Overuse Of Health Care Resources Research Articles

Misdiagnosis of pancreatic intraductal papillary mucinous neoplasms and the challenge of mimicking lesions: imaging diagnosis and differentiation strategies.

The rising prevalence of pancreatic cystic lesions (PCLs), particularly intraductal papillary neoplasms (IPMNs), has been attributed to increased utilization of advanced imaging techniques. Incidental detection of PCLs is frequent in abdominal CT and MRI scans, with IPMNs representing a significant portion of these lesions. Surveillance of IPMNs is recommended due to their malignant potential; however, their overlapping imaging features with benign entities can lead to misdiagnosis, overtreatment, and overutilization of healthcare resources. This paper aims to highlight and differentiate lesions often mistaken for IPMNs, providing insight into their imaging characteristics, diagnostic challenges, and distinctive features while highlighting the incidence of wrong diagnosis for these lesions. These lesions include serous cystadenomas, cystic pancreatic neuroendocrine tumors, mucinous cystic neoplasms, lymphoepithelial cysts, duodenal diverticula, pancreatic schwannomas, chronic pancreatitis, retention cysts, intrapancreatic accessory spleens, pancreatic lipomas, choledochal cysts, and others. Utilizing various imaging modalities, including contrast-enhanced CT, MRI, and EUS, alongside histological and molecular analyses, can aid in accurate diagnosis and appropriate management. Understanding these mimicry scenarios is crucial to avoid unnecessary surveillance, interventions, and the burden they place on both patients and healthcare systems. Improved recognition of these lesions can lead to better patient outcomes and resource allocation.

Development of a Complex Care Transition Team to Improve the Transition of Patients With Complex Care Needs to the Community.

Health care systems have historically struggled to provide adequate care for patients with complex care needs that often result in overuse of hospital and emergency department resources. Patients with complex care needs generally have increased expenses, longer length of hospital stays, an increased need for care management resources during hospitalization, and high readmission rates. Mayo Clinic in Arizona aimed to ensure successful transitions for hospitalized patients with complex care needs to the community by developing a complex care transition team (CCTT) program. With typical care management models, patients are assigned to registered nurse case managers and social workers according to the inpatient nursing unit rather than patient care complexity. Patients with complex care needs may not receive the amount of time needed to ensure an efficient and effective transition to the community setting. Furthermore, after transitioning to the community, patients with complex care needs often do not have access to care management resources if further care coordination needs arise. Acute care hospital in the US Southwest. The CCTT was composed of a registered nurse case manager, social worker, and care management assistant, with physician advisor support. The CCTT followed patients with complex care needs during their hospitalization and transition to the community for 90days after discharge. The number of inpatient admissions and hospital readmission rates were compared between 6months before and after enrollment in the CCTT program. Cost savings for decreased hospital length of stay, emergency department visits, and hospital readmissions were also determined. The CCTT selected patients according to a complex care algorithm , which identified patients who required high use of the health care system. The CCTT then followed this cohort of patients for an average of 90days after discharge. A total of 123 patients were enrolled in the CCTT program from July 1, 2019, to April 30, 2021, and 80 patients successfully graduated from the program. Readmission rates decreased from 51.2% at 6months before the intervention to 22.0% at 6months after the intervention. This reduced readmission rate resulted in a cost savings of more than $1 million. The outcomes resulting from implementation of the multidisciplinary CCTT highlight the need for a patient-specific approach to transitioning care to the outpatient setting. The patient social determinants of health that often contributed to overuse of health care resources included poor access to outpatient specialists, difficulty navigating the health care system due to illness or poor health literacy, and limited social support. The success of the CCTT program prompted the implementation of other specialty-specific pilot programs at Mayo Clinic in Arizona. The investment of time and resources, including dedicated personnel to follow patients with high hospital service usage, allows health care systems to reduce emergency department visits and hospital admissions and to provide patients with the best opportunity for success as they transition from the inpatient to outpatient setting.

Inpatient thrombophilia workup; does hematology consult prevent unnecessary testing?

Hypercoagulable disorders are best described as a group of acquired and hereditary conditions that increase the risk for the development of thrombi within veins or arteries. In the setting of an unprovoked venous thromboembolism, common practice in the inpatient setting has been further investigation via a thrombophilia workup to establish an underlying cause. Current Hematology-Oncology guidelines argue against inpatient workup as the results rarely influence inpatient management. Following American Society of Hematology guidelines (Middledorp), the current study found that only 15% (11/72) of patients met appropriate criteria for thrombophilia testing. There was no relationship between appropriate thrombophilia testing and diagnosis of thrombophilia or initiation of anticoagulation. There was a relationship between appropriate thrombophilia testing and Hematology-Oncology consultation. This demonstrates the need for expert consultation if thrombophilia testing is being considered. The current study provides more evidence that a strong recommendation against inpatient testing should be made as testing does not aid in diagnosis or change management and is an overutilization of healthcare resources.

Towards More Appropriate Care for Low Back Pain: Understanding Primary Care Factors that Increase Best Practices and Collaborative Approaches to Care

Moving towards more appropriate care for low back pain is an important health services research issue in Ontario, Canada especially as evidence suggests there is overuse of health care resources for this problem. Low back pain involves excessive imaging, over-referrals for specialist care, and overuse of drug therapy. At the present time, there is also poor uptake of best practices, an evidence to practice gap, and low back pain management and outcomes have changed little over the past 35 years. 
 The emerging field of implementation science will be useful to address the central research question which asks “What factors amongst primary care physicians that manage low back pain, enable or constrain their ability to implement best practices in their care?“ Implementation science (IS) is drawn upon to help advance the uptake of research findings into practice and provide understanding as to why the implementation of evidence into practice may be successful or not. 
 Using the Consolidated Framework for Implementation Research (CFIR) model helps to identify barriers and facilitators to the uptake of best practices. Older frameworks have focused narrowly on physician behavior change, but CFIR recognizes that implementation must also consider features of context and setting to have a greater chance of success. As such, CFIR informs the study by using a meta-analytic framework, and focuses on elements of intervention characteristics, outer setting, inner setting, individual characteristics and process, which have been found to influence uptake of interventions. 
 The study uses a mixed methods approach which is appropriate when attempting to understand the social and practice environment involved in providing primary care. In this multi-phase study, a literature review was first conducted to provide a current understanding of what is currently known on the topic. This informed Phase 2, which involved sending quantitative surveys to a sample of Ontario primary care providers, mainly including family physicians. A final Phase 3 involved qualitative in-depth interviews with a subset of those providers to provide context and help explain patterns in the research findings.
 Results from 240 surveys will be presented, including a discussion of descriptive statistics, inferential statistics, hypothesis testing and a principal components analysis (PCA). Findings from 21 interviews will also be discussed, where 7 themes and multiple subthemes were found, with a particular emphasis on: the usage of evidence, inter-professional practice, changing practice patterns, expanding virtual care, and centering patient preferences. Overall, multiple barriers and facilitators for the adoption of best practices including the use of clinical practice guidelines will be discussed. 
 The research committee, engaged in the project co-design, is made up of an interdisciplinary team of health service researchers, clinicians and academics with diverse expertise and experience. The study aims to address gaps in the application of best practices for providers delivering low back pain care and recommends more integrated models of care. An overall goal is to help improve low back pain management at the primary care level, as this remains a prevalent and costly issue for the Canadian province of Ontario. 

Developing Safe Harbors to Address Malpractice Liability and Wasteful Health Care Spending

This Viewpoint discusses the feasibility of developing safe harbors that account for the role of medical malpractice liability and go beyond generic guidelines discouraging the overuse of health care resources.

Evaluation of the Patient With Paroxysmal Spells Mimicking Epileptic Seizures.

The diagnostic issue of paroxysmal spells, including epileptic seizure (ES) mimics, is one that neurologists frequently encounter. This review provides an up-to-date overview of the most common causes of ES mimics encountered in the outpatient setting. Paroxysmal spells are characterized by changes in awareness, attention, perception, or abnormal movements. These can be broadly classified as ES and nonepileptic spells (NES). NES mimics ES but are distinguished by their symptomatology and lack of epileptiform activity on electroencephalography. NES may have psychological or physiological underpinnings. Psychogenic non-ES are the most common mimics of ES. Physiological causes of NES include syncope, cerebrovascular, movement, and sleep-related disorders. Distinguishing NES from ES at times may be challenging even to the most experienced clinicians. However, detailed history with an emphasis on the clinical clues, including taking a moment-by-moment history of the event from the patient and observers and physical examination, helps create an appropriate differential diagnosis to guide further diagnostic testing. An accurate diagnosis of NES prevents iatrogenic harm, including unnecessary exposure to antiseizure medications and overuse of health care resources. It also allows for the correct specialist referral and appropriate treatment.

Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery

Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits. All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery. Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors. Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions. Prognostic IV.

AUTHOR REPLY

We want to thank Urology and the Editorial Response authors for 1 considering the importance of how the social determinants of health (SDH) affect shared decision making (SDM) for prostate cancer screening. Health literacy (HL) plays a particularly important role in prostate cancer screening, when considering the best interest of the patient and mitigating over-utilization of health care resources. It is well documented that racial barriers influence access to health care screening; surprisingly, our study illustrates that African-American men had higher rates of PSA testing.

The Search for Biomarkers in Fibromyalgia.

Fibromyalgia is the most common of the central sensitivity syndromes affecting 2–5% of the adult population in the United States. This pain amplification syndrome has enormous societal impact as measured by work absenteeism, decreased work productivity, disability and injury compensation and over-utilization of healthcare resources. Multiple studies have shown that early diagnosis of this condition can improve patient outlook and redirect valuable healthcare resources towards more appropriate targeted therapy. Efforts have been made towards improving diagnostic accuracy through updated criteria. The search for biomarkers for diagnosis and verification of Fibromyalgia is an ongoing process. Inadequacies with current diagnostic criteria for this condition have fueled these efforts for identification of a reproducible marker that can verify this disease in a highly sensitive, specific and reproducible manner. This review focuses on areas of research for biomarkers in fibromyalgia and suggests that future efforts might benefit from approaches that utilize arrays of biomarkers to identify this disorder that presents with a diverse clinical phenotype.

Engaging medical trainees in resource stewardship through resident-led teaching sessions: a choosing wisely educational initiative.

Implication StatementOveruse of healthcare resources is prevalent, including among medical trainees. As front-line clinicians and near-peers, residents are well-positioned to teach resource stewardship to medical students and address barriers students may face while trying to “choose wisely.” We describe the implementation of two resident-led, case-based teaching sessions for medical students that focus on resource stewardship. Similar teaching models can be adapted by residents at their own institutions to enhance resource stewardship proficiency amongst trainees.

What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy. Cross-sectional study. Health claims database from a third-party payer. Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression. A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types (P = .1). Increased lag time from consultation to surgery was noted immediately after PA implementation by 2.38 days (95% CI, 0.23-4.54; P = .030); otherwise, there was no significant change over time (P = .98). A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.

Lower versus traditional treatment threshold for neonatal hypoglycaemia: No difference between the groups at 18 months of age, awaiting long-term outcomes.

Neonatal hypoglycaemia has long been a medical conundrum. The mere definition and operational threshold with which to offer treatment has long been and continues to be debated. Severe and symptomatic hypoglycaemia negatively impacts long-term neurodevelopment. How to balance treatment without risking adverse consequences and without overutilization of health care resources are discussed often. As a result, this research study sets out to challenge the dogma of the required treatment at glucose <47 mg/dL. One aspect that distinguishes this study from others was its unique clinical design. While most other studies are retrospective, this study was a prospective, randomized, non-inferiority study assessing the current operational threshold for hypoglycaemia treatment with a lower threshold. The study allowed for neurodevelopmental outcomes <0.5 standard deviations below the mean, as a threshold for non-inferiority. Given one standard deviation from the mean is considered normal, this was a reasonable threshold. Additionally, the study was able to achieve its goal of 85% neurodevelopmental follow-up at age 18 months, which is impressive for a condition that is usually short-term and often viewed as benign. There were a few critical aspects of this study. First, it was underpowered to assess infants of diabetic mothers. Second, aside from the treatment threshold, there was no defined protocol for how to treat hypoglycaemia, and it was left to provider discretion despite wide practice variations. Lastly and most importantly, follow-up at 18 months of age is likely too soon to detect differences in neurodevelopmental outcomes; therefore, most follow-up studies focus on 24 months of age or higher. The CHYLD studies by McKinlay et al found no difference in neurodevelopmental outcomes between neonate with hypoglycaemia (defined as glucose <47 mg/dL) and those without at 24 months of age, but did find differences in executive and visual-motor functioning at 4.5 years of age.1, 2 Several additional studies with longer-term follow-up have shown differences between cohorts with and without neonatal hypoglycaemia. For instance, Wickström et al (2018) showed evidence of motor and cognitive delay at 2-6 years of age-associated with moderate hypoglycaemia (defined as glucose <40 mg/dL).3 Kaiser used 4th-grade standardised testing to assess 10-year follow-up and found an association with decreased literacy and mathematics scores with a single incidence of glucose <45 mg/dL and even further disparity at lower thresholds of <40 mg/dL and <35 mg/dL.4 A systematic review by Shah in 2019 concluded neonatal hypoglycaemia is associated visual-motor impairment and executive dysfunction in early-childhood (2-5 years of age) and neurodevelopmental impairment and low literacy in mid-childhood (6-11 years of age).5 Given this evidence, it is reasonable to conclude while this study showed no difference at 18-month follow-up that longer-term follow-up might show differences. As this study completed in 2011, it would be interesting to see whether a 4- to 6-year follow-up is assessed, and if so, what the results show. In conclusion, while it may be too soon to instil practice changes based on the results of this study, there is potential if longer-term follow-up can show similar results. https://ebneo.org/2020/04/threshold-for-neonatal-hypoglycemia/ None.

Use of CT Scans for Abdominal Pain in the ED: Factors in Choice

Overutilization of healthcare resources is a threat to long-term healthcare sustainability and patient outcomes. CT is a costly but efficient means of assessing abdominal pain; however, 97 per cent of ED physicians acknowledge its overutilization. This study sought to understand factors that influence ED providers' decision regarding CT use in the evaluation of abdominal pain. After evaluating a patient for acute abdominal pain, ED providers filled in a form in which the primary diagnosis and index of suspicion were recorded. Bivariate and multivariate analyses were used to identify predictors of outcomes. The CT scan utilization rate was 54.82 per cent. Whereas 34.11 per cent of CT scans were normal, 30 per cent yielded an acute abdominal pathology. Tenderness and rebound tenderness were positive predictors of high index of suspicion [odds ratio (OR) 2.09 and 2.54, respectively]. These variables were also predictive of obtaining a CT scan [OR 2.64 and 3.41, respectively]. Compared with whites, the index of suspicion was 26 per cent and 56 per cent less likely to be high when patients were black [OR 0.73] or Hispanic [OR 0.44] respectively. Blacks and Hispanics were less likely to have CT scans performed than whites [OR 0.58 and 0.48, respectively]. Leukocytosis significantly affected the index of suspicion for acute abdominal pathology, obtaining a CT scan and the acuity of CT scan diagnosis on multivariate analysis. Patients aged ≥60 years had 2.03 odds of acute CT finding compared with those aged <60 years. There is a need for committed efforts to optimize CT scan utilization and eliminate socioeconomic disparities in health care.

Improving blood product utilization at an ambulatory surgery center: a retrospective cohort study on 50 patients with lumbar disc replacement

BackgroundThere is minimal literature discussing anterior lumbar spine surgery in ambulatory surgery centers (ASCs). The main concern with the anterior approach to the lumbar spine is the potential for injury to great vessels. In our facility, there are two units of crossmatched blood available in addition to cell saver during the procedure. We retrospectively looked at 50 cases of lumbar total disc arthroplasty (TDA) in our ASC to determine utilization of blood products.MethodsMedical records of 50 consecutive patients who underwent a lumbar TDA at a single ASC were reviewed. Surgeries completed at the ASC were all transferred from the post anesthesia care unit to an attached convalescence care center which allows up to 3 days of observation. Patients who had either a 1 or 2 level lumbar TDA were included in the study. Data consisting of demographics, American Society of Anesthesiologist Physical Status Classification System, length of stay, estimated blood loss, cell saver volume, transfusion, perioperative and postoperative complications were recorded. Preoperative, perioperative and postoperative medical records were reviewed.ResultsMedical records of 50 consecutive patients were reviewed. The mean age was 40.86 ± 9.45. Of these, 48 (96%) had a 1-level lumbar TDA, 1(2%) had a 2-level lumbar TDA, 1 (2%) had a lumbar TDA at L4/5 and an anterior lumbar interbody fusion at L5/S1. There were no mortalities; no patient had recorded perioperative complications. No patients received allogeneic blood transfusion, 4 (8%) were re-transfused with cell saver (2 receiving approximately 400 ml and 2 receiving approximately 200 ml of re-transfused blood). All 50 (100%) were discharged home in stable condition. We had 30-day follow-up data on 35 of 50 patients. Of the 35 patients reviewed, three (8.5%) of the patients were readmitted to the hospital. One additional patient was seen in the emergency department and discharged home after negative testing. No patient was readmitted for post-operative anemia.ConclusionThe routine use of both cell saver and crossmatched blood in the operating suite for lumbar TDA may be an over-utilization of healthcare resources. In our review of 50 patients, we had no need for transfusion of allogeneic packed red blood cells (PRBCs) and only four of the 50 patients had enough blood output for re-transfusion from the cell saver. This opens the conversation for alternatives to crossmatched PRBCs being held in the operating room. Such alternatives may be the use of cell salvage, only type O blood in a cooler for each patient or keeping type O blood on constant hold in ASCs.

Systemic overuse of health care in a commercially insured US population, 2010\u20132015

BackgroundOveruse is a leading contributor to the high cost of health care in the United States. Overuse harms patients and is a definitive waste of resources. The Johns Hopkins Overuse Index (JHOI) is a normalized measure of systemic health care services overuse, generated from claims data, that has been used to describe overuse in Medicare beneficiaries and to understand drivers of overuse. We aimed to adapt the JHOI for application to a commercially insured US population, to examine geographic variation in systemic overuse in this population, and to analyze trends over time to inform whether systemic overuse is an enduring problem.MethodsWe analyzed commercial insurance claims from 18 to 64 year old beneficiaries. We calculated a semiannual JHOI for each of the 375 Metropolitan Statistical Areas and 47 rural regions of the US. We generated maps to examine geographic variation and then analyzed each region’s change in their JHOI quintile from January 2011 to June 2015.ResultsThe JHOI varied markedly across the US. Across the country, rural regions tended to have less systemic overuse than their MSA counterparts (p < 0.01). Regional systemic overuse is positively correlated from one time period to the next (p < 0.001). Between 2011 and 2015, 53.7% (N = 226) of regions remained in the same quintile of the JHOI. Eighty of these regions had a persistently high or persistently low JHOI throughout study duration.ConclusionsThe systemic overuse of health care resources is an enduring, regional problem. Areas identified as having a persistently high rate of systemic overuse merit further investigation to understand drivers and potential points of intervention.

Regional Supply of Medical Resources and Systemic Overuse of Health Care Among Medicare Beneficiaries.

Overuse of health care resources has been identified as the leading contributor to waste in the US health care system. To explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services. Using Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas. Regions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P < 0.001). Regional characteristics associated with higher JHOI scores, indicating more systemic overuse, included number per 1000 residents of acute care hospital beds (P = 0.002) and of hospital-based anesthesiologists, pathologists, and radiologists (P = 0.02). Regional variations in health care resources including the clinician workforce are associated with the intensity of systemic overuse of health care. The role of primary care doctors in reducing health care overuse deserves further attention.

Overutilization of Health Care Resources for Breast Pain.

The objective of this study is to analyze the incidence of women with breast pain who present to an imaging center and assess the imaging findings, outcomes, and workup costs at breast imaging centers affiliated with one institution. Demographic characteristics of and imaging findings for female patients presenting with breast pain at three community breast imaging centers between January 1, 2014, and December 31, 2014, were reviewed. Patients who were pregnant, were lactating, had a history of breast cancer, or presented with palpable nipple or skin findings were excluded. A total of 799 patients met the study criteria. Pain was diffuse in 30%, was focal in 30%, and was not localized in 40%. Of the 799 patients with breast pain, 790 (99%) presented for a diagnostic evaluation; 759 (95%) of these evaluated patients had negative findings. A benign sonographic correlate was detected in the area of pain in 5% of patients (39/799). One patient had a single cancer detected in the contralateral asymptomatic breast. When correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population (5.5 cases per 1000 examinations performed), breast pain was not found to be a sign of breast cancer (p = 0.027). Patients younger than 40 years (316/799) underwent a total of 454 workup studies for breast pain; all findings were benign, and the cost of these studies was $87,322. Patients 40 years or older (483/799) underwent 745 workup studies, for a cost of $152,732. Breast pain represents an area of overutilization of health care resources. For female patients who present with pure breast pain, breast imaging centers should consider the following imaging protocols and education for referring physicians: an annual screening mammogram should be recommended for women 40 years or older, and reassurance without imaging should be offered to patients younger than 40 years.

Certificate-of-Need State Laws and Total Knee Arthroplasty

BackgroundMany states in the United States have certificate-of-need (CON) programs designed to restrain health care costs and prevent overutilization of health care resources. The goal of this study was to characterize the associations between CON regulations and total knee arthroplasty (TKA) by comparing states with and without CON programs. MethodsPublicly available data were used to classify states in to CON or non-CON categories. The 100% Medicare Standard Analytical Files from 2005 through 2014 were then used to compare primary TKA procedure volumes, charges, reimbursements, and distribution of procedures based on facility volumes between the groups. Adverse events such as infection and emergency room visits after TKA were also evaluated. ResultsAlthough CON status was associated with lower per capita utilization of TKA, the annual incidence of TKA appears to have increased over time more rapidly in states with CON laws compared with non-CON states (overall increase of 5.6% vs 2.3%, P < .01). When normalized to the Medicare population, the incidence of TKA increased 2.0% in CON states, whereas it actually decreased 7.2% in states without CON regulations (P = .011). Average reimbursement (and thus Medicare spend) was 5% to 10% lower in non-CON states at all time points (P < .0001). In non-CON states, relatively more TKAs appear to be performed in lower volume hospitals. Examination of adverse events rates did not reveal any strong associations between any adverse outcome and CON status. ConclusionCON programs appear to have influenced the delivery of care for TKA. Although our data suggest that these laws are associated with lower per capita utilization of TKA and the use of higher-volume facilities, we were unable to detect any strong evidence that CON regulations have been associated with improved quality of care or have limited growth in the utilization of this procedure over time. Confounding population and geographic factors may influence these findings and further study is needed to determine whether or not these programs have served their purpose and should be retained.

Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review

BackgroundPhysicians routinely encounter diagnostic uncertainty in practice. Despite its impact on health care utilization, costs and error, measurement of diagnostic uncertainty is poorly understood. We conducted a systematic review to describe how diagnostic uncertainty is defined and measured in medical practice.MethodsWe searched OVID Medline and PsycINFO databases from inception until May 2017 using a combination of keywords and Medical Subject Headings (MeSH). Additional search strategies included manual review of references identified in the primary search, use of a topic-specific database (AHRQ-PSNet) and expert input. We specifically focused on articles that (1) defined diagnostic uncertainty; (2) conceptualized diagnostic uncertainty in terms of its sources, complexity of its attributes or strategies for managing it; or (3) attempted to measure diagnostic uncertainty.Key ResultsWe identified 123 articles for full review, none of which defined diagnostic uncertainty. Three attributes of diagnostic uncertainty were relevant for measurement: (1) it is a subjective perception experienced by the clinician; (2) it has the potential to impact diagnostic evaluation—for example, when inappropriately managed, it can lead to diagnostic delays; and (3) it is dynamic in nature, changing with time. Current methods for measuring diagnostic uncertainty in medical practice include: (1) asking clinicians about their perception of uncertainty (surveys and qualitative interviews), (2) evaluating the patient–clinician encounter (such as by reviews of medical records, transcripts of patient–clinician communication and observation), and (3) experimental techniques (patient vignette studies).ConclusionsThe term “diagnostic uncertainty” lacks a clear definition, and there is no comprehensive framework for its measurement in medical practice. Based on review findings, we propose that diagnostic uncertainty be defined as a “subjective perception of an inability to provide an accurate explanation of the patient’s health problem.” Methodological advancements in measuring diagnostic uncertainty can improve our understanding of diagnostic decision-making and inform interventions to reduce diagnostic errors and overuse of health care resources.

Personal Genomic Testing for Cancer Risk: Results From the Impact of Personal Genomics Study.

Purpose Significant concerns exist regarding the potential for unwarranted behavior changes and the overuse of health care resources in response to direct-to-consumer personal genomic testing (PGT). However, little is known about customers' behaviors after PGT. Methods Longitudinal surveys were given to new customers of 23andMe (Mountain View, CA) and Pathway Genomics (San Diego, CA). Survey data were linked to individual-level PGT results through a secure data transfer process. Results Of the 1,042 customers who completed baseline and 6-month surveys (response rate, 71.2%), 762 had complete cancer-related data and were analyzed. Most customers reported that learning about their genetic risk of cancers was a motivation for testing (colorectal, 88%; prostate, 95%; breast, 94%). No customers tested positive for pathogenic mutations in highly penetrant cancer susceptibility genes. A minority of individuals received elevated single nucleotide polymorphism-based PGT cancer risk estimates (colorectal, 24%; prostate, 24%; breast, 12%). At 6 months, customers who received elevated PGT cancer risk estimates were not significantly more likely to change their diet, exercise, or advanced planning behaviors or engage in cancer screening, compared with individuals at average or reduced risk. Men who received elevated PGT prostate cancer risk estimates changed their vitamin and supplement use more than those at average or reduced risk (22% v 7.6%, respectively; adjusted odds ratio, 3.41; 95% CI, 1.44 to 8.18). Predictors of 6-month behavior include baseline behavior (exercise, vitamin or supplement use, and screening), worse health status (diet and vitamin or supplement use), and older age (advanced planning, screening). Conclusion Most adults receiving elevated direct-to-consumer PGT single nucleotide polymorphism-based cancer risk estimates did not significantly change their diet, exercise, advanced care planning, or cancer screening behaviors.