Utilization Of Diagnostic Procedures Research Articles

Utilization of Diagnostic Procedures After Lung Cancer Screening in the National Lung Screening Trial

ObjectiveTo examine utilization patterns of diagnostic procedures after lung cancer screening among participants enrolled in the National Lung Screening Trial. MethodsUsing a sample of National Lung Screening Trial participants with abstracted medical records, we assessed utilization of imaging, invasive, and surgical procedures after lung cancer screening. Missing data were imputed using multiple imputation by chained equations. For each procedure type, we examined utilization within a year after the screening or until the next screen, whichever came first, across arms (low-dose CT [LDCT] versus chest X-ray [CXR]) and by screening results. We also explored factors associated with having these procedures using multivariable negative binomial regressions. ResultsAfter baseline screening, our sample had 176.5 and 46.7 procedures per 100 person-years for those with a false-positive and negative result, respectively. Invasive and surgical procedures were relatively infrequent. Among those who screened positive, follow-up imaging and invasive procedures were 25% and 34% less frequent in those screened with LDCT, compared with CXR. Postscreening utilization of invasive and surgical procedures was 37% and 34% lower at the first incidence screen compared with baseline. Participants with positive results at baseline were six times more likely to undergo additional imaging than those with normal findings. DiscussionUse of imaging and invasive procedures to evaluate abnormal findings varied by screening modality, with a lower rate for LDCT than CXR. Invasive and surgical workup were less prevalent after subsequent screening examinations compared with baseline screening. Utilization was associated with older age but not gender, race or ethnicity, insurance status, or income.

Health resource utilization among US veterans with psychogenic nonepileptic seizures: A comparison before and after video-EEG monitoring

Prior to establishing the correct diagnosis, patients with psychogenic nonepileptic seizures (PNES) frequently endure significant costs and morbidities associated with utilization of health care resources. In this study of the US veterans population, we aimed to investigate for potential changes in health resource utilization before versus after video-EEG (VEEG) confirmation and disclosure of the PNES diagnosis. We prospectively studied 65 veterans with VEEG confirmed diagnosis of PNES, and followed their health care utilization during the subsequent 3 years after the diagnosis. Primary outcomes entailed comparing the quantities of post-VEEG outpatient visits and diagnostic procedures versus those during the 3-year span prior to the diagnosis. Secondary outcome involved specifically the measures of seizure-related antiepileptic drug (AED) use from time points before and after VEEG. Within the category of non-psychiatric outpatient visits, we observed significant post-diagnostic decrease in the utilization of PNES-related outpatient visits (p < 0.001). Contrastingly, we found significant post-diagnostic increase in the utilization of non-PNES-related outpatient visits (p = 0.004). When examining exclusively for psychiatric outpatient visits, we further observed a trend toward increased attendance of outpatient visits (p = 0.056) after VEEG. Utilization of diagnostic procedures was not significantly different before versus after VEEG (p = 0.293). 52.3% of the patients were prescribed AEDs for seizure-related purpose during the one-year period leading up to VEEG. By comparison, only 7.7%, 12.3%, and 10.8% of the patients were still on AEDs for seizure-related purpose at the one-year, two-year, and three-year time points after VEEG, respectively. We demonstrate new evidence that VEEG confirmation of the PNES diagnosis among US veterans can significantly reduce key measures of non-psychiatric/PNES-related resource utilization, while also potentially associating with appropriate enhancement of psychiatric outpatient visits. However, our results suggest that within this patient population, further efforts are necessary to address heightened demands for non-PNES-related outpatient visits after VEEG.

Abstract TP239: Race and the Utilization of Diagnostic Procedures in the Emergency Department for Acute Stroke in the United States

Introduction: In 2007, the AHA recommended the use of the following diagnostic procedures immediately upon admission to the emergency department (ED) for all adult patients with suspected stroke: noncontrast brain CT or brain MRI, electrocardiogram, complete blood count (CBC) including platelets, cardiac enzymes and troponin, electrolytes, urea nitrogen, creatinine, serum glucose, prothrombin time and international normalized ratio (PT/INR), and oxygen saturation. We described the overall rate of utilization of these procedures and assessed for association with race using a national ED survey. Methods: We identified 308 ED visits for ischemic and spontaneous hemorrhagic strokes in adults 18 years representing 1.2 million stroke-related ED visits in the US using the National Hospital Ambulatory Medical Care Survey for years 2008-2009. The association between rates of utilization of diagnostic procedures and race was assessed using a Pearson chi-square test. Results: Overall the most common and least common diagnostic procedures performed were measurement of oxygen saturation (93%) and PT/INR (40%), respectively. There was no difference in use of CT/MRI (82.3% vs 82.7%, p =0.952), electrocardiogram (79.3% vs 80.7%, p =0.875), CBC (82.4% vs 93.9%, p =0.093), cardiac enzymes and troponin (55.7% vs 60.9%, p =0.523), electrolytes (57.4% vs 70.0%, p =0.153), urea nitrogen and creatinine (70.0% vs 68.5%, p =0.858), serum glucose (63.8% vs 66.8%, p =0.721), PTT/INR (37.3% vs 50.8%, p =0.139), and oxygen saturation (91.9% vs 98.7%, p =0.063) in blacks and whites, respectively. Conclusion: In terms of race, we found no significant difference in the rate of ED utilization of diagnostic procedures for acute stroke in the US. The overall rates of adherence to the 2007 AHA guidelines for diagnosis of acute stroke differed by diagnostic procedure. While there was almost universal measurement of oxygen saturation, less than half of acute stroke patients had a PT/INR analysis.

Utilization and cost of diagnostic imaging and biopsies following positive screening mammography in the southern breast cancer screening region of the Netherlands, 2000–2005

We prospectively assessed trends in utilization and costs of diagnostic services of screen-positive women in a biennial breast cancer screening program for women aged 50-75 years. All 2,062 women with suspicious findings at screening mammography in the southern region of the Netherlands between 1 January 2000 and 1 July 2005 (158,997 screens) were included. Data were collected on any diagnostic examinations, interventional procedures, and surgical consultations with two-year follow-up. We used national reimbursement rates to estimate imaging costs and percutaneous biopsy costs. Cost prices, charged by hospitals, were used to estimate open surgical biopsy costs and surgical consultation costs. The largest increase in utilization of diagnostic procedures per 100 referrals was observed for axillary ultrasound (from 3.9 in 2000 to 33.5 in 2005) and for stereotactic core biopsy (from 2.1 in 2000 to 26.8 in 2005). Per 100 referrals, the open surgical biopsy rate decreased from 34.7 (2000) to 4.6 (2005) and the number of outpatient surgical consultations fluctuated between 269.8 (2000) and 309.7 (2004). Mean costs for the diagnosis of one cancer were Euro1,501 and ranged from Euro1,223 (2002) to Euro1,647 (2003). Surgical biopsies comprised 54.1% of total diagnostic costs for women screened in 2000, but decreased to 9.9% for women screened in 2005. Imaging costs increased from 23.7 to 43.8%, percutaneous biopsy costs from 9.9 to 27.2%, and consultation costs from 12.3 to 19.1%. We conclude that diagnostic costs per screen-detected cancer remained fairly stable through the years, although huge changes in the use of different diagnostic procedures were observed.

Increasing risk for venous thromboembolism among hospitalized cancer patients

9009 Background: Venous thromboembolism (VTE) contributes to morbidity and mortality in cancer patients and is a frequent complication of anti-cancer therapy. We examined the frequency, risk factors and trends associated with VTE among hospitalized US cancer patients. Methods: We conducted a retrospective cohort study using the discharge database of the University Health System Consortium. This included all 1,824,316 hospitalizations of cancer patients between 1995 and 2003 at 133 United States medical centers. To avoid overestimation, only a single randomly chosen hospitalization was included for patients with multiple admissions. Results: Among 1,015,598 individual cancer patients, 34,357 (3.4%) were diagnosed with deep venous thrombosis and 11,515 with pulmonary embolism (PE) (1.1%) for an overall VTE rate of 4.1%. Subgroups of cancer patients with highest rates included Black ethnicity (5.1% per hospitalization) and those on chemotherapy (4.9%). Sites of cancer with the highest rates of VTE included pancreas (8.2%), kidney (5.7%), ovary (5.6%), lung (5.1%) and stomach (4.9%). Amongst hematologic malignancies, myeloma (5%), non-Hodgkin’s lymphoma (4.8%) and Hodgkin’s disease (4.6%) had the highest rates of VTE. The rate of VTE rose from 3.6% per hospitalization in 1995–96 to 4.6% in 2002–03, an increase of 28%, including a near-doubling of PE rates from 0.8% to 1.5% (P&lt;0.0001). Among patients receiving chemotherapy, rates of VTE rose from 3.9% per hospitalization to 5.7%, an increase of 47% (P&lt;0.0001). In contrast, patients undergoing surgery for breast, head and neck, pancreatic or spinal cancers, experienced no significant change in the rate of VTE. Use of diagnostic procedures for VTE also did not increase over the study period. Conclusions: The rate of VTE, including PE, among hospitalized cancer patients has increased significantly in recent years. Black patients, those on chemotherapy and those with certain types of cancer are disproportionately at increased risk. The rise in VTE does not appear to be attributable to an increased utilization of diagnostic procedures. Further efforts to increase thromboprophylaxis compliance during hospitalization are needed. No significant financial relationships to disclose.

Hemisensory syndrome is associated with a low diagnostic yield and a nearly uniform benign prognosis

Objective: To describe the diagnostic yield and prognosis for patients with hemisensory syndrome. Background: The aetiology, utility of diagnostic procedures, and outcome of hemisensory syndrome in patients with exclusive hemibody...

Of Hydras, Lemmings, and Diagnostic Tests

This issue of the Archives provides data collected by the Worcester (Mass) Heart Attack Study relevant to changes with time in the utilization of various noninvasive and invasive cardiac diagnostic tests in patients with acute myocardial infarction who were admitted to hospitals in Worcester, Mass.1 The study is directly relevant to the cost-effectiveness of various cardiac diagnostic procedures. More importantly, the results are also relevant to the general problem of the utilization of diagnostic procedures in all branches of medicine. The specific results are hardly surprising. The use of three noninvasive and two invasive cardiac diagnostic tests increased dramatically from 1975 to 1984. The use of most diagnostic tests that become incorporated into medical practice, for at least a time, tends to increase dramatically with the passage of time. What is less obvious is that widespread acceptance of tests occurs without convincing evidence that performing a given test improves

Evaluation of a continuing education program in rheumatoid arthritis.

A continuing medical education (CME) program in rheumatoid arthritis was implemented and evaluated in six community hospitals. It was targeted at primary care physicians and utilized physicians identified by their peers as being educationally influential for the dissemination of content knowledge. Although inpatient and outpatient audits of physician records demonstrated little change in three control communities, substantial improvement in the utilization of diagnostic procedures and patient management was documented in the three intervention communities utilizing the influential physicians. CME delivered through community-based educationally influential physicians is an effective way to change physician behavior in small communities with no prior ongoing educational programs. This approach should improve the primary care given to patients with rheumatoid arthritis and reduce the need for participation of academic faculty in traditional CME programs.

Is a gastrointestinal series necessary in patients with gallstones?

CONSIDERABLE interest has been generated in recent years by the controversy surrounding the appropriate utilization of diagnostic procedures ( Newsweek , May 9, 1977, pp 8490; US News & World Rep , March 28, 1977, pp 35-38). Hall's 1 editorial entitled Overutilization of Radiological Examinations summarizes and discusses some of the impulses that lead physicians to overutilize radiological studies. Much of what he says represents his opinion and the opinions of others, but some statistical studies are quoted that lend strength to his argument. He quotes Bengmark et al 2 and their report of a study of 935 patients in whom requests for combined oral cholecystography and upper gastrointestinal (GI) series were made. Their study showed that when symptoms were typical of one of the two systems studied, examination of the other system added no therapeutically important information. Hall suggested that once the pertinent diagnosis has been confirmed for patients scheduled for several