Inappropriate Utilization Research Articles

1507. Evaluating the Effects of a “Urinalysis to Reflex Culture” Process Change in the Emergency Department (ED) at a Veterans Affairs (VA) Hospital

BackgroundThe ED environment makes proactive collection of urine cultures (UCs) favorable. However, unnecessary UCs can result in over-detection and over-treatment of asymptomatic bacteriuria (ASB). A previous analysis at the study facility found that UCs were collected frequently despite negative urinalyses (UA), which commonly resulted in unnecessary antibiotics. Our objective was to compare the frequency of inappropriate UC utilization and inappropriate antibiotic prescribing post implementation of a “Urinalysis to Reflex Culture” process change intervention. A secondary objective was to assess the frequency of health encounters for UTIs post implementation.MethodsAfter education, an ED process change was implemented in October 2017. This included automatic UC cancellation if UAs had <5 WBC/HPF. An option for “do not cancel (DNC)” UC was available for specific conditions (eg. pregnancy) per guidelines. Data were prospectively collected for 3 months post-implementation and included UA/UC results, presence of UTI symptoms, antibiotics prescribed and healthcare utilization. Inappropriate UC was defined as a UC ordered despite negative UA in asymptomatic patients. Inappropriate antibiotic prescribing was defined as treatment in patients with ASB. A Student’s t-test and contingency tables were applied in SAS; significance was set at P ≤ 0.05.ResultsThere were 684 UAs (37.2% post-intervention) evaluated from ED visits. Post-intervention (n = 255 UAs), 37.3% of UAs were negative with UCs cancelled. Of the remaining UAs, 37.3% were positive with a processed UC, 16.9% were ordered as DNC and 8.6% were ordered without a UC. UC processing despite a negative UA significantly decreased from 100% pre-intervention to 38.6% post-intervention (P < 0.001). Inappropriate antibiotics for ASB also decreased from 10.2% pre-intervention to 1.9% post-intervention (OR = 0.17; P < 0.0110). In patients with negative UAs, antibiotic prescribing decreased by 25.3% post-intervention (P = NS). No reports of outpatient, ED, or hospital visits for UTI symptoms were found within 7 days of initial UA post-intervention.ConclusionA “UA to Reflex Culture” process change demonstrated a significant decrease in processing of inappropriate UCs and unnecessary antibiotics for ASB. There were no missed UTIs or other adverse patient outcomes.Disclosures All authors: No reported disclosures.

Prolonged partial thromboplastin time: To mix or not to mix – is that the question?

Routine mixing studies are frequently used to evaluate patients presenting with prolonged partial thromboplastin times (PTT) and/or prothrombin times (PT). Unfortunately, mixing studies have a number of inherent limitations including lack of standardization in terms of what defines normal pooled plasma (NPP), the processing of a patient’s plasma for platelet removal (platelet poor plasma versus platelet-free plasma), performance of appropriate controls, conducting an incubation step to evaluate for a time and temperature dependent inhibitor, and finally interpretation of test results. Moreover, misinterpretation of study results can lead to a delayed or incorrect diagnosis or worse, inappropriate treatment. Within this manuscript, we present four cases illustrating the shortcomings associated with inappropriate utilization and interpretation of routine mixing studies; and present practical steps for managing abnormal PT or PTT results.

Triage for low income countries: is ESI truly the way forward?

A triage desk at the doorstep of an emergency department (ED) is to “sort, select or prioritize” presenting patients as per their clinical needs. Many triage systems exist globally, however, the need and/or practical applicability of any triage is dictated by the hospital system and setting. In low-income/developing countries, the triage system must be capable and proficient enough to pair the right patient with the most appropriate management. Ineffective and/or in-efficient triage leads to overcrowding, delays, inappropriate resource utilization and patient dissatisfaction. A sizeable proportion of triage systems rely on three to five levels/tiers. Five level triage systems, such as the Australian Triage System (ATS) and the Canadian Triage Acuity Scale (CTAS), to name a few, are widely used worldwide. Based on door-to-physician time, these systems not only allow the institution to monitor and meet the timelines recommended by the institution policies, but have also been identified as an effective triage tool hence widely adopted in hospitals of developed countries. However, both ATS and CTAS are time-consuming and require skilled and qualified nursing staff to process it. On the other hand, the ESI (Emergency Severity Index) scale which is also a 5-level triage system, categorizes patients based on resource requirement and severity of the patient’s condition. Although ESI is in the developing phase, it is proving to be nurse-friendly and reliable in both intra and inter-rated conditions. The aim of this paper is to critically analyze the merits and pitfalls of the ESI system, in addition to proposing further modifications, in order to fulfill the needs of a developing country.

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.

Spinal shock in dogs and humans: clinical and comparative findings

Spinal cord lesion site is mainly localised through correct performance and interpretation of a full neurological examination. Decreased or absent spinal reflexes localises the lesion within that reflex arc (low motor neuron), while intact or increased spinal reflexes indicates a lesion cranial to the reflex arc (upper motor neuron). In acute and severe spinal cord injury, lesion localisation may be compromised by the presence of spinal shock, because in individuals with spinal shock, the clinical presentation shows discrepancy between spinal reflexes and lesion localisation, with loss of segmental spinal reflexes caudally to a lesion, although the intumescence may remain intact. Lack of recognition of spinal shock in these patients could lead to erroneous clinical localisation of the lesion, inappropriate utilisation of diagnostic tests and incorrect reporting of patient prognosis to the owner.

The benzodiazepine nation of Croatia: an observational, comparative study of psychotropic drug utilization between Croatia and Sweden 2014–2015

ABSTRACTBackground: The consumption of psychotropic drugs (PD) is increasing worldwide with a significant variation between countries. Croatia and Sweden have similar health and pharmaceutical systems; however, Sweden is a high-income country with developed medical care, registries, and prescribing guidelines. We sought to compare the utilization of PD between Croatia and Sweden to identify areas for improvement in rational use of drugs.Methods: This was a cross-sectional study using national databases to assess utilization of PD (ATC N05, N06) in Croatia and Sweden in 2014 and 2015.Results: Prescribing of PD in Croatia increased from 127 DDD/TID (defined daily dose/1000 inhabitants) in 2014 to 131 DDD/TID in 2015. In Sweden, the total utilization was higher with an increase from 183 DDD/TID in 2014 to 188 DDD/TID in 2015. There were substantial differences. In Croatia, the utilization of benzodiazepine derivatives (N05BA) was 72.5 DDD/TID in 2014 and increased to 74.4 DDD/TID, in 2015. In Sweden, the utilization was only 11.2 DDD/TID for benzodiazepine derivatives in both years.Conclusions: There were substantial differences in utilization of PD between Croatia and Sweden. Highlighting the problem of inappropriate benzodiazepine utilization in Croatia can help to introduce measures to change prescribing habits and improve prescribing quality.

Managing inappropriate utilization of laboratory resources.

Background The inappropriate use of laboratory resources, due to excessive number of tests not really necessary for patient care or by failure to order the appropriate diagnostic test, may lead to wrong, missed or delayed diagnosis, thus potentially jeopardizing patient safety. It is estimated that 5-95% of tests are currently used inappropriately, depending on the appropriateness criteria, thus significantly contributing to the potential of generating medical errors, the third leading cause of death in the US. Content In this review, we discuss the reasons as well as the medical and financial consequences of inappropriate utilization of laboratory tests. We then provide demand management (DM) tools as a means for overcoming this issue and also discuss their benefits, challenges, limitations and requirements for successful implementation. Summary and outlook When based on current evidence, adapted to local conditions and developed in close collaboration with clinicians, DM is a reasonable strategy for progressing toward better management of over- and underuse of laboratory resources.

Evaluation of potentially inappropriate medication utilization in elderly patients with cancer at outpatient oncology unit.

The aim of the study was to evaluate potentially inappropriate medication use in elderly patients with cancer. This study was conducted at outpatient oncology clinic from December 2014 to March 2015 among elderly cancer patients. Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment criteria were used to identify potentially inappropriate medication in elderly patients. Among 114 cancer patients 55.26% of them were male and the mean age of them was 71.78 ± 5.50 (years). The most common concurrent diseases were hypertension in 45 (39.47%) and diabetes in 26 (22.81%) patients. Polypharmacy (≥5 medications) was seen in 94.73% of them. Eighteen patients (15.79%) utilized medications inappropriately according to Screening Tool of Older Person's Prescriptions criteria. Medication omissions were identified in 112 patients (98.25%) with Screening Tool to Alert doctors to Right Treatment criteria. Clinical pharmacists could improve the current prescribing practices in elderly patients with cancer by assessing potentially inappropriate medications.

Towards preventive pharmacovigilance through medicine misuse identification: an example with recombinant human growth hormone for aesthetic purposes.

Historically, somatropin has been used for conditions related with ageing, but since the marketing of recombinant human growth hormone (rhGH), increasing promotional pressure has prompted aesthetic uses, despite lack of evidences about its efficacy and safety for those purposes. A routine analysis of the Pharmacovigilance Center of São Paulo (Brazil) showed reports of suspected adverse reactions in young adults and mature patients receiving rhGH. After presuming an off-label use of this expensive product, a drug utilisation study within the pharmacovigilance database has been carried out. The analysis showed a bimodal age distribution of the rhGH reports. Up to 17.1% of the 1289 reports (n = 220) involved patients aged ≥ 20years taking rhGH for off-label uses. This information was the basis to design interventions in order to reduce inappropriate utilisation of this expensive product. Analyses of how medicines are being used through pharmacovigilance databases are a way to identify its irrational utilisation, thus facilitating preventive actions to improve how medicines are used and reducing avoidable adverse effects.

Assessing adherence to current national guidelines for appropriate albumin use at an academic medical center.

Objective:To assess adherence to current national guidelines for appropriate albumin use at an academic medical center.Methods:This retrospective chart review of 150 randomly selected patients prescribed and administered at least one dose of albumin was conducted in an urban academic medical center to evaluate the adherence of albumin orders to current national guidelines. Inclusion criteria consisted of discharged patients at least 18-years-old admitted to the intensive care unit or medical/surgical unit from September 1, 2015 to August 31, 2016. The primary outcome was the number of patients who inappropriately received albumin based on national guidelines and FDA approved indications. Secondary outcomes included the number of patients who received the incorrect concentration or dose of albumin based on indication, as well as the cost associated with inappropriate albumin prescribing. Descriptive statistics were used to report outcomes.Results:There were 68 instances (45%) where albumin was prescribed inappropriately according to guideline recommendations. Of the 82 instances where albumin was used appropriately, 18 patients received an incorrect dose (22%), and 6 received the inappropriate concentration of albumin (7%). The cost for the 150 patients included in the study associated with inappropriate albumin prescribing was approximately $13,000.Conclusions:This study identified areas for pharmacist intervention to ensure appropriate albumin utilization, as well as proper dosing for the most frequently incorrectly dosed indications, including hepato-renal syndrome, spontaneous bacterial peritonitis, and paracentesis. This study also identified an unexpected indication with significant inappropriate albumin utilization, perioperative hypotension, which is an area for further intervention to monitor and decrease use.

Does Reverse Triiodothyronine Testing Have Clinical Utility? An Analysis of Practice Variation Based on Order Data from a National Reference Laboratory.

Clinical laboratories are under pressure to increase value by improving test utilization. The clinical utility of reverse triiodothyronine (rT3) is controversial. A study was conducted to identify order patterns that might suggest inappropriate utilization of rT3. All orders for thyroid tests placed over a period of one year at a national reference laboratory were reviewed. Order patterns by client (hospital) and by provider were analyzed. A Pareto analysis was conducted to determine the percentage of orders placed as a function of the percentage of providers. A systematic review of the indexed literature and an informal review of the web were conducted to identify indications for rT3 testing. There were 402,386 orders for 447,664 thyroid tests, including 91,767 orders for rT3. These orders were placed by 60,733 providers located at 1139 different organizations. Only 20% of providers who ordered thyroid tests placed an order for rT3. Of those who placed an order for rT3, 95% placed two orders or fewer for rT3. One hundred providers (0.1% of the 60,733 providers who placed orders for thyroid tests) accounted for 29.5% of the orders for rT3. Of the 100 providers, 60 with the highest order volumes for rT3 were classified as practitioners of functional medicine. A systematic review of Medline found little evidence to support the high volumes of orders for rT3. A survey of Web sites for functional medicine suggests that rT3 is useful for the diagnosis of rT3 dominance and can be used to direct triiodothyronine replacement therapy. There is wide practice variation in rT3 testing. A high proportion of tests are ordered by a relatively small proportion of providers. There is little evidence to support high volumes of rT3 testing placed by some practitioners.

A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool.

The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.

Asbestos in automotive waste. Contemporary recycling methods of waste from automotive industry

Increasing requirements concerning the environmental protection and waste management result in the development both new and effective recycling methods of various fractions of waste. From the technical and natural sciences point of view, the utilization of hazardous waste is essential. The inappropriate utilization of hazardous waste causes the environmental degradation. Particularly harmful waste is asbestos using not so long ago in many sectors of economy, including automotive industry. Despite of the ban of production and exploitation of asbestos, waste containing asbestos minerals are still in the environment.&#x0D; The necessity of the utilization of asbestos waste leads to the development of high-efficiency recycling methods with the application of different technologies. This paper shows the current state of knowledge concerning the asbestos waste with particular reference to the automotive industry. The recycling methods of asbestos used both in laboratory and industrial scale are also presented.

19. THE IMPLEMENTATION OF COGNITIVE ADAPTATION TRAINING (CAT) ACROSS COUNTRIES

Overall : Cognitive Adaptation Training is a psychosocial treatment using environmental supports such as signs, checklists, electronic devices and the organization of belongings to cue and sequence adaptive behavior in the home or work environment. In randomized trials, CAT has been found to improve multiple domains of functional outcome for individuals with schizophrenia including, social and occupational functioning, recidivism, medication follow through and community adjustment. Implementation of CAT has taken multiple forms across various countries. In Canada, a model has been adopted in which CAT is provided by occupational therapists (OT) for 4 months. During this time. the OT trains a caseworker to continue CAT after the 4 month time frame. This method has produced large effect sizes for sustained functional changes over time in patients receiving CAT treatment. In the Texas Money Follows the Person Behavioral Health Pilot, CAT has been used in conjunction with substance use treatment and managed care service coordination to assist people in moving from nursing facilities to community living. 65% of all enrollees in the program have sustained independent living at 1 year. Improvements in functional outcome are evidenced by significant improvement in social and occupational role functioning, community living and quality of life. In addition, cost savings to the state for these Medicaid recipients is sizeable. It takes only 1.4 additional months of community residence to recover intervention costs; 97% of participants met these criteria. Also in Texas, in a program for high utilizers of hospital and emergency services, CAT provided by bachelor’s and master’s level psychologists has been used to identify the unique cause of multiple hospitalizations and emergency visits, set up supports to address these problems, and reduce inappropriate service utilization. This program has reduced hospitalizations by 80% and saved an average of $40,000 per participant across 9 months. In Finland, CAT has been used to reduce the need for sheltered housing and for improving the quality of life for outpatients with psychosis. CAT has been found to fit well in the Finnish service system and providing interventions in the patient’s daily living environment has been found to be more suited to the patients’ need than traditional outpatient clinic visits. An outcome study is ongoing. In Australia, CAT has been adapted for the recent onset psychosis population by including greater use of technology and focusing on return to work and school. The versatility of the CAT program, its facility for training, and its ability to be adapted across cultures and countries suggests that CAT could be a useful tool in value-based care in which CAT is used to reduce the overall cost of care and to improve outcomes that matter to patients.

Abstract 174: Clinical Redesign Project to Improve Troponin Utilization at a University affiliated Community Hospital

Background: Cardiac troponin (CTn) is central to the diagnosis of acute coronary syndromes (ACS), however, in patients with low pre-test probability, the specificity of a positive CTn assay diminishes significantly. Overutilization of CTn assay is a rather prevalent problem and doctors often order further expensive testing for non-specific elevation in CTn. Methods: A clinical redesign team, formed in October 2015, defined four appropriate indications for ordering CTn assays, namely, chest pain, new EKG changes, cardiac arrest and angina equivalents such as shortness of breath and fatigue. We started by administering anonymous questionnaires, pertaining to CTn ordering practices, to different groups of healthcare providers at our hospital. Upon obtaining results of the questionnaire we executed a multifaceted intervention, including educational seminars and insertion of prompts in the electronic medical record system. We divided our study period into pre- and post-intervention periods of 1-year duration each and included a 17-week post-intervention interim analysis. We used Pearson’s correlation to test the null hypothesis that the pre- and post-intervention CTn assay volumes were not correlated and we used ANOVA to compare mean CTn assay volumes in the 38-week pre- and 17-week post-intervention period. Result: Overall: there was a 4% increase in ED patient volume and a 14% decrease in the total cTn order volume. Average cTn assays per ED patient decreased by 19%, from 0.26 to 0.21. The proportion of appropriate cTn assays increased post-intervention (45 vs 40% p=0.03). Interim analysis revealed a statistically significant decrease in weekly cTn order volume (r=0.903, p=0.0001). Percentage of cTn assays associated with a discharge diagnosis of ACS increased from 5.1% to 5.8% post-intervention (p= 0.001). Conclusion: cTn utilization can be effectively addressed by an organized multifaceted step-wise approach. Inappropriate utilization of cTn assays comes with associated cost implications due to the cost of the assay (nearly $50,000 cost savings in a year alone). It is quintessential to understand cTn ordering attitudes among different groups of healthcare providers. Our study also highlights the relevance of pre-test probability of ACS in any given patient before ordering cTn.

Antibiotic Use in the Intensive Care Unit: Optimization and De-Escalation

Appropriate antimicrobial therapy is essential to ensuring positive patient outcomes. Inappropriate or suboptimal utilization of antibiotics can lead to increased length of stay, multidrug-resistant infections, and mortality. Critically ill intensive care patients, particularly those with severe sepsis and septic shock, are at risk of antibiotic failure and secondary infections associated with incorrect antibiotic use. Through the initiation of active empiric antibiotic therapy based upon local susceptibilities, daily evaluation of signs and symptoms of infection and narrowing of antibiotic therapy when feasible, providers can streamline the treatment of common intensive care unit (ICU) infections. Optimizing antibiotic dosing through prolonged infusions can be beneficial in intensive care populations with altered pharmacokinetics. Antimicrobial stewardship teams can assist ICU providers in managing and implementing these tactics. This review will discuss the current literature on antibiotic use in the ICU applying antimicrobial stewardship strategies. Based upon the most recent evidence, ICUs would benefit from employing empiric guidelines for antibiotic use, collecting appropriate specimens and implementing molecular diagnostics, optimizing the dosing of antibiotics, and reducing the duration of total therapy. These strategies for antibiotic use have the potential to enhance patient care while preventing adverse outcomes.

Dose Township-County Service Utilization (TCSU) Influence Patient’ Choice Afterward?

Background: Patients tend to seek high-level institution for treatment inappropriately in recent years Rural China, Chinese government is seeking to optimize the supply of medical care through first point of care in the community and service collaboration between township hospital and county hospital. Objective: Township-County Service Utilization (TCSU) is a health-seeking behavior in which patients ask for medical help firstly in the township hospital and secondly in the county hospital for once disease within 30 days, it’s supposed to be an important model of service collaboration between township hospitals and county hospitals in China. Our aim is to explore whether TCSU could influence patient’s choice of medical institutions afterword. Methods: This study was carried out in Macheng city, Hubei province, China. TCSU patients were selected by Microsoft Office Excel 2010 based on the New Rural Cooperative Medical System (NCMS) database from 2012 to 2014. The inpatient and outpatient records happened in the township hospitals and county hospitals were extracted and were merged into one database as they shared the same patient identifier. If the interval time was less than 31 days for the same disease, the patient would be marked as TCSU patient. From 2012 to 2014, the number of TCSU patient in the sample county were 1410, 3462, 5147, respectively. TCSU patients’ yearly choice of medical institution were divided into two parts, before the TCSU and after the TCSU, by the time of their first TCSU in a year. Accumulated and compared the RCC (Ratio of choosing county hospitals) of all TCSU patients (4 types) before and after TCSU experience, then compared RCC in next year (2014) for TCSU patients of 2013 with that for the whole rural Results: 1) We selected out 2136 TC patients in total from 402 thousand residents, in general, the choice of hospitals for TCSU patients was changed after TCSU, and RCC increased significantly (23.2 vs 64.6 in 2012, 28.6 vs 58.2 in 2013, 28.7 vs 48.2 in 2014, P Conclusion: TCSU experience can influence on the patents’ choice of hospitals afterward, and TCSU patents are more likely to choose county hospitals when they fall ill next time, the influence can last a long time. Multi-institutional service maybe act an important role in inappropriate utilization, and more attention should be payed to the quality of service collaboration between township hospitals and county hospitals.

Analysis of antibiotic multi-resistant bacteria and resistance genes in the effluent of an intensive shrimp farm (Long An, Vietnam)

In Vietnam, intensive shrimp farms heavily rely on a wide variety of antibiotics (ABs) to treat animals or prevent disease outbreak. Potential for the emergence of multi-resistant bacteria is high, with the concomitant contamination of adjacent natural aquatic habitats used for irrigation and drinking water, impairing in turn human health system. In the present study, quantification of AB multi-resistant bacteria was carried out in water and sediment samples from effluent channels connecting a shrimp farming area to the Vam Co River (Long An Province, Vietnam). Bacterial strains, e.g. Klebsiella pneumoniae and Aeromonas hydrophila, showing multi-resistance traits were isolated. Molecular biology analysis showed that these strains possessed from four to seven different AB resistance genes (ARGs) (e.g. sul1, sul2, qnrA, ermB, tetA, aac(6)lb, dfrA1, dfr12, dfrA5), conferring multidrug resistance capacity. Sequencing of plasmids present within these multi-resistant strains led to the identification of a total of forty-one resistance genes, targeting nine AB groups. qPCR analysis on the sul2 gene revealed the presence of high copy numbers in the effluent channel connecting to the Vam Co River. The results of the present study clearly indicated that multi-resistant bacteria present in intensive shrimp cultures may disseminate in the natural environment. This study offered a first insight in the impact of plasmid-born ARGs and the related pathogenic bacteria that could emerged due to inappropriate antibiotic utilization in South Vietnam.

A quasi-experimental study for inappropriate laboratory utilization from a payer perspective in Cyprus

ObjectiveLaboratory tests have progressively acquired a dominant role in screening, diagnosis, disease monitoring and outcome assessment. This trend has also adversely led to the inappropriate ordering of laboratory tests, the results of which are highly unlikely to establish or change diagnosis, and, in extent, influence the treatment decision-making of a specific disease. This practice raises the cost of healthcare while it exposes patients to unjustified risk as healthcare professionals may be led to perform unnecessary procedures. Study DesignA quasi-experimental study in the form of an interrupted time series analysis was performed to assess the potential impact of introduction of co-payment on cholesterol test ordering. MethodsThis study was performed using public health care sector data from Nicosia General Hospital and Nicosia primary health care centers. Daily ordering for all outpatient cholesterol tests were tracked for 43 consecutive months; 33 months prior to, and 10 months after the introduction of this measure. ResultsCo-payment resulted in an instant and significant reduction in cholesterol test ordering. The measure's impact remained unchanged throughout the observation period. ConclusionCo-payment can be considered to be a potent and durable measure to successfully contain inappropriate laboratory ordering. However, the long–term effect of this measure must be assessed to ensure that co-payment does not exert a negative effect on public health.

Rate of Inappropriate Imaging Utilization by the Emergency Department in Community Hospitals

Objective: To retrospectively analyse the use of imaging studies in the Emergency Department of community hospitals using evidence based guidelines and clinical judgement. Methods: Medical records of 661 patients who visited the Emergency Department (ED) in 2015 and underwent imaging studies were reviewed. The Canadian Association of Radiologists, American College of Radiologists and Choosing Wisely Canada guidelines were used to determine the appropriateness of imaging studies. The use of prior patient imaging, the rate at which studies were repeated and the respective impacts on patient management of the imaging studies were also examined. Results: Of the 1056 imaging studies reviewed, 228 (22%) were found to be clinical situations where no imaging study was indicated while 168 (16%) were considered a suboptimal choice of imaging study or modality. When no study was recommended, a positive impact on the diagnosis was noted in 105 (46%) cases and on patient management 83 (36%) times. Notably, 219 (21%) patients had a relevant examination performed in the last 30 days, and 147 (14%) reports noted that the results of the prior study also concurred with the imaging study evaluated. Conclusion: In this study, 228 (22%) radiographs and CT studies, excluding MVC related imaging and extremity imaging, were not indicated based on appropriateness criteria and consequently had a limited impact on patient management. This supports the need for increased clinical decision support for ED physicians, regional health information exchanges and consideration of Computerized Physician Order Entry in the ED with embedded appropriateness criteria at the point of ordering.