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IMPORTANCE: Up to two-thirds of African American individuals carry the benign rs2814778-CC genotype that lowers total white blood cell (WBC) count. OBJECTIVE: To examine whether the rs2814778-CC genotype is associated with an increased likelihood of receiving a bone marrow biopsy (BMB) for an isolated low WBC count. DESIGN, SETTING, AND PARTICIPANTS: This retrospective genetic association study assessed African American patients younger than 90 years who underwent a BMB at Vanderbilt University Medical Center, Mount Sinai Health System, or Children’s Hospital of Philadelphia from January 1, 1998, to December 31, 2020. EXPOSURE: The rs2814778-CC genotype. MAIN OUTCOMES AND MEASURES: The proportion of individuals with the CC genotype who underwent BMB for an isolated low WBC count and had a normal biopsy result compared with the proportion of individuals with the CC genotype who underwent BMB for other indications and had a normal biopsy result. RESULTS: Among 399 individuals who underwent a BMB (mean [SD] age, 41.8 [22.5] years, 234 [59%] female), 277 (69%) had the CC genotype. A total of 35 patients (9%) had clinical histories of isolated low WBC counts, and 364 (91%) had other histories. Of those with a clinical history of isolated low WBC count, 34 of 35 (97%) had the CC genotype vs 243 of 364 (67%) of those without a low WBC count history. Among those with the CC genotype, 33 of 34 (97%) had normal results for biopsies performed for isolated low WBC counts compared with 134 of 243 individuals (55%) with biopsies performed for other histories (P

This cohort study examines the potential implications of the ISCHEMIA trial on the appropriateness of percutaneous coronary intervention in patients with stable ischemic heart disease.

Importance Physicians frequently use cardiac monitoring, or telemetry, beyond the duration recommended by published practice standards, resulting in “alarm fatigue” and excess cost. Prior studies have demonstrated an association between multicomponent quality improvement interventions and safe reduction of telemetry duration. Objective To determine if a single-component intervention, a targeted electronic health record (EHR) alert, could achieve similar gains to multicomponent interventions and safely reduce unnecessary monitoring. Design, Setting, and Participants This cluster-randomized clinical trial was conducted between November 2016 and May 2017 on the general medicine service of the Division of Hospital Medicine at the University of California, San Francisco Medical Center and included physicians of 12 inpatient medical teams (6 intervention, 6 control). Interventions The EHR alert was randomized to half of the teams on the general medicine service. The alert displayed during daytime hours when physicians attempted to place an order for patients not in the intensive care unit whose telemetry order duration exceeded the recommended duration for a given indication. Main Outcomes and Measures The primary outcome was telemetry monitoring hours per hospitalization, which was measured using time-stamped orders data from the EHR database. Physician responses to the alert were collected using EHR reporting tools. The potential adverse outcomes of rapid-response calls and medical emergency events were measured by counting the notes documenting these events in the EHR. Results Of the 1021 patients included in this study, in the intervention arm, there was a mean (SD) age of 64.5 (18.9) and 215 (45%) were women; in the control arm, there was a mean (SD) age of 63.8 (19.1) and 249 (46%) were women. The 12 teams were stratified to 8 house-staff teams and 4 hospitalist teams, with 499 hospitalizations analyzed in the intervention arm and 567 hospitalizations analyzed in the control arm. The alert prompted a significant reduction in telemetry monitoring duration (−8.7 hours per hospitalization; 95% CI, −14.1 to −3.5 hours;P = .001) with no significant change in rapid-response calls or medical emergency events. The most common physician response to the alert was to discontinue telemetry monitoring (62% of 200 alerts). Conclusions and Relevance A targeted EHR alert can safely and successfully reduce cardiac monitoring by prompting discontinuation when appropriate. This single-component electronic intervention is less resource intensive than typical multicomponent interventions that include human resources. Trial Registration ClinicalTrials.gov identifier:NCT02529176

Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown.To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE.A population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE.Receipt of an ECG within 30 days of an AHE.Primary outcome was receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months.A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P .001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts.Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.

Importance Pelvic examination is no longer recommended for asymptomatic, nonpregnant women and may cause harms such as false-positive test results, overdiagnosis, anxiety, and unnecessary costs. The bimanual pelvic examination (BPE) is an invasive and controversial examination component. Cervical cancer screening is not recommended for women younger than 21 years. Objectives To estimate prevalence of potentially unnecessary BPE and Papanicolaou (Pap) tests performed among adolescent girls and women younger than 21 years (hereinafter referred to as young women) in the United States and to identify factors associated with receiving these examinations. Design, Setting, and Participants A cross-sectional analysis of the National Survey of Family Growth from September 2011 through September 2017 focused on a population-based sample of young women aged 15 to 20 years (n = 3410). The analysis used survey weights to estimate prevalence and the number of people represented in the US population. Data were analyzed from December 21, 2018, through September 3, 2019. Main Outcomes and Measures Receipt of a BPE or a Pap test in the last 12 months and the proportion of potentially unnecessary examinations and tests. Results Responses from 3410 young women aged 15 to 20 years were included in the analysis with 6-year sampling weights applied. Among US young women aged 15 to 20 years represented during the 2011-2017 study period, 4.8% (95% CI, 3.9%-5.9%) were pregnant, 22.3% (95% CI, 20.1%-24.6%) had undergone STI testing, and 4.5% (95% CI, 3.6%-5.5%) received treatment or medication for an STI in the past 12 months (Table 1). Only 2.0% (95% CI, 1.4%-2.9%) reported using an IUD, and 33.5% (95% CI, 30.8%-36.4%) used at least 1 other type of hormonal contraception in the past 12 months. Among US young women aged 15 to 20 years who were surveyed in the years 2011 through 2017, approximately 2.6 million (22.9%; 95% CI, 20.7%-25.3%) reported having received a BPE in the last 12 months. Approximately half of these examinations (54.4%; 95% CI, 48.8%-59.9%) were potentially unnecessary, representing an estimated 1.4 million individuals. Receipt of a BPE was associated with having a Pap test (adjusted prevalence ratio [aPR], 7.12; 95% CI, 5.56-9.12), testing for sexually transmitted infections (aPR, 1.60; 95% CI, 1.34-1.90), and using hormonal contraception other than an intrauterine device (aPR, 1.31; 95% CI, 1.11-1.54). In addition, an estimated 2.2 million young women (19.2%; 95% CI, 17.2%-21.4%) reported having received a Pap test in the past 12 months, and 71.9% (95% CI, 66.0%-77.1%) of these tests were potentially unnecessary. Conclusions and Relevance This analysis found that more than half of BPEs and almost three-quarters of Pap tests performed among young women aged 15 to 20 years during the years 2011 through 2017 were potentially unnecessary, exposing women to preventable harms. The results suggest that compliance with the current professional guidelines regarding the appropriate use of these examinations and tests may be lacking.

Importance Many Medicare beneficiaries undergo more intensive colonoscopy screening than recommended. Whether this is favorable for beneficiaries and efficient from a societal perspective is uncertain. Objective To determine whether more intensive colonoscopy screening than recommended is favorable for Medicare beneficiaries (ie, whether it results in a net health benefit) and whether it is efficient from a societal perspective (ie, whether the net health benefit justifies the additional resources required). Design, Setting, and Participants Microsimulation modeling study of 65-year-old Medicare beneficiaries at average risk for colorectal cancer (CRC) and with an average life expectancy who underwent a screening colonoscopy at 55 years with negative results. Interventions Colonoscopy screening as recommended by guidelines (ie, at 65 and 75 years) vs scenarios with a shorter screening interval (5 or 3 instead of 10 years) or in which screening was continued to 85 or 95 years. Main Outcomes and Measures Quality-adjusted life-years (QALYs) gained (measure of net health benefit); additional colonoscopies required per additional QALY gained and additional costs per additional QALY gained (measures of efficiency). Results Screening previously screened Medicare beneficiaries more intensively than recommended resulted in only small increases in CRC deaths prevented and life-years gained. In comparison, the increases in colonoscopies performed and colonoscopy-related complications experienced were large. As a result, all scenarios of more intensive screening than recommended resulted in a loss of QALYs, rather than a gain (ie, a net harm). The only exception was shortening the screening interval from 10 to 5 years, which resulted in 0.7 QALYs gained per 1000 beneficiaries. However, this scenario was inefficient because it required no less than 909 additional colonoscopies and an additional $711 000 per additional QALY gained. Results in previously unscreened beneficiaries were slightly less unfavorable, but conclusions were identical. Conclusions and Relevance Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.

This cohort study examines the clinical usefulness and cost of blood cultures and imaging in patients with presumed cellulitis.

The patient’s medical history was significant for chronic obstructive lung disease, obstructive sleep apnea, type II diabetes mellitus, hypertension, hyperlipidemia, and major depressive disorder. The patient denied palpitations or light-headedness in the postoperative period. The patient reported a history of intermittent dizziness and falls over the preceding months. A telemetry strip that prompted the referral is shown in Figure 1. On examination, the patient was in no apparent distress. Her heart rate was regular without murmurs or gallops. Auscultation of lungs revealed normal breath sounds. She had a resting tremor in her right hand. There was no rigidity in any extremities, and the rest of the physical examination findings were normal. She was admitted to the cardiology service for management of new-onset atrial flutter. Serum chemistries (including potassium and magnesium) and complete blood cell count were within normal limits. A 12-lead electrocardiogram (ECG) was performed on arrival to the telemetry unit. It was determined that the ECG demonstrated artifactual waves, most prominent in the limb leads (Figure 2). It was determined that she had pseudoatrial flutter waves and she was subsequently discharged with an event monitor to determine the underlying cause of her falls.

Importance Low-value diagnostic tests have been included on primary care specialty societies’ “Choosing Wisely” Top Five lists. Objective To evaluate the effectiveness of a standardized patient (SP)-based intervention designed to enhance primary care physician (PCP) patient-centeredness and skill in handling patient requests for low-value diagnostic tests. Design, Setting, and Participants Randomized clinical trial of 61 general internal medicine or family medicine residents at 2 residency-affiliated primary care clinics at an academic medical center in California. Interventions Two simulated visits with SP instructors portraying patients requesting inappropriate spinal magnetic resonance imaging for low back pain or screening dual-energy x-ray absorptiometry. The SP instructors provided personalized feedback to residents regarding use of 6 patient-centered techniques to address patient concerns without ordering low-value tests. Control group physicians received SP visits without feedback and were emailed relevant clinical guidelines. Main Outcomes and Measures The primary outcome was whether resident PCPs ordered SP-requested low-value tests during up to 3 unannounced SP clinic visits over 3 to 12 months follow-up, with patients requesting spinal magnetic resonance imaging, screening dual-energy x-ray absorptiometry, or headache neuroimaging. Secondary outcomes included PCP patient-centeredness and use of targeted techniques (both coded from visit audiorecordings), and SP satisfaction with the visit (0-10 scale). Results Of 61 randomized resident PCPs (31 control group and 30 intervention group), 59 had encounters with 155 SPs during follow-up. Compared with control PCPs, intervention PCPs had similar patient-centeredness (Measure of Patient-Centered Communication, 43.9 [95% CI, 42.0 to 45.7] vs 43.7 [95% CI, 41.8 to 45.6], adjusted mean difference, −0.2 [95% CI, −2.9 to 2.5]; P = .90) and used a similar number of targeted techniques (5.4 [95% CI, 4.9 to 5.8] vs 5.4 [95% CI, 4.9 to 5.8] on a 0-9 scale, adjusted mean difference, 0 [95% CI, −0.7 to 0.6]; P = .96). Residents ordered low-value tests in 41 SP encounters (26.5% [95% CI, 19.7%-34.1%]) with no significant difference in the odds of test ordering in intervention PCPs relative to control group PCPs (adjusted odds ratio, 1.07 [95% CI, 0.49-2.32]). Rates of test ordering among intervention and control PCPs were similar for all 3 SP cases. The SPs rated visit satisfaction higher among intervention than control PCPs (8.5 [95% CI, 8.1-8.8] vs 7.8 [95% CI, 7.5-8.2], adjusted mean difference, 0.6 [95% CI, 0.1-1.1]). Conclusions and Relevance An SP-based intervention did not improve the patient-centeredness of SP encounters, use of targeted interactional techniques, or rates of low-value test ordering, although SPs were more satisfied with intervention than control residents. Trial Registration clinicaltrials.gov Identifier:NCT01808664

Overtreatment of asymptomatic bacteriuria (ASB) in patients with urinary catheters remains high. Health care professionals have difficulty differentiating cases of ASB from catheter-associated urinary tract infections.To evaluate the effectiveness and sustainability of an intervention to reduce urine culture ordering and antimicrobial prescribing for catheter-associated ASB compared with standard quality improvement methods.A preintervention and postintervention comparison with a contemporaneous control group from July 2010 to June 2013 at 2 Veterans Affairs health care systems. Study populations were patients with urinary catheters on acute medicine wards and long-term care units and health care professionals who order urine cultures and prescribe antimicrobials.A multifaceted guidelines implementation intervention.The primary outcomes were urine cultures ordered per 1000 bed-days and cases of ASB receiving antibiotics (overtreatment) during intervention and maintenance periods compared with baseline at both sites. Patient-level analysis of inappropriate antimicrobial use adjusted for individual covariates.Study surveillance included 289,754 total bed-days. The overall rate of urine culture ordering decreased significantly during the intervention period (from 41.2 to 23.3 per 1000 bed-days; incidence rate ration [IRR], 0.57; 95% CI, 0.53-0.61) and further during the maintenance period (to 12.0 per 1000 bed-days; IRR, 0.29; 95% CI, 0.26-0.32) (P .001 for both). At the comparison site, urine cultures ordered did not change significantly across all 3 periods. There was a significant difference in the number of urine cultures ordered per month over time when comparing the 2 sites using longitudinal linear regression (P .001). Overtreatment of ASB at the intervention site fell significantly during the intervention period (from 1.6 to 0.6 per 1000 bed-days; IRR, 0.35; 95% CI, 0.22-0.55), and these reductions persisted during the maintenance period (to 0.4 per 1000 bed-days; IRR, 0.24; 95% CI, 0.13-0.42) (P .001 for both). Overtreatment of ASB at the comparison site was similar across all periods (odds ratio, 1.32; 95% CI, 0.69-2.52). When analyzed by type of ward, the decrease in ASB overtreatment was significant in long-term care.A multifaceted intervention targeting health care professionals who diagnose and treat patients with urinary catheters reduced overtreatment of ASB compared with standard quality improvement methods. These improvements persisted during a low-intensity maintenance period. The impact was more pronounced in long-term care, an emerging domain for antimicrobial stewardship.

The Center for Medicare and Medicaid Services (CMS) recently decided to reimburse for annual lung cancer screening with low-dose computed tomography (LDCT) among personswhomeet the inclusioncriteria for theNationalLungCancer Screening Trial (NLST).1 Those who have smoked for more than30pack-years, continue to smoke,orquitwithin the past 15 years and are 55 to 77 years old will be eligible for free annual LDCT screening—roughly 6% of the US population older than 40 years.2 For the initial LDCT screening, a “lung cancer screening counseling and shared decision-making visit” will be required. Counseling visits will be reimbursed annually thereafter but will not be required.What considerations should be included in shared decision making? The Teachable Moment published in this issue by Schneider andArenberg3 reminds us that lung cancer screening—likemostmedicaldecision-making—isagamble; that there are good bets and bad bets—and that the odds are stacked against some people who will be eligible for LDCT screening. Thinking hard about how to optimally select people to screen is critically important as we move forward with populationbased lung cancer screening programs.

Although blood transfusion is a lifesaving therapy for some patients, transfusion has been named 1 of the top 5 overused procedures in US hospitals. As unnecessary transfusions only increase risk and cost without providing benefit, improving transfusion practice is an effective way of promoting high-value care. Most high-quality clinical trials supporting a restrictive transfusion strategy have been published in the past 5 to 10 years, so the value of a successful patient blood management program has only recently been recognized. We review the most recent transfusion practice guidelines and the evidence supporting these guidelines. We also discuss several medical societies' Choosing Wisely campaigns to reduce or eliminate overuse of transfusions. A blueprint is presented for developing a patient blood management program, which includes discussion of specific methods for optimizing transfusion practice.

Overuse of medical care is an increasingly recognized problem in clinical medicine.To identify and highlight original research articles published in 2015 that are most likely to reduce overuse of medical care, organized into 3 categories: overuse of testing, overtreatment, and questionable use of services. The articles were reviewed and interpreted for their importance to clinical medicine.A structured review of English-language articles on PubMed published in 2015 and review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults.Between January 1, 2015, and December 31, 2015, we reviewed 1445 articles, of which 821 addressed overuse of medical care. Of these, 112 were deemed most relevant based on their originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by consensus using the same criteria. Findings included a doubling of specialty referrals and advanced imaging for simple headache (from 6.7% in 2000 to 13.9% in 2010); unnecessary hospital admission for low-risk syncope, often leading to adverse events; and overly frequent colonoscopy screening for 34% of patients. Overtreatment was common in the following areas: 1 in 4 patients with atrial fibrillation at low risk for thromboembolism received anticoagulation; 94% of testosterone replacement therapy was administered off guideline recommendations; 91% of patients resumed taking opioids after overdose; and 61% of patients with diabetes were treated to potentially harmfully low hemoglobin A1c levels (7%). Findings also identified medical practices to question, including questionable use of treatment of acute low-back pain with cyclobenzaprine and oxycodone/acetaminophen; of testing for Clostridium difficile with molecular assays; and serial follow-up of benign thyroid nodules.The number of articles on overuse of medical care nearly doubled from 2014 to 2015. The present review promotes reflection on the top 10 articles and may lead to questioning other non-evidence-based practices.

Carotid ultrasonography is performed frequently to identify carotid stenosis in patients with no history of carotid-territory cerebrovascular ischemia. The premises of such testing are that the potential benefit of endarterectomy or stenting exceeds the potential harm in patients with asymptomatic stenosis and that discovery of asymptomatic stenosis may trigger beneficial changes in lifestyle or medical management that otherwise would not have occurred. However, given low contemporary rates of stroke in medically managed patients with asymptomatic carotid stenosis, invasive carotid procedures cannot be justified in this population. Moreover, among patients at increased cardiovascular risk, there is no evidence that carotid imaging motivates behavioral change or improves risk stratification beyond consideration of conventional risk factors. In this focused review, we address topics that should help health care professionals advise patients who inquire about carotid screening and patients in whom asymptomatic carotid stenosis has already been identified. We conclude that there is currently no role for carotid imaging in patients without a history of carotid-territory stroke or transient ischemic attack.

Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care.To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care.Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357).Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region.The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier.Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers).Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.

IMPORTANCE: Routine cancer screening has unproven net benefit for patients with limited life expectancy. OBJECTIVE: To examine the patterns of prostate, breast, cervical, and colorectal cancer screening in the United States in individuals with different life expectancies. DESIGN, SETTING, AND PARTICIPANTS: Data from the population-based National Health Interview Survey (NHIS) from 2000 through 2010 were used and included 27 404 participants aged 65 years or older. Using a validated mortality index specific for NHIS, participants were grouped into those with low ( .05 for all cancers). Our sensitivity analysis showed that screening was also common in individuals with less than 5-year life expectancy. CONCLUSIONS AND RELEVANCE: A substantial proportion of the US population with limited life expectancy received prostate, breast, cervical, and colorectal cancer screening that is unlikely to provide net benefit. These results suggest that overscreening is common in both men and women, which not only increases health care expenditure but can lead to net patient harm.