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Diabetes is an ambulatory care sensitive condition that quality of care can prevent complications development and hospitalization needs. However, diabetes patients with disability face greater challenges with receiving quality diabetes care than those without disabilities. This study examined diabetes-related avoidable hospitalizations (DRAH) focusing on the association with disability. We used nationally representative health insurance cohort data from 2002 to 2013. The study population is people who were newly diagnosed with type 2 diabetes. We measured the cumulated number of DRAH using the Prevention Quality Indicators (PQIs). The variables of interest were disability severity and type. We performed a recurrent events analysis using Cox proportional hazard regression model. Among 49,410 type 2 diabetes patients, 12,231 (24.8%) experienced DRAHs at least once during the follow-up period. Among the total population, 5924 (12.0%) diabetes patients were registered as disabled. The findings report that disability severity was significantly associated with higher risks for DRAH, where severely disabled diabetes patients showed the highest hazard ratio of 2.24 (95% CI 1.80-2.79). Among three DRAH indicators, severely disabled diabetes patients showed increased risks for long-term (AHR 2.21, 95% CI 1.89-2.60) and uncontrolled (AHR 2.28, 95% CI 1.80-2.88) DRAH. In addition, intellectual (AHR 5.52, 95% CI 3.78-8.05) and mental (AHR 3.97, 95% CI 2.29-6.89) disability showed higher risks than other types of disability. In conclusion, diabetes patients with disability are at higher risk for DRAH compared to those without disabilities, and those with intellectual and mental disabilities were more likely to experience DRAH compared to those with physical or other types of disability. These findings call for action to find the more appropriate interventions to improve targeted diabetes primary care for patients with disability. Further research is needed to better understand determinants of increasing risks of DRAH., (© 2022. The Author(s).)

Introduction: The classic findings of acute appendicitis-right lower quadrant pain, anorexia, and leukocytosis-have been well known. However, emergency medicine and surgical providers continue to rely on imaging to confirm the diagnosis. We aimed to evaluate the increase in reliance on computed tomography (CT) scans for acute appendicitis diagnosis over time., Methods: We conducted a retrospective study of patients ≥18 years presenting to UNC Hospitals with signs and symptoms of acute appendicitis who subsequently underwent appendectomy from 2011 to 2015. Demographic, clinical, laboratory, and pathologic data were reviewed. We evaluated the incidence of CT scans stratified by year, age, and sex., Results: Within our male population, 55.2% (278/504) had classic appendicitis symptoms. Of the 278 male patients with classic appendicitis symptoms, 248 underwent CT imaging. Male patients <45 years of age were more likely to present with classic appendicitis symptoms (216/357, 60.5%) compared with patients aged 46-65 (52/108, 48.1%) or >65 (10/39, 25.6%). Of the male patients <45 years with classic appendicitis symptoms, the incidence of CT scans increased over time (68.3% in 2011, 84.2% in 2012, 92.3% in 2013, 93.9% in 2014, 92.3% in 2015). When considering the 216 CT scans that could have been avoided in our population, we calculate an approximate savings of $173 998.80 over 5 years., Conclusion: The incidence of CT scans for acute appendicitis confirmation has increased over time even in men. CT scans for the diagnosis or confirmation of acute appendicitis should rarely be indicated in men aged <45 years with classic appendicitis symptoms.

Introduction: Early-onset neonatal sepsis is a rare but potentially lethal infection that is very often suspected in daily practice. Previous national guidelines recommended the use of systematic paraclinical tests for healthy term newborns with suspected infection. These guidelines were updated in 2017 by the French Health Authority (Haute Autorité de santé), and promote initial clinical monitoring taking into account the infectious risk level for term and near-term born infants., Objectives: To assess the impact of the new recommendations on antibiotic therapy prescription and invasive tests, and on the outcomes of infants born from 36weeks' gestation., Materials and Methods: This study compared the management and the outcome of neonates born from 36weeks' gestation at the level III University Hospital of Nancy, according to their infectious risk level during two periods, before and after the update of national recommendations: from July 1 to December 31, 2017, versus July 1 to December 31, 2018. Data were retrospectively collected from the infants' files. This study compared the number and length of antibiotic treatment and the number of invasive tests, the number of documented infections, the number and length of hospitalization, and mortality between the two periods., Results: During the first period, among 1248 eligible newborns, 643 presented an infectious risk factor, versus 1152 newborns with 343 having an infectious risk factor during the second period. Antibiotic treatment was initiated for 18 newborns during the first period (1.4%) and for nine during the second (0.8%) (P=0.13). The mean (SD) duration of the antibiotic treatment was longer in the first than in the second period: 6.3±2days vs. 3.1±2.3days (P=0.003). There was no death related to neonatal infection. A total of 1052 blood samples were collected during the first period versus 51 during the second (P<0.01). There was no documented infection. In the first period, there were 18 newborns (1.4%) hospitalized for suspected infection versus nine (0.8%) in the second period (P=0.13). The duration of hospitalization was 5.7±1.7days in the first period versus 5.2±3days in the second (P=0.33)., Conclusion: In this study, the application of the new guidelines enabled a reduction of antibiotic exposure and a reduction of invasive tests without additional risk., (Copyright © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Importance: In response to calls to reduce unnecessary diagnostic testing with computed tomographic pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), there have been growing efforts to create and implement decision rules for PE testing. It is unclear if the use of advanced imaging tests for PE has diminished over time., Objective: To assess the use of advanced imaging tests, including chest computed tomography (CT) (ie, all chest CT except for CTPA), CTPA, and ventilation-perfusion (V/Q) scan, for PE from 2004 to 2016., Design, Setting, and Participants: Cohort study of adults by age group (18-64 years and ≥65 years) enrolled in 7 US integrated and mixed-model health care systems. Joinpoint regression analysis was used to identify years with statistically significant changes in imaging rates and to calculate average annual percentage change (growth) from 2004 to 2007, 2008 to 2011, and 2012 to 2016. Analyses were conducted between June 11, 2019, and March 18, 2020., Main Outcomes and Measures: Rates of chest CT, CTPA, and V/Q scan by year and age, as well as annual change in rates over time., Results: Overall, 3.6 to 4.8 million enrollees were included each year of the study, for a total of 52 343 517 person-years of follow-up data. Adults aged 18 to 64 years accounted for 42 223 712 person-years (80.7%) and those 65 years or older accounted for 10 119 805 person-years (19.3%). Female enrollees accounted for 27 712 571 person-years (52.9%). From 2004 and 2016, chest CT use increased by 66.3% (average annual growth, 4.4% per year), CTPA use increased by 450.0% (average annual growth, 16.3% per year), and V/Q scan use decreased by 47.1% (decreasing by 4.9% per year). The use of CTPA increased most rapidly from 2004 to 2006 (44.6% in those aged 18-64 years and 43.9% in those ≥65 years), with ongoing rapid growth from 2006 to 2010 (annual growth, 19.8% in those aged 18-64 years and 18.3% in those ≥65 years) and persistent but slower growth in the most recent years (annual growth, 4.3% in those aged 18-64 years and 3.0% in those ≥65 years from 2010 to 2016). The use of V/Q scanning decreased steadily since 2004., Conclusions and Relevance: From 2004 to 2016, rates of chest CT and CTPA for suspected PE continued to increase among adults but at a slower pace in more contemporary years. Efforts to combat overuse have not been completely successful as reflected by ongoing growth, rather than decline, of chest CT use. Whether the observed imaging use was appropriate or was associated with improved patient outcomes is unknown.

Method: A retrospective chart review was used to assess the feasibility of identifying these indicators in the data (160,897 patients from 464 practices across Australia). Conditional logistic regression was used to assess the independent contribution of nEOL indicators in patients aged 75-84 and ≥85 years using a case-control design matching by practice., Results: The strongest indicators for nEOL status were advanced malignancy, residential aged care, nutritional vulnerability, anaemia, cognitive impairment and heart failure. Other indicators included hospital attendance, pneumonia, decubitus ulcer, chronic obstructive pulmonary disease, antipsychotic prescription, male sex and stroke., Discussion: Consideration of routinely collected patient data may suggest nEOL status and trigger advance care planning discussions.

Background: No recent data have investigated rates of diagnostic testing for pulmonary embolism (PE) in US emergency departments (EDs), and no data have examined computed tomographic pulmonary angiography (CTPA) rates in subgroups at high risk for adverse imaging outcomes, including young women and children. We hypothesized that over-testing for PE remains a problem., Methods and Results: We used electronic health record and billing data for 16 EDs in Indiana and 11 hospitals in the Dallas-Fort Worth area from 2016 to 2019 to locate ED patients who had any of the following: D-dimer, CTPA, scintillation ventilation perfusion lung scanning or formal pulmonary angiography. The primary outcomes were ED encounter volume-adjusted CTPA rate, PE yield rate with subgroup reporting for children (<18 years) and women under 45 years. We also examined the most frequent diagnoses. From a total visit volume of 1 828 010 patient encounters, 97 125 (5.3% of the total volume) had a diagnostic test for PE, including 25 870 patients who had CTPA order without D-dimer (59% of all tests for PE). The yield rate for PE from CTPA scans was 1.3% (1.1%-1.5%) in Indiana and 4.8% (4.2%-5.1%) in Dallas-Fort Worth (pooled rate 3.1%). Linear regression showed that increased D-dimer ordering correlated with increased PE yield rate (Pearson's R 2 =0.43; P <0.001). From the pooled sample, 59% of CTPAs done were in women, with 21% of all CTPAs performed on women under 45 years of age, and 1.4% (1.3%-1.5%) on children. The most frequent diagnoses were symptom-based descriptions of chest pain (34%) and shortness of breath (6.5%) and the condition-based diagnosis of pneumonia (4.1%)., Conclusions: Over-testing for PE in American EDs remains a major public health problem. Centers with higher D-dimer ordering had higher yield of PE on CTPA. These data suggest the potential for implementation of D-dimer based protocols to reduce low-yield CTPA ordering.

Objective: Guidelines from the Society for Vascular Surgery and the Choosing Wisely campaign recommend that peripheral vascular interventions (PVIs) be limited to claudication patients with lifestyle-limiting symptoms only after a failed trial of medical and exercise therapy. We sought to explore practice patterns and physician characteristics associated with early PVI after a new claudication diagnosis to evaluate adherence to these guidelines., Methods: We used 100% Medicare fee-for-service claims to identify patients diagnosed with claudication for the first time between 2015 and 2017. Early PVI was defined as an aortoiliac or femoropopliteal PVI performed within 6 months of initial claudication diagnosis. A physician-level PVI utilization rate was calculated for physicians who diagnosed >10 claudication patients and performed at least one PVI (regardless of indication) during the study period. Hierarchical multivariable logistic regression was used to identify physician-level factors associated with early PVI., Results: Of 194,974 patients who had a first-time diagnosis of claudication during the study period, 6286 (3.2%) underwent early PVI. Among the 5664 physicians included in the analysis, the median physician-level early PVI rate was low at 0% (range, 0%-58.3%). However, there were 320 physicians (5.6%) who had an early PVI rate ≥14% (≥2 standard deviations above the mean). After accounting for patient characteristics, a higher percentage of services delivered in ambulatory surgery center or office settings was associated with higher PVI utilization (vs 0%-22%; 23%-47%: adjusted odds ratio [aOR], 1.23; 48%-68%: aOR, 1.49; 69%-100%: aOR, 1.72; all P < .05). Other risk-adjusted physician factors independently associated with high PVI utilization included male sex (aOR, 2.04), fewer years in practice (vs ≥31 years; 11-20 years: aOR, 1.23; 21-30 years: aOR, 1.13), rural location (aOR, 1.25), and lower volume claudication practice (vs ≥30 patients diagnosed during study period; ≤17 patients: aOR, 1.30; 18-29 patients: aOR, 1.35; all P < .05)., Conclusions: Outlier physicians with a high early PVI rate for patients newly diagnosed with claudication are identifiable using a claims-based practice pattern measure. Given the shared Society for Vascular Surgery and Choosing Wisely initiative goal to avoid interventions for first-line treatment of claudication, confidential data-sharing programs using national benchmarks and educational guidance may be useful to address high utilization in the management of claudication., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Over the past few years, a significant overuse of radiological investigations influenced the quality and cost of healthcare of the country as it may lead to non-compliance of the patient due to non-affordability and also may harm the patient in terms of radiation hazards. Pakistan, being a low-income, resource-constraint country, is facing financial impact on families as well as health system due to multiple reasons., Objectives: The purpose of study is to identify reasons of unnecessary use of radiological diagnostic modalities in Pakistani hospitals as perceived by radiologists., Methods: A cross-sectional study was conducted on a total of all 105 radiologists, having at least 1 year experience of working in radiology, working in five tertiary care hospitals in Lahore. A self-constructed, self-administered, pretested 5-point Likert scale opinion-based questionnaire was administered after taking informed consent. It includes questions about excessive radiological use that may be attributed to the physicians, investigations, patients and other non-categorized causes. Results were analyzed using SPSS version 23., Results: Since the assessment forms were handed over and collected from the radiologists in person, the response rate was 100%. Of a total of 105 respondents, 78 (74.28%) respondentsagreed that there is an actual increase, 25 (23.80%) respondents disagreed and 2 (1.90%) respondents were unsure. Most important reasons for increased usage of radiological investigations are 'need of accuracy of diagnosis' (P = 0.009), 'trend of physicians to repeat tests in order to confirm preset diagnoses' (P-value = 0.03), 'lack of knowledge about proper usage of radiological advances' (P-value = 0.005) and 'lack of proper clinical examination' (P-value = 0.04)., Conclusion: Unnecessary use of radiological investigations is actually there as perceived by radiologists, which is attributed to inadequate knowledge, attitude and training of physicians to refer patients to radiological resources. This research can be a stepping stone for future researchers as it can be used for elaborating these causes individually and finding ways as to how each of these causes can be controlled and minimized to bring about a decline in excessive usage of these modalities for the betterment of the patients., (© The Author(s) 2019. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The risk assessment profile (RAP) score has been used to determine patients who would most benefit from lower extremity duplex ultrasound screening (LEDUS). We hypothesized that revising our LEDUS protocol to perform screening ultrasound examinations in patients with an RAP ≥8 within 48 h of admission would reduce the number of LEDUS performed without changing outcomes., Methods: A retrospective review was conducted on trauma patients admitted from July 1, 2014, to June 30, 2015, and July 1, 2016, to June 30, 2017. In 2014-2015, patients with an RAP score ≥5 underwent weekly LEDUS examinations starting on hospital day 4. In 2016-2017, the protocol was changed to start screening patients with an RAP score ≥8 by hospital day 2. Both protocols screened with weekly ultrasounds after the first examination. Demographic data, injury characteristics, LEDUS examination findings, chemoprophylaxis type, and venous thromboembolism incidence were collected., Results: A total of 602 patients underwent LEDUS examination in 2014-2015, whereas only 412 underwent LEDUS in 2016-2017. No significant difference was seen in the number of patients diagnosed with deep vein thrombosis (DVT) or pulmonary embolism. DVTs were most often identified on the first LEDUS examination in both cohorts. Of patients diagnosed with a DVT on an LEDUS examination, a significantly higher RAP score (12 versus 10), and a shorter time to first duplex (1 versus 3 d), and DVT diagnosis (2 versus 4 d) were observed in the 2016-2017 cohort. In patients diagnosed with a pulmonary embolism, no significant differences were demonstrated between cohorts., Conclusions: Refinement of LEDUS protocols can decrease overutilization of hospital resources without compromising trauma patient outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The diagnostic cascade in the emergency department (ED) has not been fully elucidated. Aim To inspect whether the usage of consulting medicine and imaging contributes to hospital outcomes. We also propose a theoretical model for better understanding the diagnostic cascade of needless medical testing., Methods: A two-level study was conducted. The first local phase was a retrospective archive study that was conducted between 2014 and 2017 in a tertiary hospital. We extracted the number of requested imaging and consultations for each patient, and main time lags were calculated. The second-phase (January-April 2018) was conducted on a national level. We examined 22 hospitals with the emphasis on five hospital outcomes: recurrent ED visits (within 24 h), median waiting time at the ED, rate of early discharge at the same day and day after and percentage of patients spending >4 h in the ED., Results: A 5% upsurge in CT scans was observed (p = .032), and a significant increase was found in the number of consultations (14%, p = .002). On a national level, a linear regression model found that the proportion of patients discharged from the hospital on the same day and on the day after and the proportion of patients staying in the ED > 4 h predict ED recurrence visits within 24 h (p = .025; R 2  = 46.3%)., Conclusions: Upsurge in resource usage in the ED leads to a diagnostic cascade of health consumption. Further study is necessary to examine the proposed model in a global scale., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The growth of endovenous ablation in the United States over the last few years has raised concerns of overuse by many vascular societies and payers. Reasons for such growth are unclear (ie, increased awareness, less invasive procedure, or inappropriate overuse). The Medicare Provider Utilization and Payment database was analyzed to define metrics of current practice trends in Medicare patients by providers., Methods: The Medicare Provider Utilization and Payment database was queried for endothermal ablation Current Procedural Terminology codes (36475, 36476, 36478, and 36479) from 2012 through 2015. These results were imported into a relational database program. Queries were designed to ascertain the practice trends of all providers, inclusive of all specialties, and the data were exported to a spreadsheet program for analysis. Analysis for ablations per patient was calculated by assessing the number of beneficiaries who underwent at least one ablation by a provider in relation to the total number of ablations performed by that provider., Results: Most saphenous vein ablations were done by vascular surgeons (29%), cardiologists (21%), or general surgeons (14%). The remaining one-third was performed by 33 other provider specialties ranging from nuclear medicine specialists to ophthalmologists. Regional variation was significant with 51% of ablations being performed in the south (Florida, 15.7% and Texas, 11.4%). The Western region had the greatest percentage growth of 62% with the addition of 14,788 cases added between 2012 and 2015. Ablations per patient averaged 1.8 in the aggregate dataset. Over the 4-year period, there was a steady increase seen in the number of patients undergoing ablation, number of ablations performed, number of providers performing ablation, average amount of ablations being performed as well as the number and proportion of providers performing more than ablations per patient. The number of ablations per patient was higher than average in specialties without any formal vascular training., Conclusions: Endovenous ablation is performed by a wide variety of subspecialists with different levels of formal training for the management of chronic venous disease. This data analysis can help to establish better guidelines and governance over the use of endovenous ablation, but care should be taken to realize this is only an average and many patients will require more than two ablations for appropriate care. As our health care system shifts from a fee-for-service to a value-based system, and taxpayer-funded resources in Medicare patients become less available, it is important that practice trends be scrutinized using data-driven initiatives so that the appropriate physician treats the appropriate patient for the appropriate reasons., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Previous studies have demonstrated the impact of appropriate use criteria (AUC) education and feedback interventions in reducing unnecessary ordering of transthoracic echocardiography (TTE) by trainees. To our knowledge, no study has evaluated the impact of the addition of price transparency to this education and feedback model on TTE utilization by resident physicians. We performed an education and feedback quality improvement initiative combining charge transparency data with information on AUC. We hypothesized that the initiative would reduce the number of complete TTE ordered and increase the number of limited TTE ordered, anticipating there would be substitution of limited for complete studies. Residents rotating on inpatient teaching cardiology ward teams received education on AUC for TTE, indications for limited TTE, and hospital charges for TTE. Feedback was provided on the quantity and charges for complete and limited TTE ordered by each team. We analyzed the effects of the intervention using a linear mixed effects regression model to adjust for potential confounders. The post-intervention weeks showed a reduction of 4.6 complete TTE orders per 100 patients from previous weekly baseline of 31.3 complete TTE orders per 100 patients (p value = 0.012). Charges for complete TTE decreased $122 from baseline of $980 per patient (p value = 0.040) on a per-week basis. Secondarily, there was no statistically significant change in limited TTE ordering during the intervention period. This initiative shows the feasibility of a house staff-driven charge transparency and education/feedback initiative that decreased medical residents' ordering of inpatient TTE.

Background: Concern over high false-positive rates and the potential for unintended harm to patients is a critical component of the lack of widespread adoption of lung cancer screening., Methods: An institutional database was used to identify patients who underwent lung cancer screening between 2/2015 and 2/2018 at Rush University Medical Center and Rush Oak Park Hospital. Reads were executed by dedicated thoracic radiologists and communicated using the Lung Imaging Reporting and Data System (Lung-RADS V.1)., Results: Six hundred and four patients were screened over the study period. We identified 21 primary lung cancers and 8 incidental cancers. We identified a false-positive rate of 17.5%. Only 9 patients underwent further investigative workup for benign disease (5.3%); however, only 4 (2.9%) of those patients were found to have inflammatory or infectious lesions, which are common mimickers of lung cancer. Excluding Lung-RADS category 3 for the purpose of quantifying risk of unintended harm from unnecessary procedures, we found a 6.9% false-positive rate, while diagnosing 25% of all Lung-RADS category 4 patients with primary lung cancer., Conclusion: False-positive rates in lung cancer screening programs continue to decline with improved radiologic expertise. Additionally, false-positive reporting overestimates the risk of unintended harm from further investigative procedures as only a percentage of positive findings are generally considered for tissue diagnosis (i.e., Lung-RADS category 4).

Introduction: Few studies described strategies to improve the use of diagnostic tests in intensive care units (ICU). No study assessed whether their impact was sustained or not. In this study, we assessed whether a multi-faceted intervention for more appropriate use of laboratory testing can decrease the number of tests, is sustainable, is not associated with additional morbidity and represents a potential cost saving., Material and Methods: An open-label prospective cohort study in two separated units of the same medical intensive care unit (ICU) including respectively 3315 and 2392 consecutive patients. After the observation period (2010), a reduction in ICU A of unnecessary diagnostics tests as part of a program including senior supervisory of juniors' orders, encouragements for orders containment at each everyday round discussions (period 2; 2011). Period 3 (2012) consisted in the prolongation of the protocol as a routine care without supervision; Period 4 (2013) was a new period of observation without intervention. No modification was implemented in ICU B in periods 2-4., Results: After the intervention, a decrease in the overall number of tests per ICU-patient-days (37.3±5.5 (baseline) to 15.2±3.2 (- 59%); p<0.0001) was observed. The total cost of the tests decreased from 239±41 to 104±28 euros per ICU-patient days; p<0.0001. The effect on laboratory test orders was sustainable in period 3 (-49%) and 4 (-30%). No significant secondary effect of the intervention was observed in period 2. In ICU B, there was no significant change in the overall laboratory test orders in between the periods., Conclusions: Laboratory test containment is effective, likely safe and sustainable provided that an educational program is repeatedly promoted, that it makes sense for the whole team, that senior and junior physicians are both committed in the program, and that encouragements for laboratory orders containment at each everyday round discussions., Competing Interests: The authors have declared that no competing interests exist.

Introduction: The prevalence and the variability of clinical practice in acute bronchiolitis make it a perfect candidate to monitor the proper use of resources. The aim of this study is to analyse the differences in the use of non-recommended resources in the management of bronchiolitis in the Emergency Department, before and after the establishment of a new protocol., Methods: A retrospective study was conducted on a sample of patients diagnosed with acute bronchiolitis in the Emergency Department of a tertiary hospital, before (December 2014) and after (December 2016) the implementation of a new protocol. A comparison was made on the use of diagnostic tests and treatments in both groups., Results: The analysis included a total of 113 patients with acute bronchiolitis examined in December 2014, and 128 patients in December 2016. The clinical characteristics in both groups were similar. In the post-protocol period, there was a significant decrease in the use of salbutamol, both in the Emergency Department (33.6% vs 19.5%, P<.01) and at discharge (46.7% vs 15.2%, P<.001); adrenaline (12.4% vs 2.4%, P=.002), and nebulised hypertonic saline solution (5.3% vs 0.8%, P=.04). Rapid respiratory syncytial virus (RSV) testing was also decreased (40.7% vs 26.6%, P=.01). This decrease was not associated with an increase in the number of admissions or re-assessments in the Emergency Department., Conclusions: The establishment of a new protocol for acute bronchiolitis decreased the use of non-recommended resources, mainly the use of bronchodilators and rapid RSV testing., (Copyright © 2017 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)

Importance: Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse., Observations: A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits)., Conclusions and Relevance: Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.

Objectives: A programme was introduced in Canterbury, New Zealand to evaluate the diagnosis and treatment of frenulum releases in newborn infants with suspected tongue-tie (ankyloglossia). The primary goals were to support breastfeeding and ensure that unnecessary surgery was avoided., Methods: Local healthcare professionals reached consensus on a pathway for improving management of infants with tongue-tie and breast-feeding difficulties. This embedded an expert breast-feeding review and assessment of lingual function using a validated method, the Bristol Tongue-tie Assessment Tool (BTAT). Infants with breastfeeding problems related to tongue-tie had a frenotomy at a hospital outpatient clinic. An education programme was developed to support introduction of the new clinical pathway and included seminars and online information for healthcare professionals and the general public., Results: Frenotomy intervention rate reduced markedly from 11.3% in 2015 to 3.5% by mid-2017. Feeding methods were not different before or after surgery between infants who received a frenotomy and those who did not. Initially, the BTAT threshold for frenotomy was set at ≤5, however the final clinical pathway combined a breastfeeding assessment and a BTAT threshold of ≤4. The education programs assisted with the changes in practice, while increased use of the clinician guidance and public health information websites confirmed growing awareness of tongue-tie and community breastfeeding support., Conclusions: Establishing consistent multidisciplinary assessment of tongue-tie in infants with feeding difficulties led to a marked reduction in frenotomy intervention rate. 23% of the frenotomy group in the 2016 audit showed a significant improvement in the ability to breastfeed, but overall there was no difference in the feeding pattern of infants who either received or were declined a frenotomy. The development of a supportive education programme and availability of online information about tongue-tie for health professionals and consumers contributed to successful uptake of the new clinical pathway., (Copyright © 2018 Canterbury District Health Board. Published by Elsevier B.V. All rights reserved.)

Importance: Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation., Objectives: To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time., Design, Setting, and Participants: Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017., Exposures: Hospital discharge date (quarter of the year) and hospital in which patients received MV., Main Outcomes and Measures: The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations., Results: The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98)., Conclusions and Relevance: Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.

Background: Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCL X ) remain a challenging problem. We examined the reasons for CCL X , clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCL X ., Methods and Results: We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCL X (n=866; 65%). Reasons for CCL X included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCL X (C statistic, 0.985). CCL X subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCL X ; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCL X was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009)., Conclusions: In this study, prehospital ECG without overreading or transmission lead to frequent CCL X . CCL X subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCL X patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCL X and influence clinical outcomes.

The aims of this study was to determine the trends in rates of caesarean sections in Turkey. The data source for this study was the Turkey Demographic and Health Survey (TDHS) 1993-1998-2003-2008-2013 conducted by Hacettepe University, Institute of Population Studies. Cross tables and binary logistic regression were used for analysis. It was found that the caesarean section rate, which was 14.3% in 1993, increased to 51.9% in 2013. The rate increased with maternal age and educational level at childbirth. The Caesarean section rate was higher in women who were under health insurance coverage, first time mothers, childbirth in the private health institutions, those staying in the Western region and urban areas, and having the highest level of wealth. This study aims to contribute to the literature of caesarean sections especially in developing countries, in which caesarean section has become a major healthcare issue. Impact Statement What is already known on this subject: Caesarean section is among the most widely practiced obstetric surgery worldwide. Previous studies have suggested that the rates of caesarean section were affected by the biological, genetic and medical factors. What the results of this study add: Besides the biological, genetic and medical factors, it is believed that social factors (income and social status, education, employment, etc.) play an important role on the caesarean section in developing countries. Although the laws on caesarean sections have been enforced since 2012 in Turkey, this study shows that there has been a significant increase in caesarean section between the 1993 and 2013 periods. The study also reveals that prohibiting caesarean sections, except in cases of medical necessity, is a problematic issue in the health system despite all efforts. What the implications are of these findings for clinical practice and/or further research: This study may be of interest for authorities and researchers in terms of showing the social factors associated with the caesarean section.

Background: A large proportion of endovascular aortic aneurysm repair (EVAR) patients are routinely admitted to the intensive care unit (ICU) for postoperative observation. In this study, we aimed to describe the factors associated with ICU admission after EVAR and to compare the outcomes and costs associated with ICU vs non-ICU observation., Methods: All patients undergoing elective infrarenal EVAR in the Premier database (2009-2015) were included. Patients were stratified as ICU vs non-ICU admission according to location on postoperative day 0. Both patient-level (sociodemographics, comorbidities) and hospital-level (teaching status, hospital size, geographic location) factors were analyzed using univariate and multivariable logistic regression to determine factors associated with ICU vs non-ICU admission. Overall outcomes and hospital costs were compared between groups., Results: Overall, 8359 patients underwent elective EVAR during the study period, including 4791 (57.3%) ICU and 3568 (42.7%) non-ICU admissions. Patients admitted to ICU were more frequently nonwhite and had more comorbidities, including congestive heart failure, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, and hypertension, than non-ICU patients (all, P < .03). ICU admissions were more common in small (<300 beds), urban, and nonteaching hospitals and varied greatly depending on surgeon specialty and geographic region (P < .001). A pattern emerged when admission location was clustered by hospital; ICU patients were treated at hospitals where 96.7% (interquartile range, 84.5%-98.9%) of patients were admitted to ICU after EVAR, whereas non-ICU patients were treated at hospitals where only 7.5% (interquartile range, 4.9%-25.8%) were admitted to ICU after EVAR. A multivariable logistic regression model accounting for patient-, operative-, and hospital-level differences had a significantly lower area under the curve for predicting ICU admission after EVAR than a model accounting only for hospital factors (area under the curve, 0.76 vs 0.95; P < .001). The overall rate of adverse events was higher for ICU vs non-ICU patients (16.3% vs 13.7%; P < .001). Failure to rescue (2.9% vs 3.9%; P = .42) and in-hospital mortality (0.4% vs 0.4%; P = .81) were similar between groups. After adjusting for patient and hospital factors as well as for postoperative adverse events, ICU admission after EVAR cost $1475 (95% confidence interval, $768-2183) more than non-ICU admission (P < .001)., Conclusions: Among patients undergoing elective EVAR, postoperative ICU admission is more closely associated with hospital practice patterns than with individual patient risk. Routine ICU admission after EVAR adds significant cost without reducing failure to rescue or in-hospital mortality., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Context: Routine radioactive iodine (RAI) ablation for low-risk differentiated thyroid cancer (DTC) is not supported by current practice guidelines., Objective: To assess recent stage-specific trends in use of RAI ablation., Design, Setting, and Patients: Retrospective study of patients with DTC (1999 to 2015) identified from the California Cancer Registry. Statistical analysis included standardized differences, P values, and multivariable analyses using RAI as the predictor variable., Main Outcome Measures: Trends and drivers of RAI ablation for low-risk DTC., Results: Of 46,906 patients with DTC who underwent near-total or total thyroidectomy [mean age 48.2 ± 15.5 (standard deviation) years, 77% female), 25,457 (54%) received RAI. The proportion of patients with regional/distant disease who received RAI remained stable at 68%. Use of RAI for patients with localized disease (no extrathyroidal extension, lymph node, or distant metastases) decreased from 55% (1999) to 30% (2015), with the most substantial change occurring in tumors <1 cm (39% to 11%). The rate also decreased for localized tumors between 1 and 2 cm (62% to 34%) and 2 and 4 cm (67% to 49%) and remained stable at 59% for tumors >4 cm. In multivariable analyses, patients with localized disease were less likely to receive RAI if they were >65 years old [odds ratio (OR) 0.77, 95% confidence interval (CI): 0.71 to 0.83], had tumors <1 cm (OR 0.33, 95% CI: 0.31 to 0.35), or were treated in an academic hospital (OR 0.71, 95% CI: 0.67 to 0.75)., Conclusions: The rate of RAI ablation decreased over time, mainly attributable to decreased use for localized DTCs <2 cm. Many patients with low-risk DTC still receive RAI unnecessarily.

Background: Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription., Objective: To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS., Methods: A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups., Results: The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group., Conclusions: This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship., Disclosures: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.

Although blood transfusion is a lifesaving therapy for some patients, transfusion has been named 1 of the top 5 overused procedures in US hospitals. As unnecessary transfusions only increase risk and cost without providing benefit, improving transfusion practice is an effective way of promoting high-value care. Most high-quality clinical trials supporting a restrictive transfusion strategy have been published in the past 5 to 10 years, so the value of a successful patient blood management program has only recently been recognized. We review the most recent transfusion practice guidelines and the evidence supporting these guidelines. We also discuss several medical societies' Choosing Wisely campaigns to reduce or eliminate overuse of transfusions. A blueprint is presented for developing a patient blood management program, which includes discussion of specific methods for optimizing transfusion practice.

Background: The appropriate use criteria considers cardiac stress testing within 2 years after percutaneous coronary intervention (PCI) to be rarely appropriate, unless prompted by symptoms or change in clinical status. Little is known about the patterns of cardiac stress testing after PCI in the single-payer Canadian healthcare system, where mechanisms for reimbursement are different from the United States., Methods and Results: Frequency and timing of cardiac stress testing within 2 years of PCI performed between April 2004 and March 2013 in Ontario, Canada, was determined from linked provincial databases. Subsequent rates of coronary angiography and revascularization after stress testing were ascertained. Of the 112 691 patients with PCI, 67 442 (59.8%) underwent at least 1 stress test, with 38 267 (34.0%) undergoing repeat stress testing (ie, >1 stress test) within 2 years. Patients who underwent stress testing were younger, had less medical comorbidities, were more likely to reside in urban areas, and had higher incomes. Spikes in incidence of repeat stress testing were observed at 3 to 4 months, 6 to 7 months, and 12 to 13 months after the prior stress test. Of those tested, only 5.9% underwent subsequent coronary angiography, and only 3.1% underwent repeat revascularization within 60 days of stress testing., Conclusions: More than half of all patients undergo cardiac stress testing within 2 years of PCI, with one third undergoing repeat stress tests. Only 1 of 30 tested patients underwent repeat revascularization. These findings reinforce the appropriate use criteria recommendations against routine stress testing after PCI. Further work is needed to aid with the selection of patients most likely to benefit from stress testing after PCI., (© 2017 American Heart Association, Inc.)

Objective: Cardiologists participate in the diagnosis and interventional treatment of numerous high-risk patients. The goal of this study was to investigate how the current malpractice system in Turkey influences cardiologists' diagnostic and interventional behavior and to obtain their opinions about an alternative patient compensation system., Methods: The present cross-sectional study assessed the practice of defensive medicine among cardiologists who are actively working in various types of workplace within the Turkish healthcare system. A 24-item questionnaire was distributed to cardiology residents, specialists, and academics in Turkey in print format, by electronic mail, or via cell phone message., Results: A total of 253 cardiologists responded to the survey. Among them, 29 (11.6%) had been sued for malpractice claims in the past. Of the cardiologists who had been sued, 2 (6.9%) had been ordered to pay financial compensation, and 1 (3.4%) was given a sentence of imprisonment due to negligence. In all, 132 (52.8%) of the surveyed cardiologists reported that they had changed their practices due to fear of litigation, and 232 (92.8%) reported that they would prefer the new proposed patient compensation system to the current malpractice system. Among the cardiologists surveyed, 78.8% indicated that malpractice fear had affected their decision-making with regard to requesting computed tomography angiography or thallium scintigraphy, 71.6% for coronary angiography, 20% for stent implantation, and 83.2% for avoiding treating high-risk patients., Conclusion: The results of this survey demonstrated that cardiologists may request unnecessary tests and perform unneeded interventions due to the fear of malpractice litigation fear. Many also avoid high-risk patients and interventions. The majority indicated that they would prefer the proposed alternative patient compensation system to the current malpractice system.

Background: The performance of prostate health index (phi) in predicting prostate biopsy outcomes has been well established for patients with prostate-specific antigen (PSA) values between 2 and 10 ng/mL. However, the performance of phi remains unknown in patients with PSA >10 ng/mL, the vast majority in Chinese biopsy patients. We aimed to assess the ability of phi to predict prostate cancer (PCa) and high-grade disease (Gleason Score ≥7) on biopsy in a Chinese population., Methods: This is a prospective, observational, multi-center study of consecutive patients who underwent a transrectal ultrasound guided prostate biopsy at four hospitals in Shanghai, China from August 2013 to December 2014., Results: In the cohort of 1538 patients, the detection rate of PCa was 40.2%. phi had a significantly better predictive performance for PCa than total PSA (tPSA). The areas under the receiver operating characteristic curve (AUC) were 0.90 and 0.79 for phi and tPSA, respectively, P < 0.0001. A considerable proportion of patients in the cohort had PSAs >10 ng/mL (N = 838, 54.5%). The detection rates of PCa were 35.9% and 57.7% in patients with tPSA 10.1-20 and 20.1-50 ng/mL, respectively. The AUCs of phi (0.79 and 0.89, for these two groups, respectively) were also significantly higher than tPSA (0.57 and 0.63, respectively), both P < 0.0001. If a phi ≤35 was used as the cutoff, 599/1538 (39%) biopsies could have been avoided at a cost of missing small numbers of PCa patients: 49 (7.93%) PCa patients, including 18 (3.69%) high-grade tumors., Conclusions: Results from this study suggest that phi can be used to predict PCa and high-grade disease in Chinese men with high PSA levels (>10 ng/mL)., (© 2017 Wiley Periodicals, Inc.)

This study assessed the prescribing pattern of irrational use of antibiotic among children under age of 12 years in public and private sector hospitals in Pakistan. The prospective clinical evaluation of drug utilization pattern of antimicrobials from Patient Bedside File (PBF) of in-patients and Culture Sensitivity Test (CST) reports were evaluated to determine the antibiotic resistance. Two indicators recorded to assess antibiotic prescribing were; dose of prescribed antibiotic (low-dose, rational and high -dose) and Indication (valid or invalid). Antibiotics resistance for 25 selected antibiotics was determined by culture sensitivity test. This study showed that in Private Sector Hospital 77.7% neonates, 13.3% infants and 9% children admitted in ICU were receiving antibiotics, among them only 57.3% neonates, 62% infants and 59.9% children were found valid that is prescribed antibiotics for right indication. 27% neonates, 19% infants and 22.1% children were prescribed under dose of antibiotics, which may lead to antimicrobial resistance and increased cost of hospital stay. Only 29.1% neonates, 30% infants and 36.8% children were receiving rational dosing. In Public Sector Hospital, 65.6% neonates, 19.4% infants and 15% children were receiving antibiotics. Among them valid indication was found in 35.3% neonates, 35.6% infants and 39.8% in children. 33.3% neonates, 26.6% infants and 28.2% children were receiving under dose that may lead to resistance not only among those who were prescribed under dose but also such bacteria become resistant and spread to other population to increase antimicrobial resistance. The irrational prescribing of antibiotics was found very high (above 50%) in Public sector hospital (Hospital-B) for every age group whereas in Private sector hospital (Hospital-A) this practice was found near to 50%. In this study the prescribing frequency of Amikacin, Cefixime, Cefotaxime, Meropenem, Amoxicillin, Vancomycin, Azithromycin, Levofloxacin and Clarithromycin was found above 80% in both hospitals (A and B). Among these, Amoxicillin, Penicillin, Erythromycin and Cephalexin showed higher resistance i.e. 49.2%.

Avoiding low value care received increasing attention in many countries, as with the Choosing Wisely campaign and other initiatives to abandon care that wastes resources or delivers no benefit to patients. While an extensive literature characterises approaches to implementing evidence-based care, we have limited understanding of the process of de-implementation, such as abandoning existing low value practices. To learn more about the differences between implementation and de-implementation, we explored the literature and analysed data from two published studies (one implementation and one de-implementation) by the same orthopaedic surgeons. We defined 'leaders' as those orthopaedic surgeons who implemented, or de-implemented, the target processes of care and laggards as those who did not. Our findings suggest that leaders in implementation share some characteristics with leaders in de-implementation when comparing them with laggards, such as more open to new evidence, younger and less time in clinical practice. However, leaders in de-implementation and implementation differed in some other characteristics and were not the same persons. Thus, leading in implementation or de-implementation may depend to some degree on the type of intervention rather than entirely reflecting personal characteristics. De-implementation seemed to be hampered by motivational factors such as department priorities, and economic and political factors such as cost-benefit considerations in care delivery, whereas organisational factors were associated only with implementation. The only barrier or facilitator common to both implementation and de-implementation consisted of outcome expectancy (ie, the perceived net benefit to patients). Future studies need to test the hypotheses generated from this study and improve our understanding of differences between the processes of implementation and de-implementation in the people who are most likely to lead (or resist) these efforts., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To estimate the proportion of guideline nonadherent Pap tests in women aged younger than 21 years and older than 65 years and posthysterectomy in a single large health system. Secondary objectives were to describe temporal trends and patient and health care provider characteristics associated with screening in these groups., Methods: A retrospective cross-sectional chart review was performed at Fairview Health Services and University of Minnesota Physicians. Reasons for testing and patient and health care provider information were collected. Tests were designated as indicated or nonindicated per the 2012 cervical cancer screening guidelines. Point estimates and descriptive statistics were calculated. Patient and health care provider characteristics were compared between indicated and nonindicated groups using χ and Wilcoxon rank-sum tests., Results: A total of 3,920 Pap tests were performed between September 9, 2012, and August 31, 2014. A total of 257 (51%; 95% confidence interval [CI] 46.1-54.9%) of tests in the younger than 21 years group, 536 (40%; 95% CI 37.7-43.1%) in the older than 65 years group, and 605 (29%; 95% CI 27.1-31.0%) in the posthysterectomy group were not indicated. White race in the older than 65 years group was the only patient characteristic associated with receipt of a nonindicated Pap test (P=.007). Health care provider characteristics associated with nonindicated Pap tests varied by screening group. Temporal trends showed a decrease in the proportion of nonindicated tests in the younger than 21 years group but an increase in the posthysterectomy group., Conclusion: For women aged younger than 21 years and older than 65 years and posthysterectomy, 35% of Pap tests performed in our health system were not guideline-adherent. There were no patient or health care provider characteristics associated with guideline nonadherent screening across all groups.

Background: Unnecessary routine interventions in uncomplicated labour and birth, like cardiotocography (CTG), amniotomy, use of scalp electrode and oxytocin treatment, are associated with further interventions that could harm the woman and the infant. A four year Action Research (AR) project was done on a labour ward to enhance the capacity of local midwives in the promotion of physiological labour and birth., Aim: To describe the use of interventions during labour and birth in healthy women at term with spontaneous onset of labour, before and after initiation of an Action Research project., Methods: A retrospective before and after comparative study of clinical records from 2009 (before) and 2012 (after), based on a random selection of records from primiparous and multiparous women. Outcome measures were duration of admission CTG, frequency of admission CTG over 30min, frequency of amniotomy, use of scalp electrode, and frequency of oxytocin augmentation in spontaneous labour., Results: 903 records were included. The duration of admission CTG (p=0.001), frequency of admission CTG duration over 30min (p=<0.001), the use of scalp electrodes (p=<0.001), and use of oxytocin augmentation of spontaneous labour (p=0.014) were reduced significantly after initiation of the AR project. There were no significant differences in frequency of amniotomy, duration of total CTG, postpartum bleeding, sphincter tears, Apgar score <5 at 5min, and mode of birth., Conclusion: Following an AR project, several interventions were reduced during labour and birth. Controlled studies in other settings are needed to assess the impact of collaborative action on decreasing unnecessary interventions., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Importance: Overuse of medical care is an increasingly recognized problem in clinical medicine., Objective: To identify and highlight original research articles published in 2015 that are most likely to reduce overuse of medical care, organized into 3 categories: overuse of testing, overtreatment, and questionable use of services. The articles were reviewed and interpreted for their importance to clinical medicine., Evidence Review: A structured review of English-language articles on PubMed published in 2015 and review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults., Findings: Between January 1, 2015, and December 31, 2015, we reviewed 1445 articles, of which 821 addressed overuse of medical care. Of these, 112 were deemed most relevant based on their originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by consensus using the same criteria. Findings included a doubling of specialty referrals and advanced imaging for simple headache (from 6.7% in 2000 to 13.9% in 2010); unnecessary hospital admission for low-risk syncope, often leading to adverse events; and overly frequent colonoscopy screening for 34% of patients. Overtreatment was common in the following areas: 1 in 4 patients with atrial fibrillation at low risk for thromboembolism received anticoagulation; 94% of testosterone replacement therapy was administered off guideline recommendations; 91% of patients resumed taking opioids after overdose; and 61% of patients with diabetes were treated to potentially harmfully low hemoglobin A1c levels (<7%). Findings also identified medical practices to question, including questionable use of treatment of acute low-back pain with cyclobenzaprine and oxycodone/acetaminophen; of testing for Clostridium difficile with molecular assays; and serial follow-up of benign thyroid nodules., Conclusions and Relevance: The number of articles on overuse of medical care nearly doubled from 2014 to 2015. The present review promotes reflection on the top 10 articles and may lead to questioning other non-evidence-based practices.

Objectives: Diabetes requires continuous medical care including prevention of acute complications and risk reduction for long-term complications. Diabetic complications impose a substantial burden on public health and care delivery. We examined trends in regional differences in hospitalisations due to diabetes-related complications among the total diabetes population in Finland., Research Design: A longitudinal register-based cohort study 1996-2011 among a total population with diabetes in Finland., Participants: All persons with diabetes identified from several administrative registers in Finland in 1964-2011 and alive on 1 January 1996., Outcome Measures: We examined hospitalisations due to diabetes-related short-term and long-term complications, uncomplicated diabetes, myocardial infarction, stroke, lower extremity amputation and end-stage renal disease (ESRD). We calculated annual age-adjusted rates per 10 000 person years and the systematic component of variation. Multilevel models were used for studying time trends in regional variation., Results: There was a steep decline in complication-related hospitalisation rates during the study period. The decline was relatively small in ESRD (30%), whereas rates of hospitalisations for short-term and long-term complications as well as uncomplicated diabetes diminished by about 80%. The overall correlation between hospital district intercepts and slopes in time was -0.72 (p<0.001) among men and -0.99 (p<0.001) among women indicating diminishing variation. Diminishing variation was found in each of the complications studied. The variation was mainly distributed at the health centre level., Conclusions: Our study suggests that the prevention of complications among persons with diabetes has improved in Finland between 1996 and 2011. The results further suggest that the prevention of complications has become more uniform throughout the country., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: The relationship between inappropriate MPI and cardiovascular outcomes is poorly understood. We sought to systematically review the literature on appropriate use criteria (AUC) for MPI, including temporal trend of inappropriate testing and resulting cardiovascular outcomes., Methods: We searched the MEDLINE database for studies related to AUC and MPI. The co-primary outcomes were abnormal test results and the presence of cardiac ischemia. Random effects odds ratios (OR) were constructed using DerSimonian-Laird method., Results: A total of 22 studies with 23,443 patients were included. The prevalence of inappropriate testing was 14.8% [95% confidence interval (CI) 11.6%-18.7%]. Inappropriate MPI studies were less likely to be abnormal (OR 0.41 95% CI 0.35-0.49, P < .0001) and to demonstrate ischemia (OR 0.40, 95% CI 0.24-0.67, P < .0001) compared to appropriate testing. No difference in the rate of inappropriate tests was detected based on the midpoint of the enrollment year (P = .54). The pattern of ordering inappropriate studies was not different between cardiology and non-cardiology providers (OR 0.74, 95% CI 0.51-1.06, P = .10)., Conclusion: Inappropriate MPI studies are less likely to yield abnormal results or demonstrate myocardial ischemia. The rate of inappropriate MPI has not decreased over time.

Purpose: The diagnosis of Gleason score (GS) ≥7 with distinction from GS < 7 remains a difficult problem instructing clinical decisions. Moreover, the present wide application of prostate biopsy to increase prostate cancer detection rate might cause unnecessary and excessive examination or treatment. Therefore, a risk assessment model for forecasting GS ≥ 7 in potential prostate cancer patients was established to reduce unnecessary prostate biopsies., Methods: Patients (n = 981; September 2009 to January 2013) who underwent trans-rectal ultrasound (TRUS)-guided core prostate biopsy were retrospectively evaluated in the first stage of the study. Age, prostate-specific antigen (PSA), free PSA (fPSA), the free/total PSA ratio (f/t), prostate volume (PV), PSA density (PSAD), digital rectal examination (DRE) findings (texture, nodules) and B-ultrasound detection results (normal or abnormal, presence of hypoechoic mass or microcalcification) were considered as potential predictive factors. After multiple logistic regression analysis, independent variables used to build a nomogram were selected using a backward elimination selection procedure. Then, a model to forecast GS ≥ 7 was designed for potential prostate cancer patients. In the second stage of the study, 410 cases (January 2013 to March 2015) were subsequently evaluated using our model for prostate biopsies, and the outcomes of biopsies were compared between the two stages., Results: PSA, DRE texture, DRE nodules and B-ultrasound results were finally brought into our nomogram; a obviously greater area under the receiver operating characteristic (ROC) curve was obtained for the model than utilizing PSA, fPSA or PSAD alone (0.831 vs. 0.803, 0.770, 0.780 separately). We thereafter sought the best cutoff value in the ROC curve at 0.87, which provided sensitivity as high as 90%. Meanwhile, the specificity was 45.8%, which was much higher than the specificity of PSA, fPSA and PSAD at the same sensitivity level (37.7, 24.6 and 35.2%, respectively). In the first stage, the detection rate of GS ≥ 7 in the high-risk group was significantly higher than in the low-risk group (80.3 vs. 35.0%, p < 0.001). Furthermore, in the second stage, with the application of the new model associated with our former models, the rate of GS ≥ 7 was improved from 71.0 (697/981) to 79.2% (267/337) (p = 0.003)., Conclusions: The model for forecasting GS ≥ 7 is effective, which could reduce unnecessary prostate biopsies without delaying patients' diagnoses and treatments.

Introduction: Doctors are unfamiliar with diagnostic accuracy parameters despite routine clinical use of diagnostic tests to estimate disease probability., Methods: Trainee doctors completed a questionnaire exploring their understanding of diagnostic accuracy parameters; ability to calculate post-test probability of a common surgical condition (appendicitis) and their perceptions on training in this area. To determine whether the method of information provision altered interpretation, trainees were randomised to receive diagnostic test information in three ways: positive test only; positive test with specificity and sensitivity; positive test with positive likelihood ratio in layman terms., Results: 326 candidates were recruited across 30 training sessions. Trainees scored a median of three out of seven in questions concerning knowledge of diagnostic accuracy parameters. This was affected neither by training level (P = 0.737) nor by experience in acute general surgery (P = 0.738). 30 (11.8%) candidates correctly estimated post-test probability; with 86.6% overestimating this value. Neither level of training (P = 0.180) nor experience (P = 0.242) influenced the accuracy of the estimate. Provision of the ultrasound scan results in different ways was not associated with likelihood of a correct response (P = 0.857)., Conclusion: This study highlights the deficiencies in trainee doctors' understanding and application of diagnostic tests results. Most trainees over-estimated disease probability, increasing the risk of unnecessary intervention and treatment.

Introduction: The acute surgical model has been trialled in several institutions with mixed results. The aim of this study was to determine whether the acute surgical model provides better outcomes for patients with acute biliary presentation, compared with the traditional emergency surgery model of care., Methods: A retrospective review was carried out of patients who were admitted for management of acute biliary presentation, before and after the establishment of an acute surgical unit (ASU). Outcomes measured were time to operation, operating time, after-hours operation (6pm - 8am), length of stay and surgical complications., Results: A total of 342 patients presented with acute biliary symptoms and were managed operatively. The median time to operation was significantly reduced in the ASU group (32.4 vs 25.4 hours, p=0.047), as were the proportion of operations performed after hours (19.5% vs 2.5%, p<0.001) and the median length of stay (4 vs 3 days, p<0.001). The median operating time, rate of conversion to open cholecystectomy and wound infection rates remained similar., Conclusions: Implementation of an ASU can lead to objective differences in outcomes for patients who present with acute cholecystitis. In our study, the ASU significantly reduced time to operation, the number of operations performed after hours and length of stay.