Wide Variation In Utilization Research Articles

Association between emergency department computed tomography utilization rate and patient satisfaction: A clinician level analysis across a regional healthcare system

BackgroundComputed Tomography (CT) use is common during emergency department (ED) visits, and ED clinicians may order CTs for myriad reasons, including desire to improve patient satisfaction. ObjectivesTo determine if greater CT use by ED clinicians is associated with increased average patient satisfaction scores for those providers. MethodsThe study took part across 15 non-pediatric hospitals in a regional healthcare system. We compared clinician CT use rate for adult patients discharged from the ED with Net Promotor Score (NPS) for that clinician. NPS is a patient satisfaction metric with a possible range of scores from −100 to +100. We included ED clinicians (physicians and non-physician providers (NPPs)) with at least 500 adult patient encounters resulting in ED discharge from July 2020 through June 2022. We assessed for an association between CT use and clinician NPS using univariate and multivariate regression models. ResultsAcross the 15 hospitals, 166 physicians and 74 NPPs were included in the study. The median CT rate was 25.7 ​% (range 7.1 ​%–48.9 ​%). In both models, there was a statistical association between CT utilization and NPS such that every absolute increase in CT use by 10 ​% resulted in a 3-point improvement in provider NPS on the 200-point scale. When examined in a sensitivity analysis, none of the hospitals individually showed this same association. ConclusionsWe found a 26 ​% rate of CT use by clinicians for adults discharged from the ED, with wide variation in utilization between clinicians. There was a small and inconsistent association between CT utilization and clinician specific NPS scores.

Does the Performance of Splenectomy as Part of Cytoreductive Surgery Carry a Worse Prognosis Than in Patients Not Receiving Splenectomy? A Propensity Score Analysis and Review of the Literature

Background & Objectives Ultra-radical (UR) procedures, including splenectomy, are utilized to increase complete cytoreduction rates during Cytoreductive Surgery (CRS) performed with the aim of complete macroscopic clearance of disease. The purpose of this study was to investigate if splenectomy negatively impacts survival when undertaken during CRS for advanced ovarian cancer (AOC) and compare published splenectomy and cytoreduction rates. Methods A retrospective review of all consecutive patients who underwent cytoreductive surgery for AOC between 16/05/2013-28/01/2019. Survival, baseline patient characteristics, complications and surgical parameters were recorded. Propensity scored matching (PSM) was performed to reduce bias. Results 154 patients identified over 71 months. 97 underwent standard, 57 underwent UR surgery, 27 patients received splenectomy (17.5%) No difference was seen in overall survival (OS) between all patients (median OS 34 months (95%CI 25.9–41.1) and patients who underwent splenectomy (median OS not yet reached) (p = >0.05). After PSM for various baseline covariates, no significant difference in splenectomy versus non-splenectomy patients (3-year survival 54% compared to 56%) (P > 0.05). Three splenectomy specific complications occurred; one each of pancreatic tail injury, left pleural effusion and streptococcal pharyngitis during chemotherapy. We found wide variation in utilization of splenectomy in published case series; from 9% to 35%. Conclusions Splenectomy performed as part of CRS is not detrimental to survival in AOC. There is a wide variation in utilization of splenectomy in published case series with little correlation with cytoreduction rates.

Advances in robotic surgery for pediatric ureteropelvic junction obstruction and vesicoureteral reflux: history, present, and future.

The introduction of robotic surgical technology into urological reconstruction, particularly pediatrics, has introduced new horizons for reducing the morbidity and enhancing the efficacy of surgical repair of congenital conditions in children. In reviewing the evolution of pediatric urological applications of robotic surgery, we wanted to address the different levels of reported utilization of pyeloplasty and ureteral reimplantation as two of the most common procedures. Review of the published literature sought to explore the described variation in clinical application of these two common procedures, and the evolution of the practice over time. Reported outcomes suggest that variations in patient selection, the learning curve and in reporting of outcomes all contribute to the wide variation in utilization of pediatric robotic pyeloplasty and ureteral reimplantation. These technologies are demonstrating their potential as well as the challenges of use in children and there is a steady evolution of capability. Practitioners should be aware of both the possibilities as well as the risks of such new technology in the care of our patients. This requires thorough and open reporting of outcomes, the willingness to introduce change and integrate new findings into practice.

Utilization of long-term care after decompressive hemicraniectomy for severe stroke among older patients.

While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial. To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC. Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data. Among 397,503 acute ischemic stroke patients, 130 (0.03%) underwent DHC. Mean age was 72years, and 75% were between the ages of 65 and 74. Mortality was highest (38%) within the first 30days. At 2years, 59% of the original cohort had died. The 30-day rate of acute hospital readmission was 25%. Among survivors, 75% returned home 1year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC. There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.

Use of coronary angiography and revascularization procedures following acute myocardial infarction. A European perspective.

There is little evidence to inform routine practice in the use of coronary angiography and revascularization procedures after acute myocardial infarction. Large differences in the uptake of these procedures have been reported but representative data are scarce. Outcome studies have produced opposing conclusions concerning the impact of the high rate of these cardiac procedures. A population-based patient sampling approach was utilized to identify routine practice in representative samples from 11 European countries. Data were collected retrospectively on treatment in the 6 months following acute myocardial infarction (n=2807). There was wide variation in utilization of coronary angiography and revascularization procedures. Even after restricting the analysis to patients <65 years (n=1262), there remained a 6 13 fold variation in the use of these procedures. A decreased likelihood of undergoing these procedures was associated with older age. In addition, there was an independent and negative association between female sex and utilization of coronary angiography and coronary artery bypass grafting (CABG). The effect on patient outcome of the observed variation in use of these procedures is not known but has important cost and resource implications for the health services. Outcome research is needed to define patient selection criteria and to measure the cost-utility of different angiography and revascularization rates.

A Method for Assessing the Impact of a Computer-Based Decision Support System on Health Care Outcomes

The wide variation in utilization of diagnostic resources has not been decreased by the proliferation of new diagnostic technologies. We wish to test the hypothesis that the introduction of a medical decision support system into clinical practice could potentially lead to more efficient use of diagnostic information, and therefore lead to a reduction in overall laboratory use and cost of care. We have devised and are currently implementing a randomized controlled trial of a computer based decision support system, the University of Pittsburgh version of Quick Medical Reference (QMR). The main purpose of the study is to determine the effect of the QMR program on specific outcome measures: length of hospital stay, number and types of diagnostic tests ordered, and overall charges. An important part of this evaluation is relating the initial level of diagnostic uncertainty expressed by the admitting housestaff team to utilization of diagnostic resources. The purpose of this paper is to describe the methodology for carrying out this controlled trial, and to describe our initial experiences with its implementation.

The first febrile seizure: A study of current pediatric practice

A natonwide survey of pediatricians was conducted to ascertain their methods of evaluation and ofmanagement of a child who had had a “first” febrile seizure. Two hundred and sixty (58%) of the sample of 445 pediatricians responded to the single mailing. Nearly one-quarter (24%) routinely hospitalized the child. A wide variation in utilization of diagnostic studies for this condition was reported. Those procedures for which the highest proportion of respondents indicated routine performance were: lumbar puncture (41%); measurements of concentrations of serum calcium (38%) and of blood sugar (43%); and electroencephologram (36%). Of the 260 respondents, only 15% prescribed phenobarbital therapy for a defined period of time after the occurrence of the first febrile seizures. Fifty-four percent of pediatricians advised parents to administer phenobarbital only when the child had a febrile illness. The results demonstrate that practicing pediatricians vary widely in the evaluation and management of children with an initial febrile seizure. Lack of consensus among pediatric practitioners concerning the management of this and other conditions will seriously hamper future peer review efforts.