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Poor adherence to prescription medication can compromise treatment effectiveness and cost the billions of dollars in unnecessary health care expenses. Though various interventions have been proposed for estimating adherence rates, few have been shown to be effective. Digital systems are capable of estimating adherence without extensive user involvement and can potentially provide higher accuracy with lower user burden than manual methods. In this paper, we propose a smartwatch-based system for detecting several motions that may be predictors of medication adherence, using built-in triaxial accelerometers and gyroscopes. The efficacy of the proposed technique is confirmed through a survey of medication ingestion habits and experimental results on movement classification.

Introduction Oncologists have increasingly been proponents of shared decision making (SDM) to enhance patient outcomes and reduce unnecessary health care spending. However, its effect on patient out-of-pocket costs is unknown. This study investigated the relationship between patient preferences for SDM and financial toxicity (FT) in patients with metastatic breast cancer (MBC). Patients and Methods This cross-sectional study utilized surveys of women aged ≥ 18 with MBC who received care at two academic hospitals in Alabama from 2017 to 2019. Patients self-reported their SDM preference (Control Preferences Scale) and FT (Comprehensive Score for Financial Toxicity [COST] tool; 11-item scale, with lower scores indicating worse FT). Effect sizes were calculated using the proportion of variance explained (R2) or Cramer’s V. Differences in FT by SDM preference were estimated using mixed models clustered by site and treating medical oncologist. Results In 95 women with MBC, 44% preferred SDM, 29% preferred provider-driven decision making, and 27% preferred patient-driven decision making. Patients preferring SDM were more often college educated (53% vs. 39%; V = 0.12) with an income greater than $40,000/y (55% vs. 43%; V = 0.18). Overall median COST was 22 (interquartile range, 16-29). After adjusting for patient demographic and clinical characteristics, patients preferring patient-driven decision making trended toward worse FT (COST 17: 95% confidence interval, 12-22) compared to those preferring SDM (COST 19: 95% confidence interval, 15-23) and those preferring provider-driven decision making (COST 22: 95% confidence interval, 17-27). Conclusion Patients preferring more patient-driven decision making reported worse FT, although differences did not reach statistical significance. Further research is needed to understand this relationship.

INTRODUCTION Persons living with dementia require assistance in making day-to-day and health care decisions. Health care professionals select treatments based on the care partner (CP) report of the person's function; however, the accuracy of CPs' appraisal has received limited exploration. METHODS Retrospective analyses of observational, programmatic data were performed across 161 dyads (CPs and persons with dementia) participating in an evidence-based, community-level dementia intervention program. We examined the differences in the appraisal of activities of daily living performance by CPs versus occupational therapists specialized in dementia treatment and investigated factors related to this discrepancy. RESULTS The discrepancy in the assessment of function is common between CPs and clinicians. CPs tend to overestimate the abilities of persons with dementia. Appraisal discrepancy was most strongly associated with (1) sex of the person with dementia, (2) timing of assessment performance, (3) number of behavioral symptoms of the person with dementia, and (4) cognitive abilities of the person with dementia. DISCUSSION Many factors influence the ability of CPs to appraise the function of persons with dementia. The inaccurate appraisal could result in insufficient daily assistance for, or even unnecessary health care utilization, of the person with dementia. Timeliness of intervention is crucial as their health status may change quickly.

Objective: Provide guidance for preventive health and health maintenance after spinal cord injury (SCI) for primary care providers (PCPs). Main message: Individuals with SCI may not receive the same preventive health care as the general population. Additionally, SCI-related secondary conditions may put their health at risk. SCI is considered a complex condition associated with many barriers to receiving quality primary care. Attention to routine preventive care and the unique health considerations of persons with SCI can improve health and quality of life and may prevent unnecessary health care utilization. Conclusion: PCPs are experts in preventive care and continuity of care, however individuals with SCI may not receive the same preventive care due to numerous barriers. This article serves as a quick reference for PCPs.

Quality improvement (QI) initiatives and health services research (HSR) are commonly used to target health care quality. These disciplines are increasingly important because of the movement toward value-based health care as alternative payment and care delivery models drive institutions and investigators to focus on reducing unnecessary health care use and improving care coordination. QI efforts frequently target medical error and/or efficiency of care through the Plan-Do-Study-Act methodology. Within the QI framework, strategies for data display (e.g., Pareto charts, run charts, histograms, scatter plots) are leveraged to identify opportunities for intervention and improvement. HSR is a multidisciplinary field of study that seeks to identify the most effective way to organize, deliver, and finance health care to maximize the quality and value of care at both the individual and population levels. HSR uses a diverse set of quantitative and qualitative methodologies, such as case-control studies, cohort studies, randomized control trials, and semistructured interview/focus group evaluations. This manuscript provides examples of methodologic approaches for QI and HSR, discusses potential challenges associated with concurrent quality efforts, and identifies strategies to successfully leverage the strengths of each discipline in care delivery.

Background: Medication errors pose a significant risk to patients, resulting in morbidity, mortality, and unnecessary health care utilization. Pharmacists, using their professional judgment, have an important role as a final check for identifying and resolving these problems. Little is known, however, about pharmacist perspectives and experiences with dispensing or withholding potentially dangerous prescriptions. Objectives: To ( a) evaluate the extent to which pharmacists would not dispense a likely harmful prescription which has been confirmed by the prescriber and ( b) assess pharmacist attitudes and experiences with dispensing likely harmful prescriptions. Methods: An anonymous, self-administered, 25-item survey was emailed to members of a state pharmacy association and a pharmacy college alumni list. A series of static prescription vignettes (1 reasonable and 4 likely dangerous doses) were presented and asked if they would fill each prescriber-confirmed prescription. Pharmacists also were asked a series of Likert-type, open-ended, multiple choice, and demographic items regarding their professional experiences and role perceptions. Results: There were 497 usable responses. Three of the 4 dangerous prescriptions were withheld by the majority of pharmacists (sumatriptan as the exception). No demographic variable was universally associated with filling dangerous vignette prescriptions; rather, there were vignette-specific differences. The majority of pharmacists reported refusing to fill a potentially harmful prescription during their career. Conclusions: There appears to be meaningful variation in how pharmacists react when presented with likely harmful prescriptions. More research is needed to better understand this role, its determinants, and the potential effects on patient safety.

BackgroundThere are few if any well-known approaches to reducing avoidable health care utilization and costs in patients with social needs. This study’s objective was to explore the goals, and approaches to organizing and delivering care, of interventions attempting to reduce avoidable resource use by addressing patients’ medical and social needs.MethodsSemi-structured interviews were conducted with study investigators about early interventions in the peer-reviewed literature. A template analysis approach was used to review interview transcripts for common themes and create a final code list. Coder dyads separately coded each interview and resolved any discrepancies.ResultsInterviews were conducted with 15 investigators of interventions that delivered a variety of health services and addressed several individual social needs. Participants frequently described their overall goal as meeting patients’ diverse needs to prevent unnecessary acute care utilization. Reported approaches to addressing medical needs included assistance with receipt of primary care and care coordination across settings. Social needs were described as tightly linked with medical needs; addressing social support and housing were perceived as distinct from addressing other social needs. Participants described their overall approach to meeting patients’ needs in terms of establishing connections, partnership, respect, and being adaptable to patients’ priorities.ConclusionsFindings shed new light on how to simultaneously address medical and social needs. Opportunities for future research include evaluating different approaches to addressing medical needs (primary care versus care coordination), separately evaluating the impacts of housing or social support, and hiring and training procedures to promote trauma-informed, patient-centered care.

The global pandemic caused by severe acute respiratory syndrome coronavirus 2 has upended surgical practice. In an effort to preserve resources, mitigate risk, and maintain health system capacity, nonurgent surgeries have been deferred in many jurisdictions, with urgent procedures facing increasing wait times and unpredictability given potential future surges. Shared decision making, a process that integrates patient values and preferences with the scientific expertise of clinicians, may be of particular benefit during these unprecedented times. Aligning patient choices with their values, reducing unnecessary health care use, and promoting consistency between providers are now more critical than ever before. We review important aspects of shared decision making and provide guidance for its perioperative application during the coronavirus disease 2019 pandemic.

Background National costs of lung cancer care exceed $12 billion. We investigate the resource-savings benefit of a single-day thoracic oncology multidisciplinary clinic (MDC) in the diagnostic period prior to non–small-cell lung cancer (NSCLC) treatment. Materials and Methods From July 2007 to January 2015, patients with NSCLC treated with multimodality therapy at a tertiary hospital-based cancer center in Maryland were identified. Patient and treatment details were collected. Health care resources utilized in the 90 days prior to receipt of first oncologic treatment were identified using billed activity codes. Associated total charges, including professional fees and hospital-based technical fees, were identified and inflated to 2014 dollars using the Consumer Price Index. Codes were categorized into provider visits, procedures, pathology/laboratory, radiology, and other tests. χ2, Student t, and Wilcoxon rank-sum tests compared charges of patients seen in and out of the MDC. Results Two-hundred ninety-seven (non-MDC = 161, 54%; MDC = 136, 46%) of 308 patients identified had total charges available. Patients seen through MDC had on average a 23% decrease in total charges per patient incurred ($5839 savings; range, $5213-$6464) compared with patients seen through non-MDC settings. Evaluation through MDC reduced the average number of provider visits per patient (non-MDC, 6.8 vs. MDC, 4.8; P Conclusions Evaluation of patients with NSCLC through a coordinated single-day MDC reduced hospital charges per patient by 23% during the diagnostic period prior to treatment when compared with evaluation through traditional referral-based thoracic oncology clinics.

A positive doctor-patient relationship is believed to play a key role in the healing process in clinics. While challenges to the doctor-patient relationship are a global concern, complex social contexts which introduce familial collectivism and totalitarian bureaucracy to maintain a doctor's authority have complicated doctor-patient relationships in China. This study delineates a multi-dimensional therapeutic landscape of hospitals in China, focusing on the doctor-patient relationship performances used to improve patients' healing experiences. Based on fieldwork in two primary hospitals in Eastern China, we find that primary hospitals in China are not only professional spaces, but hybrids of professional and non-professional spaces. In these spaces, both professional and other discourses in various forms of social-environmental engagement affect therapeutic experiences. Varying time and space in hospitals allow doctors to construct multi-dimensional therapeutic landscapes vis-a-vis patients to secure patients' compliance with their recommendations, and thus improve health outcomes. We argue that these dimensions may also cause negative therapeutic experience such as unnecessary health care. This study contributes to the literature on therapeutic landscapes of health care by providing a critical view on the construction of multi-dimensional therapeutic hospital landscapes. Furthermore, it links the critical health geographies literature with China's broader social context to explicate the cultural and social transformation of health care spaces in contemporary China. Findings from this study inform both theoretical and empirical debates regarding therapeutic landscapes of health care by embedding the professional spaces of health care into broader geographical discourses. This calls for health professionals to reflect on ethical concerns in multi-dimensional health care landscapes.

Introduction Unnecessary health care not only drive up costs, but also contribute to avoidable patient harms, underscoring an ethical obligation to eliminate practices which are harmful, lack evidence, and prevent spending on more beneficial services. To date, de-implementation ethics discussions have been limited and focused on clinical ethics principles. An analysis of de-implementation ethics in the broader context of the health care system is lacking. Methods To better understand the ethical considerations of de-implementation, recognizing it as a health care systems issue, we applied Krubiner and Hyder's bioethical framework for health systems activity. We examine ethics principles relevant to de-implementation, which either call for or facilitate the reduction of low value surgery. Results and Discussion From 11 health systems principles proposed by Krubiner and Hyder, we identified the 5 principles most pertinent to the topic of de-implementation: evidence and effectiveness, transparency and public engagement, efficiency, responsiveness, and collaboration. An analysis of de-implementation through the lens of these principles not only supports de-implementation but proves an obligation at the health system level to eliminate low value care. Recognizing the challenge of defining “value,” the proposed framework may increase the legitimacy and objectivity of de-implementation. Conclusions While there is no single ideal ethical framework from which to approach de-implementation, a health systems framework allows for consideration of the systems-level factors impacting de-implementation. Framing de-implementation as a health systems issue with systems-wide ethical implications empowers providers to think about new ways to approach potential roadblocks to reducing low-value care.

OBJECTIVES: The aim of the study was to validate rates of fever after pediatric gastrointestinal endoscopy, to describe clinical outcomes of postendoscopy fever (PEF) cases, and to assess the effect of a PEF clinical care guideline (CCG) on hospital use. PATIENTS AND METHODS: Episodes of PEF were reviewed from a large prospective database of all adverse events following pediatric gastrointestinal endoscopy at an academic children’s hospital. A CCG was implemented to standardize care of children with reported fever after endoscopy and reduce unnecessary resource use. Chi-squared analysis was performed to compare rates of hospital use for evaluation of PEF before and after implementation of the CCG. RESULTS: PEF occurred in 0.55% of the 27,100 endoscopies performed during the present study period. In the 150 cases of reported fever, the rate of identified endoscopy-related infection was low (4.0%). The rate of PEF was significantly higher in patients who underwent interventional procedures (0.81%) than those who underwent diagnostic endoscopy (0.51%, P = 0.02). In patients who experienced PEF, the CCG significantly reduced hospital use, decreasing emergency department visits and hospital admissions by 52.1% (P < 0.0001) without leading to negative patient outcomes. CONCLUSION: PEF in children rarely represents clinically significant infection and may be due in part to inflammation from tissue damage and/or physiologic stress. The present study shows that implementation of a PEF CCG may reduce unnecessary care while maintaining patient safety. Furthermore, multicenter studies are required to confirm the overall safety of similar clinical algorithms.

Medical child abuse (MCA) is a rare but potentially deadly variant of child maltreatment. MCA results in unnecessary health care for a child because of a caregiver's exaggeration, fabrication, or induction of physical and/or psychological symptoms of illness. These unnecessary health care interventions result in a morbidity rate of 100% in the form of complications and disabilities and a mortality rate as high as 9%. Although MCA is relatively rare, it is estimated that pediatric health care professionals, including pediatric nurse practitioners, will most likely encounter at least one MCA victim in the course of their career. This continuing education article will discuss MCA in terms of definition and features, epidemiology, perpetrators, variants in presentation, consequences, and implications for practice.

To maximize care quality and reduce unnecessary health care spending, Medicare Advantage plans can adopt a high-value care delivery model that includes three interventions — community, capability, ...

OBJECTIVES Although recent health care reform efforts have focused on minimizing high cost health care utilization, the relationship between acute care use and health care expenditures among certain vulnerable populations such as Medicaid-insured children remains poorly understood. We sought to evaluate the association between acute care utilization and health care expenditures and to identify characteristics associated with high spending. METHODS We performed a retrospective cohort study of Medicaid-enrolled children 1-21 years old from 1/1/2016 to 12/31/2016. Children were categorized by acute care use (including emergency department and urgent care visits) as 0, 1, 2, 3, and 4 or more visits. Our main outcomes were annualized spending, total per-member-per-year spending, and acute care-related per-member-per-year spending. RESULTS There were 5.1 million Medicaid-enrolled children that comprised the study cohort, accounting for US $32.6 billion in total spending. Children with 4 or more acute care visits were more likely to be younger than 2 years or older than 14 years, female, and have a chronic condition. Children with 4 or more acute care visits consisted of only 4% of the cohort but accounted for 15% (US $4.7 billion) of the total spending. Increasing acute care visits were associated with increasing total annualized spending in adjusted analyses (P < 0.001). This association was disproportionately observed in older age groups and children without chronic medical conditions. CONCLUSIONS Medicaid spending for children increases with increasing acute care use; this trend was disproportionately observed in older age groups and children without chronic medical conditions. Improved understanding of factors contributing to frequent acute care utilization and disproportionate spending is needed to potentially reduce unnecessary health care costs in these pediatric populations.

We present a case of a 60-year-old male diagnosed with Zollinger-Ellison syndrome (ZES) after a protracted multicentric workup for chronic diarrhea and unexplained weight loss. ZES is intrinsically difficult to diagnose due to nonspecific symptoms, which are mimicked by other more frequent pathologies, such as peptic ulcer disease secondary to Helicobacter pylori or nonsteroidal anti-inflammatory drugs. The diagnostic challenge can be further complicated by patient noncompliance, resulting in delayed management and unnecessary health care. In our case report, the patient did not adhere to the care plan preceding endoscopy and failed to maintain communication with the treating doctor. As a result, crucial information was missing, and establishing the diagnosis of ZES took six months. Delay in appropriate management also contributed to poor disease course, heavy necrotic ulceration of the duodenum and proximal jejunum that was discovered on repeat endoscopy.

Background Overuse of medical care is a major problem across health systems as well as in Iran. By our knowledge, this is the first scoping review in which medical overuse in the Iranian healthcare system was investigated. Objective To perform an inclusive search for original studies that report medical overuse in the Iranian healthcare system. Methods A systematic search of the literature conducted in bibliographic databases including PubMed, Embase, Scopus, Web of Sciences, Cochrane and Scientific Information Database using a comprehensive search strategy without time limit until the end of 2018, accomplished by reference tracking, author contacting and expert consultation to identify studies on the overuse of medical care. Results We reviewed 4124 published articles based on predetermined inclusion criteria. The author’s consensus included a total of 40 articles. Of these, 31 were in English and 9 in Farsi, published between 19975-2018. The result categorized into two distinct clinical areas: treatment (17 articles), and diagnostic (23 articles) services. Almost all of the studies only described the magnitude of unnecessary overuse. Unnecessary overuse of Antibiotics, MRI, and CT-scan were the most reported topics. The ranges of their overuse proportion were as follows; Antibiotic (31 to 97%); MRI (33 to 88%), and CT-scan (19 to 50%). Conclusions Our review showed, even so, the magnitude of unnecessary overuse of medical services is high but there are only a few interventional studies in clinical and administrative level for finding effective methods for decreasing these unnecessary services. Researchers should be encouraged to conducting interventional studies. We suggest the ministry of health to use the golden opportunity of COVID-19 epidemic for designing Iran national policy and action plan for controlling and preventing unnecessary health care services and including a section for “Interventional Research” in the action plan.

Background Perioperative patient education and engagement are critical components of care in patients undergoing bariatric surgery, given the short length of stay and the requirements to adhere to various instructions. The use of patient engagement mobile technology may promote adherence to perioperative protocols and improve care by potentially identifying complications earlier and reducing associated health care costs. Materials and methods We introduced a mobile app that provides bariatric patients with access to educational materials and the ability to report on their symptoms. Using the data from the app and linking the data to patient outcomes collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we examined the effects of the app on readmission, length of stay, visits to the emergency department (ED), and patient satisfaction. Results A total of 505 patients were enrolled in the app between July 2017 and March 2019. Among them, 396 patients who met the inclusion criteria for the study were compared with 458 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who were not enrolled in the app for the same study period. While the use of the app was not associated with the rates of prolonged length of stay, ED visits, and readmission, patients who completed a survey at 30 d after discharge reported that the app helped them avoid phone calls to the hospital (48.5%) and ED visits (13.0%). Furthermore, 94.8% of these patients reported that they would recommend the app to other patients undergoing the same surgery. Conclusions Additional features, such as the ability for patients to directly communicate with the health care providers within the app, may be effective in decreasing unnecessary health care utilization.

Antibiotic stewardship aims to better patient outcomes, reduce antibiotic resistance, and decrease unnecessary health care costs by improving appropriate antibiotic use. More than half of annual antibiotic expenditures for antibiotics in the United States are prescribed in the ambulatory setting. This review provides a summary of evidence based strategies shown to improve antibiotic prescribing in ambulatory care settings including: providing education to patients and their families, providing education to clinicians regarding best practices for specific conditions, providing communications training to clinicians, implementing disease-specific treatment algorithms, implementing delayed prescribing for acute otitis media, supplying prescribing feedback to providers with peer comparisons, using commitment letters, and prompting providers to justify antibiotic prescribing for diagnoses for which antibiotics are not typically recommended. These various mechanisms to improve stewardship can be tailored to a specific practice's work flow and culture. Interventions should be used in combination to maximize impact. The intent with this review is to provide an overview of strategies that pediatric providers can take from paper to practice.

BACKGROUND Choosing Wisely Canada is an initiative to reduce overprescribing and overtesting. This study assessed adherence to 4 Choosing Wisely Canada recommendations for interventions commonly performed in primary care: (a) antibiotic prescriptions for infections that are probably viral in origin, (b) routine vitamin D tests in low-risk adults, (c) annual screening blood tests and (d) prescriptions of antipsychotic medication to treat symptoms of dementia. METHODS We conducted a retrospective cohort study of data from the electronic medical records of patients who had an encounter between 2014 and 2016 with a participating Manitoba Primary Care Research Network primary care provider in Manitoba, Canada. Patient encounter data were reviewed for prescribing and testing practices. Descriptive statistics and multivariable models assessed associations between patient and provider characteristics and rates of prescribing and testing. RESULTS Data for 164 195 patients from 230 providers were included in the study. Sixteen percent (n = 25 629) of patients had an encounter that involved potentially unnecessary diagnostic testing and treatment. A minority of providers contributed to above-average rates of prescribing and testing: 29% (n = 69) of providers prescribed antibiotics for a viral indication,11% (n = 24) prescribed an antipsychotic to a patient diagnosed with dementia, 9% (n = 24) ordered prostate-specific antigen tests and 14% (n = 34) ordered vitamin D tests at above-average rates, respectively. Patient and provider characteristics were associated with each of the prescribing and testing practices assessed. INTERPRETATION This study demonstrated that fewer than 30% of primary care providers contributed to interventions in direct contradiction to Choosing Wisely Canada recommendations. Improvement strategies specific to each prescription or testing recommendation should target specific providers to prevent patient harm and reduce unnecessary health care spending.

The 30-day all-cause readmission rate following coronary artery bypass graft (CABG) surgery is considered an important outcome measure for patients because higher rates can be an indicator of low quality and unnecessary health care costs. Our research uses rigorous methods to explore the impact of mandatory public reporting of all-cause readmission rates following CABG surgery in California. We used a hierarchical logistic regression model on 173, 823 CABG patient records. This model standardised outcomes across 10 U.S. states that were not previously comparable due to different CABG definitions and metrics. Additionally, in order to account for the differences in medical practice across different states, we applied a differencein-difference method to estimate the impact of public reporting. Finally, a recycled prediction method was used to estimate the number of averted readmissions following public reporting initiation in California.

Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.

Objectives To evaluate the prevalence of potentially unnecessary repeat testing (PURT) and the associated economic burden for an inpatient population at a large academic medical facility. Methods We evaluated all inpatient test orders during 2016 for PURT by comparing the intertest times to published recommendations. Potential cost savings were estimated using the Centers for Medicare & Medicaid Services maximum allowable reimbursement rate. We evaluated result positivity as a determinant of PURT through logistic regression. Results Of the evaluated 4,242 repeated target tests, 1,849 (44%) were identified as PURT, representing an estimated cost-savings opportunity of $37,376. Collectively, the association of result positivity and PURT was statistically significant (relative risk, 1.2; 95% confidence interval, 1.1-1.3; P < .001). Conclusions PURT contributes to unnecessary health care costs. We found that a small percentage of providers account for the majority of PURT, and PURT is positively associated with result positivity.

Objective: To identify older adults who could benefit from integrated care, we examined (a) health, social, and functional characteristics of older, hospitalized adults who required continuing care on discharge and (b) associations between these characteristics and potentially unnecessary health care use. Method: Personal characteristics were extracted from patient charts ( N = 214) and examined in relation to three outcomes: discharge to institutional care, unnecessary hospital stay (alternative level of care), and long hospital stay. Results: Twenty-nine percent of the sample was discharged to an institution, 32.7% was coded as alternate level of care, and 27.6% had a long length of stay. Independent predictors of potentially avoidable health care use were mental and behavioral issues, living alone, functional status, and preadmission concerns about the patient managing in the community. Discussion: High users of health care services were identifiable prior to hospital admission, supporting the use of community-based integrated care approaches.

Unnecessary health care is a tremendous problem that negatively impacts individuals and also increases health care costs across the system. While much scholarly attention has been paid to the role of patients and providers, payors' role in contributing to the problem is underexplored. The article recommends that payors should nudge providers away from unnecessary care by requiring electronic alerts intended to deter unnecessary care.

The American health care system has undergone several reforms and is likely to undertake another reformation soon, given the sociopolitical landscape. Shifts from fee-for-service (FFS) to value-based reimbursement (VBR) models continue to transfer a significant percentage of clinical and financial risk from payers to providers. Value-based models aim to reduce potentially unnecessary health care costs, improve the quality of care provided, and increase efficiency. 1 This aim cannot be attained unless all health care providers are completely clear about their accountabilities and competent in their professional roles.

The Centers for Medicare and Medicaid Services has proposed alternate payment models to improve the efficiency and decrease the redundancy of health care. Bundled payments or episode-based care is one example. Herein, we report on the successful implementation of a quality improvement project in which changing the clinical workflow for postoperative radiation treatment to the hip to prevent heterotopic ossification improved the efficiency of patient care and decreased cost by eliminating redundant imaging through multidisciplinary participation. This project is a model for interdisciplinary collaboration to improve patient care and reduce unnecessary health care spending in the era of bundled payment/episodes of care program implementation.

Background Radiographic neuroimaging in minor pediatric head injuries contains risks of radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) head injury protocol identifies head-injured children who are at very low risk of clinically important traumatic brain injuries and can safely not receive a head computed tomography (CT) scan. Local problem The identified urgent care facility had no facility-wide protocol to manage head injuries. Methods The purpose of the evidence-based practice project was to educate health care providers on the risks of indiscriminate head CT prescription and the utility of the PECARN head injury protocol in the management of minor pediatric head injuries. Interventions A knowledge assessment was conducted using pre- and posttests and the likelihood to adopt the PECARN head injury protocol in clinical practice was evaluated using the Evidence-Based Practice Attitude Scale. Additionally, rates of head CT scans ordered that were inappropriate according to the PECARN head injury protocol were calculated postproject and compared with preproject rates. Results Data analysis was performed using descriptive statistics. Findings included increase in provider knowledge on the use of the PECARN head injury protocol and high likelihood of intent to adopt the PECARN head injury protocol in clinical practice. In addition, rates of head CT prescription postproject were lower than preproject rates, and 82.61% of CT scans ordered postproject were appropriate according to the PECARN head injury protocol. Conclusions Using the PECARN head injury protocol was associated with consistency of care, reduced unnecessary health care resource utilization, and health care costs.

Background: Noninvasive telemonitoring (TM) can be used in heart failure (HF) patients to perform early detection of decompensation at home, prevent unnecessary health care utilization, and decrease health care costs. However, the evidence is not sufficient to be part of HF guidelines for follow-up care, and we have no knowledge of how TM is used in the Nordic Baltic region. Objective: The aim of this study was to describe health care professionals (HCPs) perception of and presumed experience with noninvasive TM in daily HF patient care, perspectives of the relevance of and reasons for applying noninvasive TM, and barriers to the use of noninvasive TM. Methods: A cross-sectional survey was performed between September and December 2016 in Norway and Lithuania with physicians and nurses treating HF patients at either a hospital ward or an outpatient clinic. A total of 784 questionnaires were sent nationwide by postal mail to 107 hospitals. The questionnaire consisted of 43 items with close- and open-ended questions. In Norway, the response rate was 68.7% (226/329), with 57 of 60 hospitals participating, whereas the response rate was 68.1% (310/455) in Lithuania, with 41 of 47 hospitals participating. Responses to the closed questions were analyzed using descriptive statistics, and the open-ended questions were analyzed using summative content analysis. Results: This study showed that noninvasive TM is not part of the current daily clinical practice in Norway or Lithuania. A minority of HCPs responded to be familiar with noninvasive TM in HF care in Norway (48/226, 21.2%) and Lithuania (64/310, 20.6%). Approximately half of the HCPs in both countries perceived noninvasive TM to be relevant in follow-up of HF patients in Norway (131/226, 58.0%) and Lithuania (172/310, 55.5%). For physicians in both countries and nurses in Norway, the 3 most mentioned reasons for introducing noninvasive TM were to improve self-care, to reduce hospitalizations, and to provide high-quality care, whereas the Lithuanian nurses described ability to treat more patients and to reduce their workload as reasons for introducing noninvasive TM. The main barriers to implement noninvasive TM were lack of funding from health care authorities or the Territorial Patient Fund. Moreover, HCPs perceive that HF patients themselves could represent barriers because of their physical or mental condition in addition to a lack of internet access. Conclusions: HCPs in Norway and Lithuania are currently nonusers of TM in daily HF care. However, they perceive a future with TM to improve the quality of care for HF patients. Financial barriers and HF patients condition may have an impact on the use of TM, whereas sufficient funding from health care authorities and improved knowledge may encourage the more widespread use of TM in the Nordic Baltic region and beyond. Funding Agencies|NordForsk Nordic Program on Health and Welfare [76015]

David W Polly,1,2 Daniel Cher3 1Department of Orthopedic Surgery, 2Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 3SI-BONE, Inc., San Jose, CA, USA Background: Increasing evidence supports minimally invasive sacroiliac joint (SIJ) fusion as a safe and effective treatment for SIJ dysfunction. Failure to include the SIJ in the diagnostic evaluation of low back pain could result in unnecessary health care expenses. Design: Decision analytic cost model. Methods: A decision analytic model calculating 2-year direct health care costs in patients with chronic low back pain considering lumbar fusion surgery was used. Results: The strategy of including the SIJ in the preoperative diagnostic workup of chronic low back pain saves an expected US$3,100 per patient over 2 years. Cost savings were robust to reasonable ranges for costs and probabilities, such as the probability of diagnosis and the probability of successful surgical treatment. Conclusion: Including the SIJ as part of the diagnostic strategy in preoperative patients with chronic low back pain is likely to be cost saving in the short term. Keywords: chronic low back pain, lumbar fusion, sacroiliac joint pain, sacroiliac joint fusion, healthcare costs, decision modelingCorrigendumfor this paper has been published

Background and Objectives: Urinary tract infections (UTIs) are a common condition in women. Guidelines have been published on the diagnosis and management of such infections with the twin goals of improved patient safety and avoiding unnecessary health care costs. In this study we evaluated both physicians’ knowledge of these guidelines, and whether that knowledge translates to their clinical practice. Methods: We performed a retrospective chart review of UTI management before and after an educational intervention in a family medicine residency. Two control sites were also included. We also assessed physicians’ knowledge of current UTI management guidelines using an anonymous quiz. Results: At the intervention site, guideline adherence improved following the educational session. Inappropriate culture use decreased from 88% to 68% (P

This thesis investigates, for the first time, contemporary regulation practices for the nascent private health care sector in Mongolia for the achievement of Universal Health Coverage (UHC). The number of private health care providers has been increasing dramatically in Mongolia during the last two decades. Identifying conducive ways of harnessing and regulating private health care providers is a pressing policy issue for the Mongolian mixed health system in moving towards UHC. However, this issue is yet to be extensively examined. No evidence currently exists on the role of private providers and the appropriateness of current regulatory policy for the achievement of UHC. The lwhat, how, and whyr of the constraining and enabling factors of effective regulation remain largely unknown. This lack of evidence on the contribution of private providers affects not only Mongolia, but developing countries generally. Hence, this comprehensive and rigorous case study of regulation of the private health care sector in Mongolia makes a significant contribution to the advancement of regulatory policy and practices in that country, and informs similar developing countries, in particular, Post-Soviet states.This thesis uses a case-study approach employing both qualitative and quantitative methods. First, in order to define the current role of private providers in the provision of accessible, affordable, and equitable health services, nationally representative hospital admission records for 2013 (n=664,952), have been analysed. This quantitative analysis was supplemented with a qualitative analysis of in-depth interviews and document reviews to clarify findings. Second, to identify the gaps in regulatory policy design and implementation, stepped qualitative analysis by Sheikh et al. (2015) has been employed. Document review and analysis were complemented by participant observation and semi-structured in-depth interviews with 45 purposively-selected key informants. Third, to understand how and why regulation of private health care fails or succeeds in Mongolia, regulatory policy analysis has been conducted. The main sources of data used are the analytical synthesis of research findings, in-depth interviews, document reviews, and long-term participant observation of evolution of the system in Mongolia.This thesis has found that until this point, the contribution of the private sector to improving the system performance has been limited. Private-for-profit hospitals are concentrated in urban areas (60% of private hospital admissions were located in Ulaanbaatar, while 95% of private admissions outside Ulaanbaatar were in provincial capitals), deepening the existing rural/urban mal-distribution already established by public providers. Subsequent duplication of public and private services, both in terms of their geographical location and the range of services delivered has led to unnecessary admissions and unnecessary health care costs, having negative financial implications for both patients and overall health expenditure.This thesis has found the private sector contributes to improving access to services for disadvantaged and rural patients, filling in barriers for accessing the public sector. But, the corollary to this enhanced access is a rise in out-of-pocket payments. Private hospitals, even those that are affiliated with the national health insurance scheme, rely heavily on out-of-pocket payments. Patients paid an average of USD $172 for a private admission lsubsidizedr by health insurance, which is unaffordable for average Mongolians, especially for disadvantaged patients. This becomes even more critical when these disadvantaged patients are forced to utilize high-cost private services due to the structural barriers to accessing the public sector, where hospitalization is almost free.This thesis has also found that the regulatory architecture for health care in Mongolia is not optimally designed to improve affordability and quality of private care. The imprecise content and details of regulation in the existing law invite increased political interference. The leadership of the government has failed to establish good governance in health regulation through not engaging key actors in health regulation, nor addressing the fragmentation of different government regulators. These governance issues in the system have been facilitated by a policy of lde-regulationr that has shaped the main lrules of the gamer since the 1990s, guided by a strong privatization discourse. Currently, this is contradicting the focus on UHC, which is a critical global health discourse aimed at ensuring equity in access to quality and affordable care, but requiring more elaborate regulation. This thesis concludes that for the achievement of UHC, a strategic direction which defines the complementary role of private providers in order to optimize public-private service mix is critical. Steering the mixed system in the context of the competing discourses of privatization and UHC is not a simple task, but more elaborate regulation of private health care in mixed systems may bridge these two. A system perspective is critical rather than an isolated approach to private provider regulation, in a context where private providers and their regulation have become an importantmbut not the onlymconcern in implementing UHC.n n

Importance Emerging efforts to recognize and combat medical overuse are important solutions to mitigate patient morbidity from unnecessary health care interventions. Objectives To identify and highlight important original investigations on medical overuse in dermatology from 2017 to 2018. Evidence Review The PubMed and Embase databases coupled with articles published in 8 major dermatology and medical journals from January 1, 2017, to December 31, 2018, were searched to identify articles related to medical overuse in dermatology. Findings Of 1941 candidate articles identified through the database search and 41 through the manual journal review, 38 were deemed relevant to medical overuse in dermatology by 2 independent reviewers. Twenty-eight of these articles were determined to be high priority based on scoring for quality of methods, magnitude of clinical effect, and number of patients potentially affected. After expert reviewer scoring, 10 articles were selected for analysis based on highest scores and greatest clinical significance. Selected articles covered topics such as dermatology consultation for cellulitis, management of dysplastic nevi, prognostic utility of sentinel lymph node biopsy, laboratory monitoring for terbinafine and isotretinoin, and safe medication prescribing. For cellulitis management, dermatology consultation is important for reducing misdiagnosis, unnecessary hospitalization, and inappropriate use of antibiotics. Findings related to common dermatologic procedures revealed that clinical observation is safe for dysplastic nevi and that sentinel lymph node biopsy may not have prognostic utility over Breslow thickness. In monitoring for terbinafine and isotretinoin, patient education on clinical symptoms is likely more effective than standard laboratory test result monitoring. Finally, dermatologists should reconsider the use of cyclosporine in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis and reevaluate the use of perioperative narcotics for patients. Conclusions and Relevance This review notes actionable, evidence-based practices to reduce medical overuse in dermatology. This work may help to facilitate management changes to emphasize high-value care in dermatology while promoting awareness and further evaluation of overuse in medicine.

Background: The Choosing Wisely campaign aims to reduce unnecessary testing. Over testing for urinary tract infections and concomitant overtreatment of asymptomatic bacteriuria is a target of this campaign, aiming to decrease healthcare costs and the risks of side effects such as Clostridium difficile infection, adverse reactions, and antimicrobial resistance. During the study baseline (2017), 95 urine cultures (UC) were sent for every 1000 ED visits (9.5%). Of these, fewer than 20% were positive. Aim Statement: The aim of this improvement initiative was to reduce UC testing in the ED, by 50%, from a baseline average of nearly 100 cultures per 1000 ED patients visits, to 50 cultures per 1000 visits, by May 31st, 2018. Measures & Design: This was an interrupted time series study, analyzed using Statistical Process Control (SPC) methodology. Root cause analysis was performed using an Ishikawa diagram. A Pareto chart was completed via multi-voting. A Driver Diagram was developed using the highest ranked items from the Pareto chart to identify locally relevant and feasible interventions. Interventions 1) Medical directives were modified; Routine paired sending of UC with urinalysis by nurses was removed. 2) Physician Education and implementation of a clinical decision aid (CDA); A CDA was created using PDSA methodology, using an iterative approach from development through implementation. Outcome measure: rate of Urine Cultures sent per 1000 ED patient visits Process measure: percent of positive cultures Balancing measures: rate of 14-day ED return visits and hospital admission for patients diagnosed with UTI/Urosepsis/Pyelonephritis. Evalution/Results: At the study's conclusion, there was a decrease in UC rate, from 95 per 1000 ED visits, to 59 per 1000 ED visits (RR 38%, AR 3.6%) There was evidence of special cause variation on the SPC chart. Positive cultures increased from 19% to 34%. There was no increase in the rate of ED 14-day return visits or hospital admission for patients with a diagnosis of UTI, urosepsis or pyelonephritis. Discussion/Impact: The study interventions of uncoupling routine sending of UA and UC, and physician education and use of a clinical decision aid, effectively decreased the rate of UC testing during the study period. A reduction in inappropriate UC testing is important to limit avoidable patient morbidity and reduce unnecessary health care spending. Further studies are indicated to target interventions on patient subgroups and to reduce unnecessary antibiotic prescriptions.

The Institute of Medicine report entitled The Health Care Imperative: Lowering Costs and Improving Outcomes discussed numerous ways to decrease costs in the health care system without decreasing quality. The use of evidence-based medicine, eliminating wasteful spending such as needlessly high administrative costs, having more preventive services, having a better reimbursement system that emphasized quality, developing a less fragmented and more efficient medical delivery system, having more transparency for patients on the outcomes of different providers, having greater health care literacy for patients, and eliminating fraud were some of the recommendations. The total savings from eliminating unnecessary health care costs was estimated to be over 3 quarters of a trillion dollars each year.

There is a growing interest in identifying strategies to achieve safer primary health-care provision. However, most of the research conducted so far in this area relies on information supplied by health-care providers, and limited attention has been paid to patients’ perspectives. Objective: To explore patients’ experiences and perceptions of patient safety in English general practices with the aim of eliciting patient-centred recommendations for improving patient safety. Methods: The Patient Reported Experiences and Outcomes of Safety in Primary Care questionnaire was sent to a random sample of 6736 primary care users registered in 45 English practices. We conducted a qualitative content analysis of responses to seven open-ended items addressing patients’ experiences of safety problems, lessons learnt as a result of such experiences and recommendations for safer health care. Results: A total of 1244 (18.4%) participants returned completed questionnaires. Of those, 678 (54.5%) responded to at least one open-ended question. Two main themes emerged as follows: (i) experiences of safety problems and (ii) good practices and recommendations to improve patient safety in primary care. Most frequent experiences of safety problems were related to appointments, coordination between providers, tests, medication and diagnosis. Patients’ responses to these problems included increased patient activation (eg speaking up about concerns with their health care) and avoidance of unnecessary health care. Recommendations for safer health care included improvements in patient-centred communication, continuity of care, timely appointments, technical quality of care, active monitoring, teamwork, health records and practice environment. Conclusion: This study identified a number of patient-centred recommendations for improving patient safety in English general practices. Fil: Ricci Cabello, Ignacio. University of Oxford; Reino Unido Fil: Saletti, Lorena. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad. Universidad Nacional de Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad; Argentina Fil: Slight, Sarah. University Of Durham; Reino Unido Fil: Valderas, Jose Manuel. University of Exeter; Reino Unido

Objective To understand whether high-cost users of medical care with and without comorbid mental illness or addiction differ in terms of their sociodemographic and health characteristics. Unique characteristics would warrant different considerations for interventions and service design aimed at reducing unnecessary health care utilization and associated costs. Methods From the top 10% of Ontarians ranked by total medical care costs during fiscal year 2011/2012 (N = 314,936), prior 2-year mental illness or addiction diagnoses were determined from administrative data. Sociodemographics, medical illness characteristics, medical costs, and utilization were compared between those high-cost users of medical care with and without comorbid mental illness or addiction. Odds of being a frequent user of inpatient (≥3 admissions) and emergency (≥5 visits) services were compared between groups, adjusting for age, sex, socioeconomic status and medical illness characteristics. Results High-cost users of medical care with comorbid mental illness or addiction were younger, had a lower socioeconomic status, had greater historical medical morbidity, and had higher total medical care costs (mean excess of $2,031/user) than those without. They were more likely to be frequent users of inpatient (12.8% vs 10.2%; adjusted OR, 1.14; 95% CI: 1.12–1.17) and emergency (8.4% vs 4.8%; adjusted OR, 1.55; 95% CI: 1.50–1.59) services. Effect sizes were larger in major mood, psychotic, and substance use disorder subgroups. Conclusions High-cost medical care users with mental illness or addiction have unique characteristics with respect to sociodemographics and service utilization patterns to consider in interventions and policies for this patient group.

Background China has a large population of children under 18 years of age, whose health is of great concern to the Chinese health care system. However, few studies have been conducted to analyze the factors associated with children’s unnecessary health care utilization in China. The objective of this study is to provide some empirical evidence on this issue by investigating the role of parental health care utilization in children’s unnecessary health care use. Methods The data were obtained from the fifth Health Service Survey of Shaanxi province in 2013. We employed three dependent variables to measure children’s health care utilization: the number of children’s outpatient visits during the past 2 weeks, whether or not infusion was used if the child had any outpatient visits during the past 2 weeks, and the number of children’s inpatient visits during last year. Based on specific characteristics of these outcome variables, negative binomial models were used for the non-negative numbers of outpatient and inpatient visits, while a probit model was used for the zero-one indicator variable showing whether infusion was used during outpatient visits. Results Based on a sample of 11,024 children, our results of multivariate analysis showed that children whose parents used outpatient care were estimated to have a larger number of outpatient visits than those whose parents did not have outpatient visits in the past 2 weeks (with a difference of 0.0393 visits). Among children having outpatient visits in the last 2 weeks, the probability of obtaining infusion was 57.01 percentage points higher for children whose parents used infusion in the past 2 weeks than the probability for those whose parents did not use infusion. The predicted number of inpatient visits was higher for children whose parents used inpatient services in the last year, compared with the group whose parents did not use (with a difference of 0.0567 visits). Moreover, we noted that the positive association between parental and children’s health care use was more prominent among younger children. Conclusions Chinese children whose parents were high health care users were more likely to overuse health care services, holding other factors constant. Parents can play an important role in reducing children’s unnecessary outpatient visits, infusion use, and inpatient visits. The results suggest that interventions aimed at affecting patterns of parental use may be helpful in improving appropriate health care utilization for children.

2014 Noreen M. Clark’s career as practitioner and professor of health behavior and health education spanned many years in the field, and her extensive writings on management of chronic disease, self-regulation, physician care education, and translation and dissemination have greatly contributed to the shift in emphasis from medical solutions to self-management of chronic illness. Noreen often pointed out that over half of the population worldwide lives with at least one chronic disease, and that most everyone will be touched either directly or indirectly by the effects of a chronic illness. The financial and human costs of chronic disease are tremendous. Noreen also noted that Americans have a tendency to medicalize health-related problems, and to depend on physicians and drugs to solve them, even though in many instances this has not been an effective approach (Clark, 2009). Researchers and practitioners have made numerous calls for enhancing capacity to increase the critical role that individuals and their families play in the management of chronic disease, and the need for our health systems to educate and support individuals (and their families) to manage their disease on their own (Clark, 2009). Noreen clearly voiced the need to shift our focus to self-management programs if we want to have a major effect on improving quality of life, reducing unnecessary health care use, and cutting health care expenditures (Clark, 2009). In addition, Noreen’s influence extended beyond the United States and spanned other topics such as addressing social determinants of health through community and coalition approaches worldwide. This tribute issue contains eight selected publications written by Noreen and her colleagues over the 31-year period from 1982 to 2013 to represent some of the key areas of her work. The purpose of compiling this collection of her writings is both to honor her legacy and to bring attention to the influence of Noreen’s work on the field of public health and health care. We hope this compilation will make available to present and future generations of health educators the theoretical principles, self-management perspective, and focus on vulnerable populations that Noreen so strongly advocated and advanced. We recognize that one volume alone, however, cannot capture adequately the extensive reach she has had on the theory, research, and practice of health education.

133 Background: Specialty palliative care (SPC) has been shown to improve quality of life, reduce unnecessary health care utilization, reduce overall costs, and decrease mortality in some settings for patients with advanced or metastatic cancer, however only a small proportion are being promptly referred. As interventions that respond to patient reported outcomes (PROs) have been shown to improve symptoms and decrease mortality, we hypothesized that the rates of SPC referral would be increased by documenting, tracking, and presenting PROs for oncology visits to referring oncologists. Methods: Over a period of 2 months, 74 English-speaking established patients seen in an advanced breast cancer clinic with an embedded SPC service were approached and completed the study. All patients filled out the electronic, validated PROMIS and PRO-CTCAE PRO questionnaires in the waiting room using a touch screen tablet. Results were presented to the oncologist during the encounter if the CTCAE severity score exceeded 3 in at least 1 domain. Patient demographics, clinical features and PC referrals or appointments were assessed via chart review. Results: At baseline, 9 (12.2%) patients scored a minimum of “severe” (4/5 or 5/5) in at least 1 of the 3 anxiety domains; 17 (23.0%) had moderate-severe pain; and 27 (32.1%) reported fatigue. At study entry, 25 patients (33.8%) had been referred previously to the SPC service; 19 had actually been seen (76% of referred). Of the 63 (85.1%) patients with sufficient follow-up, 13 (20.6%) reported at least “severe” in >1 CTCAE domains, 6 (46.2%) of whom were previously referred to SPC. For the remaining 7 patients, median PROMIS T-score and PRO-CTCAE maximum severity score were 58.3 and 3.2, respectively; none were referred to SPC during the follow up period. Conclusions: The choice to refer (or not to refer) a patient to SPC is complex and tied to patient specific factors such as coordinating additional visits and fear of end of life conversations. To enable greater access to SPC, alternative referral mechanisms, such as group-based or personalized patient education, or automatic referrals triggered by evidence of need, may be required. #YRL/CDM contributed equally.

This paper analyzes the public healthcare expenditure of Middle Eastern countries in relation to different exogenous explanatory variables, through a panel study involving twelve (12) Middle East countries. More specifically, the study methodology uses panel cointegration, and panel-based error correction models derived from annual data covering the period of 2000 to 2010. The empirical results support a short-run co-integration relationship after allowing for the heterogeneous country effect. The long-run relationship is estimated using a full-modified OLS. The results of a ten-year panel study have been interpreted and commented. The public healthcare expenditure of our countries is explicated to a great extent by the single country GDP. Other strong correlation variables were found also to be statistically significant. The research reveals that e-health programming and e-health governance could lead to a decrease in unnecessary health care expenditure.

The objectives of this study are to identify whether the small area variation also exists in the oriental medicine and, if it exists, what causes, to expand our boundary of research interests on the small area variation observed at the western medicine toward the oriental medicine as one of the fundamental research foundations and to provide any fundamental findings from this study results to the healthcare politicians to promote consumer`s rational behaviors for the use of healthcare. This study analyzed the health insurance claim data (2010, 2011) which were the patients of western medicine and the outpatients of the oriental medicine with the top 10 most frequent diseases and looked into the variation of healthcare utilization among the areas after grouping resident area into an 86-area category. The study result shows that the small area variation was also observed at the part of the oriental medicine in which the characteristics of patients critically affect the healthcare expenditure per visit day rather than those of providers and the characteristics of both patients and providers equally affect the healthcare expenditure per patient. Therefore, this study suggests that government set up healthcare policies on the standardization of oriental medicine to prevent its over-utilization and unmet need, enforcing the roles of oriental medicine in the markets, enhancing the appropriate health care utilization, and expanding provision and sharing the health care information to reduce unnecessary health care utilization.

Objectives Failed back surgery syndrome (FBSS) affects 40% of patients following spine surgery with estimated costs of $20 billion to the US health care system. The aim of this study was to assess the cost differences across the different insurance providers for FBSS patients. Methods A retrospective longitudinal study was performed using the Truven MarketScan® database to identify FBSS patients from 2001 to 2012. Patients were grouped into Commercial, Medicaid, or Medicare cohorts. We collected one-year prior to FBSS diagnosis (baseline), then at year of spinal cord stimulation (SCS)-implantation and nine-year post-SCS implantation cost outcomes. Results We identified 122,827 FBSS patients, with 117,499 patients who did not undergo an SCS-implantation (Commercial: n = 49,075, Medicaid: n = 23,180, Medicare: n = 45,244) and 5328 who did undergo an SCS implantation (Commercial: n = 2279, Medicaid: n = 1003, Medicare: n = 2046). Baseline characteristics were similar between the cohorts, with the Medicare-cohort being significantly older. Over the study period, there were significant differences in overall cost metrics between the cohorts who did not undergo SCS implantation with the Medicaid-cohort had the lowest annual median (interquartile range) total cost (Medicaid: $4530.4 [$1440.6, $11,973.5], Medicare: $7292.0 [$3371.4, $13,989.4], Commercial: $4944.3 [$363.8, $13,294.0], p Conclusions Our study demonstrates a significant difference in overall costs between various insurance providers in the management of FBSS, with Medicaid-insured patients having lower overall costs compared to Commercial- and Medicare-patients. SCS is cost-effective across all insurance groups (Commercial > Medicaid > Medicare) beginning at two years and continuing through nine-year follow-up. Further studies are necessary to understand the cost differences between these insurance providers, in hopes of reducing unnecessary health care expenditures for patients with FBSS.

Objectives: The objective of this study was to examine overall trends in Emergency Department (ED) visits among adults with and without multiple chronic conditions (MCC) by urgency of visit (nonurgent, urgent, primary care sensitive) and across relevant population subgroups. Methods: Using data from the Nationwide Emergency Department Sample (NEDS) for 2007-2012 maintained by the Healthcare Cost and Utilization Project (HCUP), we examined trends in ED visits among adults who were diagnosed as having no chronic conditions (0CC), one chronic condition (1CC), and MCC based on the Clinical Classification Software codes. Separate trend analyses were conducted for ED visits that were classified as urgent, nonurgent, and primary care sensitive (PCS) based on the New York University (NYU) ED Algorithm. Trend analyses were also conducted for several population subgroups: age, sex, metropolitan hospital status, Census Region, insurance status, and median income quartiles by ZIP code. Results: Between 2007 and 2012, the overall percentage change in nonurgent ED visits made by adults with 0CC, 1CC and MCC were 8.05%, 22.50% and 35.36% respectively (p

Summary Estimates suggest that one third of United States health care spending results from overuse or misuse of tests, procedures, and therapies. The American Board of Internal Medicine Foundation, in partnership with Consumer Reports , initiated the “Choosing Wisely” campaign to identify areas in patient care and resource use most open to improvement. Nine subspecialty organizations joined the campaign; each organization identified five tests, procedures, or therapies that are overused, are misused, or could potentially lead to harm or unnecessary health care spending. Each of the American Society of Nephrology’s (ASN’s) 10 advisory groups submitted recommendations for inclusion. The ASN Quality and Patient Safety Task Force selected five recommendations based on relevance and importance to individuals with kidney disease.Recommendations selected were: ( 1 ) Do not perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms; ( 2 ) do not administer erythropoiesis-stimulating agents to CKD patients with hemoglobin levels ≥10 g/dl without symptoms of anemia; ( 3 ) avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension, heart failure, or CKD of all causes, including diabetes; ( 4 ) do not place peripherally inserted central catheters in stage 3–5 CKD patients without consulting nephrology; ( 5 ) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.These five recommendations and supporting evidence give providers information to facilitate prudent care decisions and empower patients to actively participate in critical, honest conversations about their care, potentially reducing unnecessary health care spending and preventing harm.

The concepts for classification, diagnosis and referral of patients with axial spondyloarthitis differ, although they of course basically relate to the same disease. While classification criteria and referral strategies concentrate largely on patients with chronic back pain with an age at onset before 45 years, the rheumatologist can make a diagnosis of axial SpA in patients with late onset or in patients with back pain for only some weeks if other items are fulfilled. Early recognition of patients with axial SpA is important to establish the diagnosis, potentially start therapeutic interventions and avoid unnecessary health care procedures.

Background Variation in physicians' practice patterns contributes to unnecessary health care spending, yet the influences of modifiable determinants on practice patterns are not known. Identifying these mutable factors could reduce unnecessary testing and decrease variation in clinical practice. Objective To assess the importance of the residency program relative to physician personality traits in explaining variations in practice intensity (PI), the likelihood of ordering tests and treatments, and in the certainty of their intention to order. Methods We surveyed 690 interns and residents from 7 internal medicine residency programs, ranging from small community-based programs to large university residency programs. The surveys consisted of clinical vignettes designed to gauge respondents' preferences for aggressive clinical care, and questions assessing respondents' personality traits. The primary outcome was the participant-level mean response to 23 vignettes as a measure of PI. The secondary outcome was a certainty score (CS) constructed as the proportion of vignettes for which a respondent selected “definitely” versus “probably.” Results A total of 325 interns and residents responded to the survey (47% response rate). Measures of personality traits, subjective norms, demographics, and residency program indicators collectively explained 27.3% of PI variation. Residency program identity was the largest contributor. No personality traits were significantly independently associated with higher PI. The same collection of factors explained 17.1% of CS variation. Here, personality traits were responsible for 63.6% of the explained variation. Conclusions Residency program affiliations explained more of the variation in PI than demographic characteristics, personality traits, or subjective norms.

Asthma is a chronic health condition, which results in avoidable exacerbations of disease and unnecessary health care expenditures (Seung and Mittmann 2005). Despite the development and dissemination of asthma clinical guidelines for over a decade, optimal care has not been achieved (Boulet et al. 2001). While hospital discharge databases have been frequently used for epidemiological research on asthma, this necessarily only provides information on the more severe and most poorly controlled patients (Wilchesky, Tamblyn, and Huang 2004). On the other hand, population-based administrative health databases provide the opportunity to identify factors associated with suboptimal care of asthma in ambulatory care. In Canada, ambulatory data are routinely collected and available through population-based insurance and reimbursement databases. Each province administers a universal health plan for all eligible residents. Payment of physicians on a fee-for-service basis provides a record of each service delivered to a beneficiary. In addition, provincial-specific drug insurance programs provide information on drugs dispensed from community pharmacists for each beneficiary. These data can be used to create a longitudinal record of medical services and prescribed drug use by linking information for an individual using an encrypted health care number. One of the challenges in using such administrative databases to identify predictors of poor health outcomes is the difficulty in accurately identifying patients with asthma. Several epidemiological studies have used the reason for the medical visit, coded using the International Classification of Diseases 9th version (ICD-9) diagnostic codes in the medical service claims database, as a marker of physician-diagnosed asthma (Smith, Rascati, and McWilliams 2004). However, the validity of the ICD-9 asthma diagnosis codes in the Canadian medical services claims data have been shown to have poor-to-moderate sensitivity in spite of good specificity (Kozyrskyj, Mustard, and Becker 2004; Wilchesky, Tamblyn, and Huang 2004;). In contrast, when the utilization of medication from the prescription claims database is used as a marker of asthma, sensitivity is drastically improved (Osborne et al. 1995; Pont et al. 2002; Abrahamowicz et al. 2007;). Several previous studies used the combined information from the medical service and prescription claims databases in identification of asthma (Twiggs et al. 2002; Vollmer et al. 2004;); however, to the best of our knowledge, the diagnostic properties and the incremental value of using the medical service as well as prescription claims database have not been evaluated.

Objectives In 2006, the Alberta Ministry of Health issued a policy to implement fetal fibronectin (fFN) testing as a publicly funded service for pregnant women. The goals were to reduce maternity health care utilization and unnecessary treatment, which would result in cost-savings for the health system by more accurately diagnosing false preterm labour. We conducted a post-policy implementation review to determine whether the policy implementation achieved its goals. Methods We assessed the impacts of fFN testing on clinical decision-making for ambulance transfer, hospital admission, and length of hospital stay by comparing these variables between the tested and untested patients. This post-implementation analysis was conducted separately for inpatients and outpatients and for true and false preterm labour, using multilevel regressions with episodes or visits being nested within patients. We then assessed the impact of fFN testing on costs to the health system by using decision-tree models populated with actual data and results from the regressions. Results The additional information, provided by fFN testing, influenced clinical decision-making. However, physicians placed a greater significance on positive test results than on negative results, which resulted in an inadvertent increase in health care utilization. After including the costs of fFN testing, the total cost to the system increased by $4.2 million (in 2014 Canadian dollars) between 2008 and 2013, with contributions of $700 000 for false labour and $3.5 million for true preterm labour. Conclusion The policy to adopt fFN testing in Alberta did not achieve the intended aims of reducing unnecessary health care utilization to achieve cost-savings for the health system. There was an inherent tendency to err on the side of caution, and physicians were influenced more by positive test results.