Appropriateness Of Utilization Research Articles

Written Informed Consent for Computed Tomography of the Abdomen/Pelvis is Associated with Decreased CT Utilization in Low-Risk Emergency Department Patients

IntroductionThe increasing rate of patient exposure to radiation from computerized tomography (CT) raises questions about appropriateness of utilization. There is no current standard to employ informed consent for CT (ICCT). Our study assessed the relationship between informed consent and CT utilization in emergency department (ED) patients.MethodsAn observational multiphase before-after cohort study was completed from 4/2010–5/2011. We assessed CT utilization before and after (Time I/Time II) the implementation of an informed consent protocol. Adult patients were included if they presented with symptoms of abdominal/pelvic pathology or completed ED CT. We excluded patients with pregnancy, trauma, or altered mental status. Data on history, exam, diagnostics, and disposition were collected via standard abstraction tool. We generated a multivariate logistic model via stepwise regression, to assess CT utilization across risk groups. Logistic models, stratified by risk, were generated to include study phase and a propensity score that controlled for potential confounders of CT utilization.Results7,684 patients met inclusion criteria. In PHASE 2, there was a 24% (95% CI [10–36%]) reduction in CT utilization in the low-risk patient group (p<0.002). ICCT did not affect CT utilization in the high-risk group (p=0.16). In low-risk patients, the propensity score was significant (p<0.001). There were no adverse events reported during the study period.ConclusionThe implementation of ICCT was associated with reduced CT utilization in low-risk ED patients. ICCT has the potential to increase informed, shared decision making with patients, as well as to reduce the risks and cost associated with CT.

Intravenous immunoglobulin utilization in the Canadian Atlantic provinces: a report of the Atlantic Collaborative Intravenous Immune Globulin Utilization Working Group

Intravenous immunoglobulin (IVIG) use for labeled and unlabeled indications is growing steadily. By use of a collaborative regional strategy, baseline IVIG usage and appropriateness of utilization were determined for Atlantic Canada. The effectiveness of strategies designed to optimize utilization was also studied. A regional working group was created to monitor IVIG utilization for a 2-year period in the four Canadian Atlantic Provinces. A registry of IVIG was created. Assessment of indication appropriateness was determined with national and provincial guidelines along with expert clinical opinion. To optimize IVIG use, IVIG guidelines and feedback reports were distributed to stakeholders. Appropriateness of IVIG use was compared over the course of the study. The leading indications for IVIG use were idiopathic thrombocytopenic purpura (17.3%), primary immune deficiency conditions (14.9%), and chronic idiopathic demyelinating polyneuropathy (11.8%). The leading prescribing specialists were neurologists (32.2%) and hematologists (26.1%). A total of 37.1 percent of IVIG usage was in accordance with labeled indications. After optimization strategies were implemented, there was little change in labeled use. There was a 4.2 percent decrease in unlabeled use not supported by evidence (p<0.001). A regional collaborative strategy for monitoring IVIG use was established. Most of the IVIG use was for labeled or appropriate indications. The majority of unlabeled use was supported by the medical literature. Strategies to optimize IVIG utilization were associated with a decrease in inappropriate IVIG use and a plateau in IVIG utilization compared to the rest of the country.

Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists

To compare prescribing trends and appropriateness of use of traditional and cyclooxygenase-2 selective (COX-2) nonsteroidal anti-inflammatory drugs (NSAIDs) by primary care physicians (PCPs) and specialists. Retrospective cohort study. One thousand five hundred and seventy-six adult patients continuously enrolled for at least 1 year with an independent practice association of a University-associated managed care plan who were started on a traditional NSAID or a COX-2 inhibitor from 1999 to 2002 and received at least 3 separate medication fills. Physician specialty was identified from office visits. Appropriateness of utilization was based on gastrointestinal risk characteristics. Primary care patients were younger and less likely to have comorbid conditions. Despite similar GI risk, COX-2 use among patients seen by PCPs was half that of patients seen by specialists (21% vs 44%, P<.001). While PCPs overused cyclooxygenase-2-specific inhibitors (COX-2s) less often than specialists (19% vs 41%, P<.001), they also tended to underuse COX-2s in patients who were at increased GI risk (46% vs 32%, P=.063). This represents a 3-fold and 8-fold difference in overuse versus underuse for PCPs and specialists, respectively. Using COX-2s as a model for physician adoption of new therapeutic agents, specialists were more likely to use these new medications for patients likely to benefit but were also significantly more likely to use them for patients without a clear indication. This study demonstrates the tension between appropriate adoption of innovative therapies for those individuals who would benefit from their use and those individuals who would receive no added clinical benefit but would incur added cost and be placed at increased risk.

Low Back Pain in Older Adults: Are We Utilizing Healthcare Resources Wisely?

1) To examine recent change in prevalence and Medicare-associated charges for non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain (LBP); and 2) to examine magnetic resonance imaging (MRI) utilization appropriateness in older adults with chronic low back pain (CLBP). Two cross-sectional surveys of 1) national (1991-2002) and Pennsylvania (2000-2002) Medicare data; and 2) patients aged >or= 65 years with CLBP. Outpatient data. Patients aged >or= 65 years with LBP. Study 1: Outpatient national and Pennsylvania Part A Medicare data were examined for number of patients and charges for all patients, and for those with nonspecific LBP. Total number of visits and charges for imaging studies, physical therapy (PT), and spinal injections was also examined for Pennsylvania. Study 2: 111 older adults with CLBP were interviewed regarding presence of red flags necessitating imaging and history of having a lumbar MRI, neurogenic claudication (NC), and back surgery. Study 1: Between 1991 and 2002, there was a 42.5% increase in total Medicare patients, 131.7% increase in LBP patients, 310% increase in total charges, and 387.2% increase in LBP charges. In Pennsylvania (2000-2002), there was a 5.5% increase in LBP patients and 33.2% increase in charges (0.2% for PT, 59.4% for injections, 41.9% for MRI/CT, and 19.3% for X rays). Study 2: None of the 111 participants had red flags and 61% had undergone MRIs (29% with NC, 24% with failed back surgery syndrome). LBP documentation and diagnostic studies are increasing in Medicare beneficiaries, and evidence suggests that MRIs may often be ordered unnecessarily. Injection procedures appear to account for a significant proportion of LBP-associated costs. More studies are needed to examine the appropriateness with which imaging procedures and non-invasive/minimally invasive treatments are utilized, and their effect on patient outcomes.

Outpatient drug expenditures and prescription policies for diseases with high cost to the National Health Insurance system in Taiwan.

The high cost of drugs, particularly those used to treat upper respiratory tract infections, is an increasingly important problem for the National Health Insurance system in Taiwan. This study proposed a new classification scheme for reimbursing drug cost and estimated its impact on expenditures and health care utilization. Data were obtained from the National Health Research Institutes' year 2000 computer file of the National Health Insurance Academic Research Database in Taiwan. Two factors were used to classify medications: 1) urgency of medications required; and 2) patient's self-care ability. Among the 10 diseases with the highest number of outpatient department (OPD) visits, 7 were upper respiratory diseases. Acute upper respiratory infections (URIs) and acute nasopharyngitis were the 2 diseases with the highest number of OPD visits. Drug expenditure for acute URIs is about 6% of total expenditure for drugs. Medications suitable for URIs patients' self-care accounted for 42.8% of the total cost of prescribed drugs for these illnesses, and treatment medications unsuitable for patients' self-care accounted for 48.6%. Other medications used for URIs could not be grouped into these categories. The total expenditure for acute nasopharyngitis was about 1.3% of total expenditure for drugs. Medications suitable for self-care in patients with nasopharyngitis accounted for 51.8% of the total cost of medication prescribed for this illness, and medications unsuitable for patients' self-care accounted for 36.8%. Reducing the medications suitable for patients' self-care and enforcing different levels of payment rates on medications unsuitable for patients' self-care may reduce the excessive use of OPD drugs, improve the appropriateness of utilization for acute URIs and the common cold, and allow medical resources to be distributed more efficiently.

Automatic helicopter standby policy for seriously injured patients.

Automatic standby (AS) of helicopter emergency medical services (HEMS) may allow improved utilization appropriateness (UA) for scene trauma, although this has not been studied. HEMS records were reviewed for 16 months, including date, county of origin, and UA. Data were analyzed descriptively with chi(2) where appropriate. Of 274 flights, there was no significant change in UA where AS was in place versus where it was not (P =.36). One county had an increase in total flights with AS in use without a significant change in UA (P =.10). In this region, use of an AS policy for scene trauma resulted in increased utilization of HEMS without a corresponding change in UA. Specifically, inappropriate utilization did not increase. This finding suggests that such a policy does not incur overutilization despite increasing total flights. Further study with larger numbers is necessary to draw definitive conclusions.

Automatic Helicopter Standby Policy for Seriously Injured Patients

Background: Automatic standby (AS) of helicopter emergency medical services (HEMS) may allow improved utilization appropriateness (UA) for scene trauma, although this has not been studied. Methods: HEMS records were reviewed for 16 months, including date, county of origin, and UA. Data were analyzed descriptively with χ 2 where appropriate. Results: Of 274 flights, there was no significant change in UA where AS was in place versus where it was not ( P = .36). One county had an increase in total flights with AS in use without a significant change in UA ( P = .10). Conclusion: In this region, use of an AS policy for scene trauma resulted in increased utilization of HEMS without a corresponding change in UA. Specifically, inappropriate utilization did not increase. This finding suggests that such a policy does not incur overutilization despite increasing total flights. Further study with larger numbers is necessary to draw definitive conclusions.

An outcomes analysis approach to utilization management: quality assessment of appropriateness of specialty referrals.

This report illustrates some methods by which to identify, guide, and develop acceptable levels of expected outcomes, defined as the validity or appropriateness of specialty referrals or procedures, through utilization management case studies and interventions. Outcomes variables may be used as standardized ongoing measures of cost-effectiveness and quality of health care services, focusing on appropriateness of utilization of specialty resources and health care technology. Community, regional, and national standards for such measures are currently being developed and evaluated for assessing the appropriateness of the use of health care technology. These standards for desired or expected outcomes need to become an integral part of utilization management as well as quality assessment and improvement, and are very helpful tools for developing specific interventions to be used for improving upon and documenting the cost-effective delivery of care within health services organizations.

Appropriateness of utilization: A method of assessment

Appropriateness of utilization: A method of assessment