Providing high-value, cost-conscious care: a critical seventh general competency for physicians

There is general agreement that the U.S. economy cannot sustain the staggering economic burden imposed by the current and projected costs of health care. Whereas governmental approaches are focused primarily on decreasing spending for medical care, it is the responsibility of the medical profession to become cost-conscious and decrease unnecessary care that does not benefit patients but represents a substantial percentage of health care costs. At present, the 6 general competencies of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) that drive residency training place relatively little emphasis on residents' understanding of the need for stewardship of resources or for practicing in a cost-conscious fashion. Given the importance in today's health care system, the author proposes that cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a new, seventh general competency. This will hopefully provide the necessary impetus to change the culture of the training environment and the practice patterns of both residents and their supervising faculty.     

Appropriate use of rapid diagnostic testing for influenza

To determine a more timely acquisition of accurate results for influenza patients, a rapid diagnostic testing for influenza were studied on 877 pediatric patients performed during the 2002-2003 flu season in our hospital. Of these, 337 patients were finally diagnosed as influenza based on the test results and treated with antiviral agents, amantadine or oseltamivir. Ten (29%) of the 34 patients whose tests were negative within 12 hours after onset became positive over 12 hours after onset. On the other hand, diagnoses based on antigen tests over 12 hours after onset were reliable because all 13 patients first confirmed negative were unchanged when tested afterward. These 10 patients missed the opportunity to take antivirals early, which possibly caused them to have significantly longer (p = 0.0003) febrile duration and higher frequency of admission (p < 0.0001) than the 106 patients first confirmed positive within 12 hours after onset. Days from onset until starting antivirals (mean 1.4 days), the febrile duration (mean 2.7 days) and frequency of hospitalization (20.5%) of the 219 patients who tested positive over 12 hours after onset were significantly worse (p < 0.0001, p < 0.0001 and p = 0.0406, respectively) than those of patients testing positive within 12 hours after onset (mean 0.2 days, mean 1.7 days and 11.3%, respectively). The febrile duration (mean 2.3 days) of the patients confirmed positive even over 12 hours, but within 48 hours, of onset was tolerable but significantly longer (p < 0.0001) than that of patients confirmed positive within 12 hours after onset. The frequency (19.6%) of hospitalization of the patients confirmed positive even over 12 hours, but within 48 hours, of onset was not significantly different from that of patients confirmed positive within 12 hours after onset. These results suggested that over 12 hours but within 48 hours after onset of illness is the best period for the rapid diagnosis to correctly determine whether a patient should be treated with antiviral agents based on the result.     

High value, cost-conscious care: An international imperative

Health care costs in the United States are the highest in the world, and are continuing to rise at a level that is unsustainable. However, although this problem is more acute in the United States than elsewhere in the world, it is a challenge for all nations to control the costs of health care. The high cost of health care in the U.S. is not accompanied by a higher quality of care, but rather is related in large measure to health system "waste" that does not benefit patients but adds to cost. Representing approximately 30% of dollars spent on health care, this waste includes a significant amount of money spent on overuse and misuse of diagnostic testing, including screening tests. The American College of Physicians, the largest specialty society for physicians in the U.S., representing internal medicine and all of its subspecialties, has embarked upon a High Value, Cost-Conscious Care initiative, aimed at identifying areas of overuse and misuse of care, and leading to development of guidelines, educational materials, and other resources targeted to health care providers, trainees, and the general public. It is incumbent upon physicians, non-physician health care professionals, patients, and other health care stakeholders to address the issue of reducing care that is not appropriate, both to improve the overall quality of care and to reduce the associated unsustainable financial burden to society.     

Improved use of laboratory diagnostic tests

The effective use of laboratory results is less effected by improvement of the quality of analyses than by standardization and qualification of the pre-analysis as well as by improvement of the diagnostic value (interpretation). The predictive value of a laboratory result of constand sensitivity and specifity is established by the prevalence of the disease in the population group examined. By preceding general examinations (anamnesis, clinical examination) the prevalence and thus the predictive value is increased. Permanent exchange of information and experiences between physicians and laboratory scientists is an essential contribution to the improvement of medical care.     

Basic principles on selection and use of diagnostic tests: properties of diagnostic tests.

In clinical practice, in order to design and implement a specific therapeutic plan, as well as communicating an appropriate prognosis, the doctor needs to establish a precise diagnosis of the condition. Sometimes all one needs is a clinical impression. More often, however, the definition of an accurate diagnosis will mandate the interpretation of specific diagnostic tests as well. The rational use of diagnostic tests in cardiology--whether laboratorial or imaging--should be based on three factors: 1) validity of results of studies on the test; 2) diagnostic properties of the test; and 3) applicability of the test in the clinical setting. The rational use and the correct interpretation of diagnostic tests are based on these three factors. In a previous article we presented the basic principles concerning the validity of the results from the study that defined the specific test, and what level of evidence that constitutes. In this article we present the diagnostic properties of tests (sensitivity, specificity, positive and negative predictive values, likelihood ratios, odds). Finally, in a forthcoming paper we will discuss the applicability of the test in clinical cardiological practice.     

Promoting use of colorectal cancer screening tests

BACKGROUND: Colorectal cancer (CRC) screening is underutilized despite evidence that screening reduces mortality. OBJECTIVE: To assess the effect of an intervention targeting physicians and their patients on rates of CRC screening. DESIGN: A randomized clinical trial of community physicians and their patients. PARTICIPANTS: Ninety-four community primary care physicians randomly assigned to an intervention consisting of academic detailing and direct mailings to patients or a control group. Patients aged 50 to 79 years in the intervention group physicians received a letter from their physician, a brochure on CRC screening, and a packet of fecal occult blood test (FOBT) cards. MEASUREMENTS: After 1 year we measured receipt of the following: (1) FOBT in the past 2 years, (2) flexible sigmoidoscopy (SIG) or colonoscopy (COL) in the previous 5 years, and (3) any CRC screening. We report the percent change from baseline in both groups. RESULTS: 9,652 patients were enrolled for 2 years, and 3,732 patients were enrolled for 5 years. There was no increase in any CRC screening that occurred in the intervention group for patients enrolled for 2 years (12.7 increase vs 12.5%, P=.51). Similar results were seen for any CRC screening among patients enrolled for 5 years (9.7% increase vs 8.6%, P=.45). The only outcome on which the intervention had an effect was on patient rates of screening SIG (7.4% increase vs 4.4%, P<.01). CONCLUSION: With the exception of an increase in rates of SIG in the intervention group, the intervention had no effect on rates of CRC screening. Future interventions should assess innovative approaches to increase rates of CRC screening.     

A controlled trial to decrease the unnecessary use of diagnostic tests

A controlled trial evaluated a program to decrease the unnecessary use of inpatient testing by medical residents in a university medical center. The program included education, concurrent feedback, and resident participation in program planning. Using specific criteria for 7,891 chart audits of patients who had repeat tests within seven days, the authors measured change in testing among 44 residents in the first year and 43 in the second year. There were no significant differences related to the program. They conclude that substantial overuse of diagnostic tests did occur, that it varied from hospital to hospital, and that the program could not overcome powerful counteracting influences. Future studies, using control groups and chart audits, should evaluate interventions other than education. Received from the Section of General Medicine, Department of Medicine, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Williams is a Henry J. Kaiser Family Foundation Faculty Scholar and Associate Professor of General Medicine. Dr. Eisenberg is Sol Katz Associate Professor of General Medicine and Chief of the Section of General Medicine. Supported primarily by a grant from Blue Cross of Greater Philadelphia. Additional support came from the National Fund for Medical Education (sponsored by the Prudential Insurance Corporation of America) and the National Health Care Management Center at the Leonard Davis Institute of Health Economics (Grant No. HS 02557, National Center for Health Services Research).     

High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions

Health care costs in the United States are increasing unsustainably, and further efforts to control costs are inevitable and essential. Efforts to control expenditures should focus on the value, in addition to the costs, of health care interventions. Whether an intervention provides high value depends on assessing whether its health benefits justify its costs. High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may have little or no value if they provide little benefit. Thus, the challenge becomes determining how to slow the rate of increase in costs while preserving high-value, high-quality care. A first step is to decrease or eliminate care that provides no benefit and may even be harmful. A second step is to provide medical interventions that provide good value: medical benefits that are commensurate with their costs. This article discusses 3 key concepts for understanding how to assess the value of health care interventions. First, assessing the benefits, harms, and costs of an intervention is essential to understand whether it provides good value. Second, assessing the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur because the intervention was performed. Third, the incremental cost-effectiveness ratio estimates the additional cost required to obtain additional health benefits and provides a key measure of the value of a health care intervention.     

Recovery and use of Plasmodium DNA from malaria rapid diagnostic tests

The purpose of this study was to show that individual malaria rapid diagnosis tests (MRDTs) could also be used to isolate Plasmodium DNA for genetic studies. We extracted and amplified Plasmodium DNA using two commercial MRDT kits. Phenol/chloroform extraction followed by a nested polymerse chain reaction (PCR) can be used to identify Plasmodium falciparum and Plasmodium vivax from MRDTs. The PCR on MRDT-isolated DNA was more sensitive than antigen capture by MRDT. Satisfactory results were also obtained if older MRDT tests were used, even after long periods of storage at ambient temperature, with no special preservation.     

Osteoporosis: diagnostic screening and its place in current care

Osteoporosis, or decreased total bone mass, results from a number of factors: accelerated trabecular bone loss in postmenopausal women; age-related loss of trabecular and cortical bone; and multiple chronic diseases and medications. Routine laboratory and radiographic tests are not helpful in assessing bone turnover. However, a ratio of urinary calcium to creatinine exceeding 0.16 on a spot urine sample obtained in the fasted state suggests high bone turnover. Both single and dual photon absorptiometry are useful research tools but are unproved screening tests, especially in light of the more frequent use of preventive measures, such as postmenopausal hormone replacement therapy, calcium supplementation, and weight-bearing exercise.