with a growing bureaucracy, following the blueprint laid out by Brennan and Berwick in the 1990s, but with no tangible measures to increase physician supply. Meaningful health care reform means accepting the reality that poverty and its cultural extensions are the major cause of geographic variation in health care utilization and a major source of escalating health care spending. And it means acknowledging Bertrand Russell's admonition that a high degree of income inequality is not compatible with political democracy, nor is it compatible with health care that this nation can afford. As solutions are sought both within and outside of the health care system, misunderstandings of how and why health care varies geographically cannot be allowed to deter these efforts, and the pervasive impact of poverty cannot be ignored.
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In 2005, draft guidelines were published for reporting studies of quality improvement interventions as the initial step in a consensus process for development of a more definitive version. This article contains the full revised version of the guidelines, which the authors refer to as SQUIRE (Standards for QUality Improvement Reporting Excellence). This paper also describes the consensus process, which included informal feedback from authors, editors and peer reviewers who used the guidelines; formal written commentaries; input from a group of publication guideline developers; ongoing review of the literature on the epistemology of improvement and methods for evaluating complex social programmes; a two-day meeting of stakeholders for critical discussion and debate of the guidelines' content and wording; and commentary on sequential versions of the guidelines from an expert consultant group. Finally, the authors consider the major differences between SQUIRE and the initial draft guidelines; limitations of and unresolved questions about SQUIRE; ancillary supporting documents and alternative versions that are under development; and plans for dissemination, testing and further development of SQUIRE.
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The constitution of the World Health Organization states that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.”1(p1) Although this perspective is notable and has proven to be significant in promoting the quality of life among individuals worldwide, it is unfortunate that this resounding message is often not heard—and too often overlooked—by many parts of American society. Sadly, this basic human right is even more difficult to achieve for the estimated 43.3 million uninsured persons in the United States, 2 many of whom are poor, underserved, and underrepresented. Furthermore, the individuals who do have health insurance experience major difficulties navigating a fragmented health care system, accessing culturally responsive and quality health care, and securing associated finances. Every day, working people struggle to make ends meet with health ailments that progressively worsen, in part because of their inability to comfortably connect with a health care provider and establish a medical “base.” In some cases, the fear of receiving bad news about their health from a physician or the stigma associated with seeking mental health treatment may prevent individuals from expeditiously moving forward for health care. Yet, what may be even more daunting is the reality of the medical bills that will most certainly accompany any visit to a health care facility. Sociocultural, economic, political, and environmental tribulations continue to plague our communities and infect our health care systems, resulting in public health crises, disease epidemics, and enduring health disparities, placing vulnerable populations at increased risk of premature mortality and lives filled with suffering. The distribution of health outcomes is extremely unbalanced across population groups in regard to race and gender.3 African American men have the shortest life expectancy (69.2 years) among the four major race–gender groups in the United States (White women, 80.5 years; White men, 75.4 years; African American women, 76.1 years).4 It is essential to understand that pervasive inequities have a detrimental impact on the physical and mental health status of many individuals, families, and communities. We must adopt the principle that health requires more than just health care. Needed attention to selected social determinants of health has been offered to the general public through provocative documentaries such as Unnatural Causes … Is Inequality Making Us Sick? 5 and Sicko.6 Nonetheless, much more remains to be done. In addition to honing in on micro-level connections between exposures and outcomes, there remains an enormous need to examine, at a macro level, the interrelated research, practice, and policy issues that are important for societies that seek to achieve social justice for all and health as a human right.
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Patient safety (PS) and quality improvement (QI) are among the highest priorities for all health systems. Resident physicians are often at the front lines of providing care for patients. In many instances, however, QI and PS initiatives exclude trainees. By aligning the goals of the health system with those of the residency program to engage residents in QI and PS projects, there is a unique opportunity to fulfill both a corporate and educational mission to improve patient care. Here, the authors briefly describe one residency program's educational curriculum to provide foundational knowledge in QI and PS to all its trainees and highlight a resident team-based project that applied principles of lean thinking to evaluate the process of responding to an in-hospital cardiopulmonary arrest. This approach provided residents with a practical experience but also presented an opportunity for trainees to align with the health system's approach to improving quality and safety.
Background: Lean Thinking is a management philosophy derived from the manufacturing industry, where Toyota has long been the gold standard. Health care organizations have started to apply this approach to patient care. After initial experimentation, the University of Michigan Health System (UMHS) has adopted Lean Thinking as its uniform approach to quality improvement and is striving to become a complete Lean organization. Projects: In 2005, the senior leadership selected an initial set of projects in areas that traced the patient's journey across different care settings within our health system. Four of the projects were as follows: orthopedic surgery clinic scheduling, radiation oncology therapy, peripherally inserted central catheter (PICC) services, and coordination of care to the outpatient setting. Lessons from lean thinking: Lean Thinking encourages service providers to focus on value as defined by the customer and the relentless elimination of waste that impedes the flow of value. A series of learning projects were conducted to test whether Lean methods would work at UMHS. The following factors were found to be key to LEAN PROJECT SUCCESS: expert guidance for initial efforts, leadership in the form of clinical champions and senior management support of the improvement work, frontline worker engagement in mapping out "current state" processes, identifying waste and designing an improved "future state," using metrics to develop and track interventions, and defining realistic project scope. Final reflections: As UMHS's experience applying Lean Thinking to our patient care processes has grown, so have support, enthusiasm, and expertise within the organization. UMHS's Lean Thinking system, now known as the Michigan Quality System, has emerged as the core improvement strategy.
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In developing the evidence-based Enteral Nutrition Practice Recommendations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) formed a task force to address the many aspects of safety in the delivery and provision of enteral nutrition support. This recently published document provides healthcare professionals with recommendations that are derived from evidence-based practice. The development and use of clinical practice guidelines (CPGs) is a recent, significant contribution for the dissemination of evidence-based medicine. This involves the review of scientific literature along with clinical skill and knowledge to generate specific recommendations assisting healthcare providers and patients with decisions regarding appropriate healthcare. A primary opportunity to improve patient outcomes will come from the effective delivery of existing therapies rather than from the new development of treatment modalities. Compliance with CPGs is challenging because it depends on a variety of factors. Both general and specific strategies have been devised with the expansion of the new discipline of implementation science. The high degree of evidence now available in medicine gives clinicians more opportunity to improve patient outcomes and quality of care. It remains for clinicians to evaluate their institutional mission and goals, and to investigate those CPGs appropriate to improve patient care in that setting.
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The pediatric intensive care unit (PICU), with limited number of beds and resource-intensive services, is a key component of patient flow. Because the PICU is a crossroads for many patients, transfer or discharge delays can negatively impact a patient's clinical status and efficiency. The objective of this study was to describe, using direct observation, PICU bed utilization. We conducted a real-time, prospective observational study in a convenience sample of days in the PICU of an urban, tertiary-care children's hospital. Among 824 observed hours, 19,887 bed-hours were recorded, with 82% being for critical care services and 18% for non-critical care services. Fourteen activities accounted for 95% of bed-hours. Among 200 hours when the PICU was at full capacity, 75% of the time included at least 1 bed that was used for non-critical care services; 37% of the time at least 2 beds. The mean waiting time for a floor bed assignment was 9 hours (median, 5.5 hours) and accounted for 4.62% of all bed-hours observed. The PICU delivered critical care services most of the time, but periods of non-critical care services represented a significant amount of time. In particular, periods with no bed available for new patients were associated with at least 1 or more PICU beds being used for non-critical care activities. The method should be reproducible in other settings to learn more about the structure and processes of care and patient flow and to make improvements.
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Importance: Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences. Objective: To assess the validity of quality indicators on low-value trauma care using trauma registry data. Design, setting, and participants: Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts. Main outcomes and measures: Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time). Results: The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs. Conclusions and relevance: This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.
Article
Objectives: Evaluating unnecessary US medical practices, and the strategies that reduce them, are increasingly recognized as crucial to healthcare financing sustainability. Provider factors are known to affect unnecessary medical practices, yet little is known about how physician responses to patient requests for unnecessary care affect these practices. Among primary care physicians (PCPs), we investigated 2 types of unnecessary medical practices triggered by patient requests: a) unnecessary specialty referrals and b) prescriptions for brand-name drugs when generic alternatives are available. Study design and methods: We used data from a survey of a nationally representative sample of 840 US PCPs in 2009. Response rates for family practice (n = 274), internal medicine (n = 257), and pediatrics (n = 309) were 67.5%, 60.8%, and 72.7%, respectively. Results: In response to patient requests, 51.9% of PCPs reported making unnecessary specialty referrals and 38.7% prescribed brand-name drugs. Family physicians (odds ratio [OR], 2.77; 95% CI, 1.77-4.34) and internal medicine physicians (OR, 4.51; 95% CI, 2.87-7.06) were more likely than pediatricians to prescribe brand-name drugs. PCP specialty was similarly associated with unnecessary referrals. Other predictors of acquiescence to patient requests included interactions with drug/device representatives, more years of clinical experience, seeing fewer safety net patients, and solo/2-person practice organizations. Area-level Medicare spending was not associated with the 2 unnecessary practices. Conclusions: Many PCPs reported acquiescing to patient requests for unnecessary care. Provider and organizational factors predicted this behavior. Policies aimed at reducing such practice could improve care quality and lower cost. Patient and physician incentives that can potentially reduce unnecessary medical practices warrant exploration.
Article
Background: Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last three decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Methods: Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (AMSTAR-2), reported effect sizes and credibility of evidence (I to IV). Results: The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: CT in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. Conclusions: We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality and most included studies had a high risk of bias.
Article
Background: Tests and treatments that are not supported by evidence and could expose patients to unnecessary harm, referred to here as low-value clinical practices, consume up to 30% of health care resources. Choosing Wisely and other organizations have published lists of clinical practices to be avoided. However, few apply to injury and most are based uniquely on expert consensus. We aimed to identify low-value clinical practices in acute injury care. Methods: We conducted a scoping review targeting articles, reviews and guidelines that identified low-value clinical practices specific to injury populations. Thirty-six experts rated clinical practices on a five-point Likert scale from clearly low value to clearly beneficial. Clinical practices reported as low value by at least one level I, II, or III study and considered clearly or potentially low-value by at least 75% of experts were retained as candidates for low-value injury care. Results: Of 50,695 citations, 815 studies were included and led to the identification of 150 clinical practices. Of these, 63 were considered candidates for low-value injury care; 33 in the emergency room, 9 in trauma surgery, 15 in the intensive care unit, and 5 in orthopedics. We also identified 87 "gray zone" practices, which did not meet our criteria for low-value care. Conclusion: We identified 63 low-value clinical practices in acute injury care that are supported by empirical evidence and expert opinion. Conditional on future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 "gray zone" practices, which may be interesting targets for value-based decision-making. Our study represents an important step toward the deimplementation of low-value clinical practices in injury care. Level of evidence: Systematic Review, Level IV.
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Objective The objective of the study was to compare the medical prescription forms in European Union (EU) countries, evaluating their convergence toward the implementation of cross-border care, as proposed by the existing EU health-care directives. It also aims to assess how the existing EU prescription models fulfill higher standards of medication prescribing quality and patient safety. Methods Prescription forms from all EU countries were purposively collected. The prescription fields and other content elements were qualitatively and quantitatively analyzed. Forms were statistically compared with each other and a theoretical EU cross-border prescription form, using hierarchical cluster analysis and nonparametric testing. Findings None of the EU countries' prescriptions include all the elements required by the cross-border legislation (CBL), with most countries having seven or less mandatory elements. Cluster analysis revealed that countries with similar prescription forms are geographically nearer. Important elements from the EU directive to assure patient safety are also absent such as the International Classification of Diseases, the patient's ID according to the European Health Insurance Card, and the patient's contact. However, Western and Nordic countries showed higher standardization when compared to the CBL and model. Conclusion Political action is still needed to harmonize medical prescription forms between countries, serving the common goal of trans-European health care and to increase EU patients' safety using medications and other prescribed treatments.
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Objective: To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations. Background: Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care. Methods: We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces. Results: Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%. Conclusions: We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.
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Importance: The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective: To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, setting, and participants: This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main outcomes and measures: Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results: Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and relevance: In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.
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How do we help our patients become exceptional patients? What are the lessons we learn from our exceptional patients that can positively impact how we practice? Sometimes without knowing, a personal experience leads to a change in your at-titude and approach to significant issues in your practice. Seventeen years ago I was quite involved with the integration of complementary medicine with con-ventional medicine. At that time my ap-proach to integrative medicine was very pragmatic. I suggested using complemen-tary medicine whenever conventional op-tions were not effective, with one excep-tion, treatment of cancer. At that time I believed that complementary medi-cine did not have a role in cancer care. I changed my approach after observing a complicated trajectory that one of my friends went through. Suzanna, a good friend of mine, at that time in her late 40s, was divorced with three grown children and no extended family. She was a successful practitioner involved with complementary medicine. She was attractive and well respected in her field and we saw her occasionally at social events. She called us one day with a sense of panic in her voice --she felt a lump in her breast. She quickly obtained a consultation with an expert, and a biopsy that was done with no delay confirmed the worse case scenario of having a diagnosis of breast cancer. The lumpectomy that fol-lowed confirmed extensive disease of inva-sive ductal carcinoma with involvement of lymph nodes. After the surgery the surgeon notified her that in addition to the surgery she would need to schedule an appoint-ment with an oncologist to arrange adju-vant chemotherapy. Suzanna was devastated. In an instant she went from being a well-known practitioner to a patient. Her first thought was, "I'm go-ing to die." She was consumed with that thought. She felt alone, helpless and hope-less, a situation which is very common for people diagnosed with cancer. 1 The Most Significant Stressors in Cancer Let's expand a little bit on those issues. Unwanted aloneness, or social isolation is something that we tend to dismiss but when we look at the scientific literature, we find interesting facts. A meta-analysis of 148 studies on this issue revealed that there is a 50% increased likelihood of sur-vival for people who have stronger social relationships. 2 It appears that social isola-tion is a leading risk factor for mortality. This risk factor is actually worse than most of the well known and established risk fac-tors such as smoking. This is something that we have to think about. The other issue is loss of control. This is very similar to helplessness. In the book Anticancer by David Schreiber, there is a description of a study that was published in 1982. 3 Three groups of mice were in-jected with tumor cells and studied for the ability to reject these tumor cells among those three groups. In the first group, which was simply observed, about 54% of the mice rejected the tumor cells, with the other 46% developing tumors. The second group of mice received electric shocks. The mice had no control over the electric shocks. Only 23% of those mice managed to reject the tumor cells. This means that 77% developed tumors. The third group was given control over the electric shocks. They quickly learned that they could stop the shocks when they pressed a lever. What the researchers found was that 63% of the mice that were able to stop the shocks were able to reject the tumor cells—only 37% developed tumors, which is even better than the mice that received no elec-trical shocks at all. When the researchers gave those mice a way to control what was happening to them, their immune systems began to work much better, even better than those that didn't have to contend with shocks at all. The third issue is hope. A well-known psychiatrist, concentration camp survivor and author, Victor Frankl, PhD said a long time ago, "There is direct connection be-tween mood, courage and hope. The loss of hope and courage can be fatal." According to Schreiber, many oncolo-gists' greatest worry is not to give false hope. In every situation in cancer, even in the most advanced situation, there are a small percentage of people that manage to survive. There are documented recoveries of stage IV cancer patients, not many, but there are some patients that beat all odds. It raises the thought or question if we should be telling such patients that they have no chance at all of recovery. By doing that we actually create false hopelessness, which is much worse than giving false hope. Who is to say when hope is false? Encouraging passivity and fostering a cul-ture of hopelessness is actually encourag-ing false hopelessness. Scientific evidence shows that we can have a substantial im-pact on our body's capacity to diffuse the mechanisms of cancer, even in advanced situations. On the other hand, being unrealistic about ones own situation, believing that thanks to using a variety of natural approaches they can refuse conventional treatments and obtain a cure is not a healthy approach either. Physicians need to walk a very deli-cate path, where they provide a realistic understanding of the situation but at the same time not cause patients to lose hope. However, most physicians find it very hard to deal with this delicate balance. As a re-sult of the physician's fear of giving false hope, a large number of patients believe that they cannot do anything to protect themselves actively against cancer – before treatment, during treatment, and after the treatment is over.
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To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation. Cluster randomised controlled trial. 114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001). Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax. Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email. Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax. A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.
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In contrast with the primary goals of science, which are to discover and disseminate new knowledge, the primary goal of improvement is to change performance. Unfortunately, scholarly accounts of the methods, experiences, and results of most medical quality improvement work are not published, either in print or electronic form. In our view this failure to publish is a serious deficiency: it limits the available evidence on efficacy, prevents critical scrutiny, deprives staff of the opportunity and incentive to clarify thinking, slows dissemination of established improvements, inhibits discovery of innovations, and compromises the ethical obligation to return valuable information to the public.The reasons for this failure are many: competing service responsibilities of and lack of academic rewards for improvement staff; editors' and peer reviewers' unfamiliarity with improvement goals and methods; and lack of publication guidelines that are appropriate for rigorous, scholarly improvement work. We propose here a draft set of guidelines designed to help with writing, reviewing, editing, interpreting, and using such reports. We envisage this draft as the starting point for collaborative development of more definitive guidelines. We suggest that medical quality improvement will not reach its full potential unless accurate and transparent reports of improvement work are published frequently and widely.
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Using the most recent data on health spending published by the Organization for Economic Cooperation and Development (OECD), we explore reasons why U.S. health spending towers over that of other countries with much older populations. Prominent among the reasons are higher U.S. per capita gross domestic product (GDP) as well as a highly complex and fragmented payment system that weakens the demand side of the health sector and entails high administrative costs. We examine the economic burden that health spending places on the U.S. economy. We comment on attempts by U.S. policymakers to increase the prices foreign health systems pay for U.S. prescription drugs.
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To determine effectiveness and costs of different guideline dissemination and implementation strategies. MEDLINE (1966 to 1998), HEALTHSTAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group. Randomized-controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors, and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria. We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multifaceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1% in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for quality improvement activities.
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The modern history of cystic fibrosis (CF) is one of continuous improvement. Guidelines and evidence-based medicine provide a general roadmap for directing improvement efforts. Data and measurement are central to quality improvement (QI), a way of keeping score and staying on track. This article describes the history and context of QI in CF, the use of guidelines and data with some examples from the work of one regional consortium, some approaches to developing QI skills with a view to implementing and managing desired changes in CF clinic settings, and the potential benefits and impact of public reporting and data transparency.