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.     

A method for testing low-value spatial clustering for rare diseases

This paper proposes a method that tests for the existence of low-value spatial clustering while accounting for the influence of high-value clustering. Although the method was developed in reference to the Tango test, it can be extended to other testing methods. The simulation results showed that the proposed method is able to effectively detect low-value clustering with substantially lower rates of type I errors than those of the Tango test, while maintaining comparable statistical power. Applying the method in a case study of leukemia in Minnesota demonstrated an overall tendency toward low-value clustering of leukemia mortality for males but provided inconclusive results for females.     

Effects of employer-offered high-deductible plans on low-value spending in the privately insured population

Enrollment in plans with high deductibles has increased more than seven-fold in the last decade. Proponents of these plans argue that high deductibles could reduce wasteful spending by providing patients with incentives to limit use of low-value services that offer little or no clinical benefit. Others are concerned that patients may respond to these incentives by reducing their use of medical services indiscriminately and regardless of clinical benefit, which may negatively impact health outcomes. This study uses individual-level insurance claims data (2008–2013) and plausibly exogenous changes in plan offerings within firms over time to estimate the intent-to-treat and local-average treatment effects of high-deductible plan offerings on spending on 24 low-value services received in the outpatient setting. We find that firm offer of a high-deductible plan leads to a 13.7% ($5.23) reduction in average enrollee spending on low-value outpatient services and a 5.2% ($105.77) reduction in overall outpatient spending. We also find reductions in spending on measures of low-value imaging and laboratory services. We find some evidence that offering high-deductible plans disproportionately reduces low-value spending relative to overall spending, indicating that deductibles may be a way to incentivize value-based decision making.     

水产低值鱼抗菌肽研究进展

抗菌肽是生物防御系统产生的一类对抗外源性病原体的肽类物质,具有抗细菌、真菌、病毒、原虫、癌细胞等多种活性,目前发现抗菌肽或类似抗菌肽的小分子肽类广泛存在于昆虫、两栖类、水产动物及哺乳动物中,具有广阔的应用前景。现就抗菌肽的理化特征、结构特点、应用前景等几个方面系统地阐述水产低值鱼抗菌肽的研究进展。     

Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy

ObjectivesTo describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered “low-value”, and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations.MethodsWe analyzed 2002–2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression.ResultsFrom 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: ?3.1%; 95%CI ?4.7, ?1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: ?2.2%; 95%CI ?3.0, ?1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: ?0.6%; 95%CI ?2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI ?1.9, 2.0]; ?0.9% [95%CI ?3.1, 1.3]; and ?1.2% [95%CI ?5.3, 2.9], respectively).ConclusionsBefore and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.     

Biases distorting priority setting

Modern health care faces an ever widening gap between technological possibilities and available resources. To handle this challenge we have constructed elaborate systems for health policy making and priority setting. Despite such systems many health care systems provide a wide range of documented low-value care while being unable to afford emerging high-value care. Accordingly, this article sets out asking why priority setting in health care has so poor outcomes while relevant systems are well developed and readily available. It starts to identify some rational and structural explanations for the discrepancy between theoretical efforts and practical outcomes in priority setting. However, even if these issues are addressed, practical priority setting may still not obtain its goals. This is because a wide range of irrational effects is hampering priority setting: biases. By using examples from the literature the article identifies and analyses a wide range of biases indicating how they can distort priority setting processes. Overuse, underuse, and overinvestment, as well as hampered disinvestment and undermined priority setting principles are but some of the identified implications. Moreover, while some biases are operating mainly on one level, many are active on the micro, meso and on the macro level. Identifying and analyzing biases affecting priority setting is the first, but crucial, step towards improving health policy making and priority setting in health care.     

医院低值耗材管理系统的设计

目的:提高医院低值耗材的管理水平,通过医院物资管理部门对低值耗材的统一管控,及时准确地掌握材料购进、保管和使用情况,实现对低值耗材专业化、信息化的管理。方法:以计算机网络技术为基础,根据医院低值耗材的采购、请领及使用流程,对医疗管理制度和各种医疗资源的数字化整合,建立医院低值耗材管理系统,构建科学合理的耗材信息化平台。结果:该系统解决了低值耗材品种种类多、使用频率高及需求量大而引起的缺乏统一管理、使用与存储缺乏有效监管及浪费现象严重等多项难题。结论:该系统使医院低值耗材管理实现专业化、信息化,可有效提高工作的透明度和效率,建立起无纸化、信息化及网络化的医院耗材管理新模式。     

Choosing Wisely after a sport and exercise-related injury

Low-value care is receiving substantial attention in many fields of medicine but little-to-none in sports medicine. Common interventions for sport and exercise-related injuries include medical imaging, medication, surgery and rehabilitation, but there is emerging evidence of the inappropriate use of these interventions.This chapter aims to increase awareness of low-value care in sports medicine by answering four key clinical questions: Does my patient need imaging? When is it appropriate to prescribe opioids? Does my patient need surgery? Does it matter how rehabilitation is delivered? Increasing awareness of low-value care in sports medicine will ensure patients with sport or exercise-related injuries avoid care that provides little-to-no benefit or causes harm and receive care that is evidence based and truly necessary.There are many situations when imaging, opioids, surgery and supervised rehabilitation are entirely appropriate. However, this chapter considers contexts where use of these interventions could be considered unnecessary and potentially harmful.     

Recomendaciones «no hacer» para retinopatías: estudio mixto de consenso

Background and objectiveAmong the main causes of blindness and severe vision loss are age-related macular degeneration, diabetic macular oedema, and retinal vein occlusion. The «Do Not Do» recommendations are strategies to improve quality of care and optimise healthcare costs. The aim of this study was to establish, by consensus, practices of low value in the above-mentioned pathologies, in addition to estimating their occurrence.Materials and methodsMixed methods study including a first phase of consensus of a multidisciplinary panel of experts using the Nominal Group technique. In the second phase, a retrospective observational study was conducted, by conducting a review of medical records.ResultsA total of 7 recommendations were established for age-related macular degeneration, 4 for diabetic macular oedema, and 5 for retinal vein occlusion. A total of 1,012 medical records were reviewed by the 4 participating hospitals. The review of medical records revealed that agreed «Do Not Do's» occurred in a range between 0.6% and 31.4% of the cases included in the study.ConclusionsThis study identified «Do Not Do» recommendations in these pathologies that occur relatively often in clinical practice. It is necessary to review the healthcare processes that will enable these practices to be eradicated, and the quality of care to be improved.     

ABC分类法在医院低值耗材仓库管理中的应用

该研究通过收集2019年1—6月医院低值耗材的发出数据,按照ABC分类法进行统计分析,并采用周转率、周转天数等财务指标进行衡量评价,对于不同种类(A、B、C类)的低值耗材采取不同的管理措施,同时提出整体建议以提高低值仓库的管理效率,避免库存积压。