Comparing the rates of low-value back images ordered by physicians and nurse practitioners for Medicare beneficiaries in primary care

BackgroundLittle is known about the extent of ordering low-value services by.PurposeTo compare the rates of low-value back images ordered by primary care physicians (PCMDs) and primary care nurse practitioners (PCNPs).MethodWe used 2012 and 2013 Medicare Part B claims for all beneficiaries in 18 hospital referral ?regions (HRRs) and a measure of low-value back imaging from Choosing Wisely. Models included random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician sex, the emergency department setting, back pain visit volume, organization, and region (HRR).FindingsPCNPs (N = 231) and PCMDs (N = 4,779) order low-value back images at similar rates (NP: all images: 26.5%; MRI/CT: 8.4%; MD: all images: 24.5%; MRI/CT: 7.7%), with no detectable significant difference when controlling for covariates.DiscussionPCNPs and PCMDs order low-value back images at an effectively similar rate.     

Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery

Demographic projections for hip fragility fractures indicate a rising annual incidence by virtue of a multimorbid, ageing population with more noncommunicable diseases (NCDs). NCDs are characterised by slow progression and long duration ranging from ischaemic cardiovascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease to various cancers. Management of this disease burden often involves commencing patients on oral anticoagulants to reduce the risk of thromboembolic events. The use of direct oral anticoagulants (DOACs) in clinical practice has increased due to their rapid onset of action, short half-life and predictable anticoagulant effects, without the need for routine monitoring. Safe and timely surgical intervention relies on reversal of anticoagulants. However, the lack of specific evidence-based guidelines for the perioperative management of patients on DOACs with hip fractures has proved challenging; in particular, the accessibility of DOAC-specific assays, justification of the cost-benefit ratio of targeted reversal agents and indications for neuraxial anaesthesia. This has led to potentially avoidable delays in surgical intervention. Following a literature review of the pharmacokinetic and pharmacodynamics of commonly used DOACs in our region including the role of surrogate markers, we propose a systematic, evidence-based guideline to the perioperative management of hip fractures DOACs. We believe this standardised protocol can be easily replicated between hospitals. We recommend that if patients are deemed suitable for a general anaesthesia, with satisfactory renal function, optimal surgical time should be 24 h following the last ingested dose of DOAC.