7 x 9 brochure evidence table overuse web.qxp

Study Outcome
Revisiting The Appropriateness Of Carotid carotid endarterectomy annually. 84.9% of Dardik, H., Faust, G., Riles, T.S.; 2003; Medicare cases judged appropriate). 10.6% judged inappropriate, primarily due to high co-morbid conditions.
This study was a retrospective chart reviewof 2,124 procedures in 6 New York hospitalsto determine appropriateness of carotidendarterectomy based on Rand effective-ness criteria.
Antibiotics For Upper Respiratory Tract Antibiotics are overused for URI. Patients Infections In Ambulatory Practice In The United were less likely to receive antibiotic pre- States, 1997-1999: Does Physician Specialty scriptions from general internists than fami- ly practitioners. Rate of prescriptions writ- ten for URI decreased over the study peri- This study used 1997-1999 NationalAmbulatory Medical Care Survey(NAMCS) data to examine antibiotic usefor upper respitory infection (URI) as afunction of patient, physician and practicecharacteristics.
The Appropriateness Of Recommendations For Chart reviews revealed that 70% of charts did not completely meet all indications for and failure to try alternative treatmentsprior to hysterectomy. The ultimate signifi- California to determine the appropriatenessof recommendation for hysterectomy (notthe surgery itself) based on guidelinesdeveloped by expert panel and three crite-ria sets published by American College ofObstetricians and Gynecologists (ACOG).
The surgeries were actually performed priorto the publication of the guidelines used.
Study Outcome
Overuse Of Transthoracic Echocardiography In TTE is overused in cases of infective endo- The Diagnosis Of Native Valve Endocarditis carditis (IE). The diagnosis of IE is a clini- cal diagnosis, and the results of the TTE did not significantly affect the duration of antibiotic therapy. The authors propose anew algorithm that would result in elimina- This study reviewed hospital records of 98 tion of 53% of the TTEs done in this study, patients with suspected infective endocardi- which can be avoided by treating patients empirically until the blood culture results impact that the study had on treatmentdecisions.
Antibiotic Treatment Of Children With Sore Antibiotics are generally overused, and the wrong antibiotics are prescribed (and mis- is underused. Antibiotics were prescribed in 53% of visits for sore throats in childrenaged 3-17. Antibiotics are indicated for sore National Hospital Ambulatory Medical Care only 15-36% of sore throats. When antibi- otics are prescribed, the correct antibiotic is children with a diagnosis of tonsillitis, strep sore throat, and pharyngitis had the GABHS testing and antibiotic treatment in children Study Outcome
Use Of Adenosine In Patients Hospitalized In A adenosine for arrhythmias where adenosine is not indicated. 26 patients from the series This retrospective record review of patientsadministered adenosine for tachyarrhyth-mias, combined with house staff surveys,was used to identify the heart rhythms forwhich patients are prescribed adenosine,and to identify reasons for misuse. This wasdone by looking at patients who receivedadenosine, and giving resident physicians aquestionnaire about reading electrocardio-grams (EKGs) and the appropriate use ofadenosine.
Emergency Medicine Versus Primary Care: A Costs were significantly higher in the ED.
Case Study Of Three Prevalent, Costly, AndNon-Emergent Diagnoses At A CommunityTeaching HospitalMartin, BC; 2000; J Health CareFinance This study examines the implications ofimplementation of a prospective paymentsystem for Medicare emergency department(ED) visits, using a large tertiary hospital asa data source. Costing systems were exam-ined, and ED costs compared to outpatientprimary care. For upper respiratory infec-tions, ED costs were on average doublethose of out patient care, largely due to dif-ferences in ancillary tests ordered and pre-scription costs.
Study Outcome
Effectiveness Of A Medical Priority Dispatch Hospital records were available for 86% of cases, of which 12 were potentially life- threatening, requiring ALS intervention.
potentially benefited from ALS interven-tion. The remaining 157 were classified as records of a regional Emergency MedicalService (EMS) service to determine theproportion of patients with abdominal painwho would benefit from advanced life support (ALS) when called for by these pro-tocols.
A Clinician’s Guide To The Appropriate And The rate of misuse and overuse of antibiotic Accurate Use Of Antibiotics: The Council For prescriptions might be lowered if clinicians Appropriate And Rational Antibiotic Therapy were to use the 5 Council for Appropriate criteria to help select appropriate antibi- otics. The 5 criteria of CARAT (evidence- based results, therapeutic benefits, safety, optimal drug for the optimal duration, andcost effectiveness) are important to consider when choosing an appropriate and accurate Antibiotic Prescribing For Children With Colds, Upper Respiratory Tract Infections And more inclined to prescribe than others; also receive antibiotics than others. Pediatricianswere 0.57 times less likely to prescribe antibiotics to children with otitis, sinusitis, physicians to the 1992 National Ambulatory or pharyngitis than non-pediatricians.
Care Medical Care Survey (NAMCS) toevaluate antibiotic prescribing practices forchildren younger than 18 years, who werediagnosed with a cold, upper respitoryinfection, or bronchitis in the U.S., amongpediatricians and nonpediatricians.
Study Outcome
Ceftriaxone Use In The Emergency Department: Based on published guidelines, ceftriaxone majority of cases (66.4%, with an additional This study evaluates ceftriaxone use in anurban pediatric emergency department(PED) to determine if overuse exists basedon published guidelines for management offebrile infants.
Insurance Coverage And Health Care Consumers’ Use Of Emergency Departments: decreased from 57.1% of visits in 1992 to Has Managed Care Made A Difference? aged care patients compared with fee-for-service patients, nor for insured compared Ambulatory Medical Care Survey (NAHMCS) data from 1992 and1996 todetermine the effect of managed care onappropriateness of emergency department(ED) utilization.
Prospective Determination Of Medical Necessity For Ambulance Transport By Paramedics Gratton, M.C., Ellison, S.R., Hunt, J.
physicians) did not require ambulancetransport (76.2% agreement) to the emer- This study prospectively assessed the med- ical necessity of emergency transport by alarge urban EMS system.
Study Outcome
Cervical Cancer Screening Among Women With Pap testing rates vary by type and reason my for malignancy have 1 more test a year terectomy for benign reasons have 1 fewertest (potential overuse).
This retrospective record and claims reviewcompared cervical cancer screening rates inwomen who had previously undergone hys-terectomy to women who had not.
Antibiotic Resistance: The Iowa Experience The profiling and educational interventions led to a substantial decrease in both overallantibiotic prescribing and drug costs. Other states may want to undertake similar pro- reports on the prevalence of drug-resistant grams to help protect their citizens from infections caused by resistant pathogens.
ment of Public Health convened a multidis-ciplinary task force in January 1998 todevelop strategies to combat antibioticresistance in the state because they werealarmed by these reports.
Health Insurance, Primary Care, And Admission rates for ACS conditions in New Preventable Hospitalization Of Children In A where there were fewer primary care physi- cians, lower percents of children with pri- vate health maintenance organization(HMO) insurance, and higher proportions of review of 1994 hospital discharge data forNew York resident children withAmbulatory-Care Sensitive (ACS) condi-tions. Relationship between ACS admissionrates and several factors were analyzed.
Study Outcome
Lansoprazole Overutilization: Methods For This study used a retrospective recordreview of all patients with prescriptions forlansoprazole at a Veterans Affairs MedicalCenter (VAMC) to identify the documentedindications for long-term lansoprazole thera-py and recommend appropriate step-downtherapy in order to improve patient care andreduce medical costs. Trends In Antimicrobial Prescribing For Inappropriate use of antibiotics for viral Bronchitis And Upper Respiratory Infections URI has decreased, but 10% of children and 20% of adults still receive inappropriate Davis, M.P., Pearson, W.S.; 2003; Am JPublic Health This study used data from the NationalAmbulatory Medical Care Survey from1993, 1995, 1997, and 1999 to examineantimicrobial prescribing patterns for adultsand children with bronchitis or upper respi-ratory infections (URIs) before and after the1998 release of national pediatric practicerecommendations for minimizing use ofantibiotics, and starting with narrow-spec-trum medications if needed.
Study Outcome
The Impact Of Peer Management On Test- ability. Hospitals with growing health care This retrospective review of inpatientrecords in a large tertiary hospital wasdesigned to examine whether changes tothe software of a care provider order entrysystem (CPOE) at a large academic hospitalcould reduce variability in ordered lab tests,chest x-rays, and EKGs. Clinical And Economic Outcomes Assessment In often leads to unnecessary revascularization that does not lead to improvement in out- come. Thus, the potential exists that stressSPECT imaging, a highly effective diagnos- This article reviews the current state of the tic tool, could reduce the inappropriate use evidence on the clinical and economic data of an invasive procedures resulting in cost- regarding different nuclear cardiology imag- ing tests. A synthesis of current economicevidence for gated, Single-Photon EmissionComputed Tomography (SPECT) is alsopresented.
Study Outcome
Self-Reported Papanicolaou Smears And There is significant overuse of pap smears Hysterectomies Among Women In The United reported that they had a pap smear within the past 3 years. 77.2-82.1% of women with- out a hysterectomy self-reported that theyhad a pap smear within the past 3 years.
terectomy need to have a pap smear due to estimate the rates of Papanicolaou smears in supracervical hysterectomy or history of cer- vical neoplasia (including cervical cancer).
10.6-11.6 million pap smears were doneunnecessarily at a cost of $375-505 millionfor the study period, based on cost data for1997.
Antimicrobial Use For Pediatric Upper The overuse of antibiotics is prevalent for Respiratory Tract Infections (URI): Reported Practice, Actual Practice, Parental Beliefs patients, despite stated beliefs that over- prescribing contributes to antibiotic resist- ance. The reasons cited included parental pressure, desire to avoid a follow-up visit inmanaged care patients, and a belief that This study surveyed 336 pediatricians and parents could elect to obtain antibiotics family physicians in Georgia regarding opin- practitioners recognize the problems associ- ated with overuse of antibiotics for URI, tices in order to examine the factors that survey results (including both pediatricians relate to the over-prescribing of antibiotics in children 5 years of age and younger.
(pediatricians only) showed significant lev-els of over-prescribing of antibiotics.
Overprescribing was worse for family physi-cians compared with pediatricians and espe-cially common for diagnoses of: sinusitis,purulent rhinitis, and common cold.
Study Outcome
Factors Affecting Prescription Of Ultra-High Class I topical corticosteroids were pre- Potency Topical Corticosteroids In Skin Disease: scribed in 3% of all skin disease-related vis- An Analysis Of US National Practice Data its, with prescription rates being highest in psoriasis (22%). There were a large number of questionable prescriptions for other con- This study analyzed data from the NationalAmbulatory Medical Care Survey(NAMCS) to examine the prescribing pat-terns of Class I (ultra-high potency) topicalcorticosteroids in patients with skin disease.
Characteristics Of Nonurgent Emergency 60.1% of all visits were nonurgent. Of all Department Use In The First 3 Months Of Life patients with non-urgent visits, 24.1% had race all resulted in increased nonurgentemergency department (ED) use.
This study analyzed 965 visits by infants inthe first 3 months of life to a single urbanemergency room to determine the charac-teristics of non-urgent emergency room vis-its.
Impact Of Simple Screening Criteria On Guidelines for tests such as stool cultures Utilization Of Low-Yield Bacterial Stool can reduce overuse, particularly through the Cultures In A Children’s Hospital tests are appropriate. Using guidelines to limit stool cultures for SSCYE for inpatientsreduced cultures by 43% (689)—primarily This study used a retrospective analysis of hospital laboratory records to estimate the (497) rather than through a dramatic num- ber of tests being rejected (192)—and saved develop guidelines for reducing unwarrant- the hospital of over $50,000 per year.
ed stool cultures for Salmonella, Shigella,Campylobacter, Yersinia enterocolitica, andE. coli 0157:H7 (SSCYE).
Study Outcome
Keeping Children Out Of Hospitals: Parents’ About 50% of hospitalizations for children And Physicians’ Perspectives On How Pediatric with 6 diagnoses may be avoidable through Hospitalization For Ambulatory Care-Sensitive better parent education and follow-up clini- avoidable hospitalization (AH) as agreed toby two of the three sources, were asthma (27%), skin infections (20%), and dehydra- tient attending physicians about pediatric agreement rate varied from 68% for parents hospital admissions concerning whether the and attending physicians. Variables mostassociated with AH were being over the ageof 10, and having a diagnosis of asthma.
Provider And Practice Characteristics Associated Potential overuse of antibiotics in children With Antibiotic Use In Children With Presumed is related to both provider and facility char- Viral Respiratory Tract Infections. acteristics. Although there seems to be a downward trend, the overall rate of antibiot- ic prescribing for the 4 ICD-9 coded diag-noses was 33.2%. Antibiotic prescribing res- idents (19.5%) was less than physicians in National Hospital Ambulatory Medical Care teaching or non-teaching hospitals (39.6%).
Survey (NHAMCS) to assess antibiotic pre- Other factors associated with increased like- scribing to children in hospital outpatient lihood of antibiotic prescribing included clinics for 4 ICD-9 code diagnoses sugges- diagnosis of bronchitis (unspecified), being tive of viral respiratory infection acute seen in a non-pediatric clinic, and being seen before the 1998 publication of theCDC/AAP guidelines.
Use Of Open Access In GI Endoscopy At An 86% of endoscopies after consultation with accepted indications compared with 65% of open access procedures. Significant patho- logic findings were present in 40% of theformer group compared with 28% of those months of endoscopies at 1 hospital in orderto compare appropriateness and yield ofendoscopy for patients referred for open-access endoscopy with those for patientswho had prior contact with a gastroenterolo-gist.
Study Outcome
Trends In Operative Management Of Pediatric Hospitals that specialized in treating pedi- Splenic Injury In A Regional Trauma System atric trauma were less likely to perform sur- gery for blunt splenic injury. At all types of hospitals, the rate of surgery was low from the years 1991 to 1993, rose in the years1994 to 1997 (more in the less specialized hospitals), and declined to an intermediate data to identify patients <19 years of age who presented to an emergency department(ED) in Pennsylvania with a diagnosis ofsplenic injury to characterize the variationin management of blunt pediatric splenicinjury, comparing nontrauma hospitals withregional centers.
Factors Associated With Emergency Department 65% of ED visits in this study were classi- Utilization For Nonurgent Pediatric Problems fied as nonurgent by qualified medical per- Nagel, R., Klein, W., Puczynski, S.;2000; Arch Fam Med This study surveyed 200 caretakers whobrought children to 2 urban emergencydepartments (EDs) for non-urgent condi-tions to identify caregiver characteristicsassociated with the utilization of EDs fornon-urgent pediatric care in Toledo, OH.
Study Outcome
National Trends In The Use Of Antibiotics By The high rate of antibiotic prescription for Primary Care Physicians For Adult Patients of antibiotics. However, there is no gold standard on this topic and the appropriate- ness of prescription may be confounded bythe subjectivity of diagnosis. The percent- age of outpatients receiving antibiotic pre- from 1980 to 1994 (1.05 per year). Overall, national trends in the prescription of antibi- antibiotics were prescribed 66% of the time otics by primary care physicians (PCPs) to for adult patients with cough, rising from adult patients with cough, and to identify age 65, being white, visiting for the firsttime to complain of cough, and being diag-nosed with bronchitis were associated withsignificantly increased odds of prescription. Beta-Blocker Dosages And Mortality After Large doses of beta-blockers may be over- Myocardial Infarction: Data From A Large doses of beta-blockers (less than 50% of the dose used in RCTs) was associated with at higher doses. In fact, in this study, treat-ment with lower doses resulted in signifi- This study reviewed the clinical records of patients surviving Acute MyocardialInfarction (AMI) to examine a potentialassociation between dosage of beta-blockerreceived at hospital discharge (for MI) andmortality.
Evaluating The Appropriateness Of Digoxin Digoxin blood tests are overused. Only 16% Canas, F.,Tanasijevic, M.J., Ma’luf, N., tients were appropriate. The vast majority of inappropriate tests (76%) were for earlyroutine monitoring, i.e., a test repeated less than 10 days after a previous test for inpa- review to determine the appropriateness of tients, and less than 10 months for outpa- tient digoxin levels at Brigham & Women’sHospital.
Study Outcome
Understanding Physician Adherence With A Pneumonia Practice Guideline: Effects Of and was associated with patient age (>65), Patient, System, And Physician Factors gender (male), employment, multilobar dis- ease, or comorbid conditions. PCP involve- tributed to increased non-compliance.
This study describes a retrospective chartreview and physician survey designed toquantify non-compliance with a CAP guide-line at the Massachusetts General Hospital.
Unnecessary Use Of Antimicrobials In Antimicrobials were overused in hospital- Hospitalized Patients: Current Patterns Of ized patients, either through prescription where antibiotics are not necessary, or mis- Antianaerobic Spectrum Of Activity application of drugs where antibiotics are necessary. Approximately 30% of the thera- This prospective observational study in anacademic hospital was designed to assessthe necessity of antibiotic prescriptions dur-ing a two-week period.
Antimicrobial Resistance In The Intensive Care dangerous and costly. Treatment of nosoco- mial infections are estimated to cost nearly $5 billion per year. While this article is more This article reviews the literature pertaining patients in an intensive care unit with noso- antibiotic misuse in its development.
comial infections and shows the percentageincrease of antimicrobial resistant pathogenswhich have increased across the spectrumsince 1994-1998.
Study Outcome
Inappropriate Use Of Emergency Medical Inappropriate ambulance use is a significant Services Transport: Comparison Of Provider patient perspectives. Approximately 43% of Richards, J.R., Ferrall, S.J.; 1999; Acad diverting resources from true emergencies.
41-50 year olds, whites, men and people This study prospectively surveyed patients without medical insurance or Medi-Cal are providers arriving at an urban universityemergency department (ED) in Californiato examine the use of EMS transport anddetermine how appropriately the service isused, evaluating both provider and patientperceptions.
Emergency Medical Care: Types, Trends, And Factors Related To Nonurgent Visits Liu, T. Sayre, M.R. Carleton, S.C.;1999; Acad Emerg Med This study used National HospitalAmbulatory Medical Care Survey (NHAMCS) data to describe and comparetrends in emergency department (ED) usefrom 1992 to 1996.
The Influence Of Insurance Status On Non- urgent Pediatric Visits To The Emergency visits can lead to inefficient utilization of than those with private health insurance.
While 58% of visits were considered non- This study used a subset of 1994 National insured patients. Males make up more than (NHAMCS) data (age <16) to investigate 50% of the caseload in both urgent and non- the overall rate of non-urgent visits was 58%, 51% for HMO, 56% for privatelyinsured, and 60% for government insuredpediatric patients.
Study Outcome
Parental Use And Misuse Of Antibiotics: Are Parents in both settings are misusing and There Differences In Urban Vs. Suburban overusing antibiotics. However, the misuse in suburbia is different from urban misuse.
likely to have misused antibiotics for their children. Parents in urban settings weremore likely to seek a prescription from This was a prospective survey of parents of children presenting to two emergencydepartment (EDs) (in NJ and CT) to com-pare the misuse of antibiotics by parents fortheir children in suburban and urban set-tings. Usual Source Of Care And Nonurgent Patients are more likely to use the ED for their usual source of care is not meeting their needs. Most participants reported highlevels of satisfaction with their USC. Access ine whether patient dissatisfaction with the usual source of care (USC) and perceivedaccess difficulties to that USC were associ-ated with nonurgent emergency department(ED) use.
Repeat Patients To The Emergency Department Cook, L.J. Knight, S. Junkins, E.P., Jr.
patients made up one third of patients, they accumulated more than 60% of all ED visitsand ED charges.
This study used three years of statewideemergency department (ED) data to stratifyED use into single, repeat, or serial use, andthen to assess differences between patientscomprising each strata.
Study Outcome
Ineffective Use Of Radiology: The Hidden Cost The authors estimate that 10-30% of diag- nostic radiologic procedures are unneces- sary. They cite self-referral by doctors who own equipment, fear of litigation and “wor-ried well” as causes. Based on various This narrative review describes the extent provides a brief description of the causes per year of in the US. They further esti- and the costs in terms of radiation-induced defects are inherited over succeeding gen-erations as a result of diagnostic testing.
Based on overuse rates of 10%-30%, theauthors cite excess deaths due to unneces-sary testing of around 110 (10%), 222 (20%)or 332 (30%).
Long Term Use Of Acid Suppression Started 196 out of 324 (60%) of general medical in- Inappropriately During Hospitalization not have an appropriate indication for the medication. 67 out of 196 (34%) were dis- charged on the medication with an appro-priate indication. 84% were discharged on This study is a retrospective chart review of months, 80% of those available for follow- inpatient teaching service to determine the up (31 out of 39) were still on it inappropri- ately. At 6 months, 50% of those available for follow-up (fifteen out of twenty-six) were still on it. Current costs of PPI are medicine service; to characterize patients hypothesis that use of PPI/H2RA continues Diagnosis And Management Of Acute Bronchitis improvement resulting from antibiotic ther-apy.
This is a general review of the diagnosisand treatment of acute bronchitis.
Study Outcome
Vulnerable Populations At Risk Of Potentially Avoidable Hospitalizations: The Case Of Nursing Home Residents With Alzheimer’s infection (UTI), and gastroenteritis, but less of dementia status, suggesting animportant quality issue.
This study linked Medicaid reimbursementdata with Massachusetts Medical ProviderAnalysis and Review data to determinewhether nursing home patients withdementia were more likely to experienceAmbulatory Care Sensitive Conditions(ACSC) admissions.
Is Appendiceal CT Scan Overused For CT scans can prevent avoidable laparotomy Evaluating Patients With Right Lower in equivocal cases, but routine scanning in cases with low likelihood of appendicitis Safran, D.B., Pilati, D., Folz, E., Oller, can, as shown in this report, lead to extend- ed hospitalizations and unnecessary costs.
This is a series of 4 cases to illustrate thecontroversy surrounding the routine use ofcomputed tomography (CT) for suspectedappendicitis.
Overuse Of Parenteral Antibiotics For Wound Antibiotic use in about one-fifth (18%) of Care In An Urban Emergency Department guidelines (although the authors themselves describe their criteria as “arbitrary in theface of no accepted consensus among infec- This study retrospectively reviewed records tion disease experts”). Some wounds were unnecessarily treated with Ceftriaxone and (EDs) for wound care but were not admit-ted, and assessed discrepancy with currentrecommendations derived from the litera-ture.
Study Outcome
An Evidence-Based Clinical Pathway For Patients who were treated according to the Bronchiolitis Safely Reduces Antibiotic Overuse more antibiotics than those not treated on the pathway (9% vs. 35%) and received nosystemic steroids (0% vs. 10%) significantly This study reviewed the charts of 181 chil- less often. The cost of hospitalization was dren admitted to an academic hospital and significantly less ($2,241 vs. $3,257), length estimated the extent to which antibiotics of stay was lower (2.09 vs. 2.55 days), and there was no statistically significant increasein return for unplanned care within 72hours (3.3% vs. 2.7% NS).
been shown to increase mortality by 81% or24% (two different studies) and cause 3 times as much deterioration in renal func- tion as placebo. Mild efficacy in decreasing (recombinant human brain natriuretic pep- capillary wedge pressure was shown in one tide), a costly vasodilator used in congestive should not have been approved, and notesthat it is being heavily marketed.
Residents adopted attending physicians’ Antibiotic Prescribing Practices In A Teaching prescribing behavior over time. In this case, Clinic: Comparison Of Resident And Staff attending physicians’ behavior was more likely to be wasteful. First- and second-year residents were significantly more likely to prescribe narrow spectrum antibiotics foracute sinusitis (56%) compared with attend- This study employed a record review of all patients in an academic practice presentingwith acute sinusitis to determine the rela-tionship between inappropriate antibioticprescribing and years of training.
Study Outcome
Association Between Medication Supplies And Healthcare Costs In Older Adults From An over-supply of medications. Both over-and chance of emergency room visits and hospi- This study used a retrospective recordreview in a tax-supported health system todetermine the costs associated with theover- and under-supply of medications toseniors in a public, urban health care sys-tem.
Is Colposcopic Biopsy Overused Among Women With A Cytological Diagnosis Of Atypical Squamous Cells Of Undetermined Significance likely to undergo colposcopic biopsy for fol- low-up of ASCUS. In a multivariate model, odds of follow-up by colposcopic biopsythan women with income less than approxi- mately $25,000. Women with private insur- ance had 2.8 times higher odds of follow-up analyze determinants of the type of follow- up received (colposcopic biopsy v. repeat The Impact Of Drug Coverage On COX-2 coverage, gastrointestinal risk had no inde- prescribed this class of medications. Drugusage was higher in Medicare beneficiaries with coverage compared with no coverage.
Beneficiary Survey were used to assess the COX-2 use was twice as high in those with impact of drug coverage on COX-2 inhibitor use among elderly people with osteoarthri- tis, taking into account risk for adverse gas- with the most generous coverage, patients with increased gastrointestinal risk are nomore likely to be prescribed COX-2inhibitors.
Study Outcome
Acetaminophen Overuse In The Ohio Medicaid A relatively small, but significant, number of patients were prescribed doses of aceta- patients were prescribed an average dose of acetaminophen greater than or equal to4g/day or greater than or equal to 3g/day Medicaid claims data to examine potential acetaminophen overuse in patients with andwithout risk factors for hepatotoxicity.
Preventable Hospitalization Among Elderly 7% of all hospitalizations in this cohort were Medicare Beneficiaries With Type 2 Diabetes Niefeld, M.R., Braunstein, J.B., Wu,A.W., Saudek, C.D., Weller, W.E.,Anderson, G.F.; 2003; Diabetes Care This study reviewed 1999 Medicare claimsdata to identify hospitalizations for diag-noses that could have been prevented withappropriate ambulatory care and associatingthem with comorbid conditions in this type2 diabetic senior cohort.
Prevalence And Correlates Of Potentially 13.4% of patient visits involved PIMs based Inappropriate Prescribing Among Ambulatory on the 2002 Beers criteria (and 4.2% visits Older Patients In The Year 2001: Comparison involved PIMs based on the Zhan criteria).
included: a visit occurring in a metropolitan area, and a visit receiving higher number ofmedications during a single visit.
This study analyzed 7,243 visits by elderlyambulatory patients in the NationalAmbulatory Medical Care Survey(NAMCS) in order to determine the preva-lence of prescribing potentially inappropri-ate medications (PIMs) based on the 2002Beers criteria, and identify factors associat-ed with receiving a PIM.
Study Outcome
Nonurgent Pediatric Emergency Department Visits: Care-Seeking Behavior And Parental for the ED visit was convenience (62.8% of cases). 38.7% stated that they were educat- emergencies by their insurance. ED refer- rals for nonurgent complaints are requiredby the insurance carrier for 74.9%, but only This study surveyed 251 parents of children 37.2% of the parents said referrals were nec- ment (ED) in order to: determine factorsassociated with utilization of emergencyservices for nonurgent illnesses by insuredchildren, assess parental knowledge of theirinsurance, and assess if that knowledgeinfluenced care-seeking behaviors.
High rates of preventable hospitalizations Hospitalizations: A Small Area Analysis In were associated with low income and race.
New JerseyCable, G.; 2002; J Health Care PoorUnderserved This study reviewed hospital discharge datafrom 53 contiguous zip codes in New Jerseyto examine the effect of income, race, andcultural factors on preventable hospitaliza-tions in New Jersey from 1993 to 1995.
Factors Related To Potentially Preventable Higher odds of preventable hospitalizations Hospitalizations Among The Elderly were associated with being older, black, liv- ing in a metropolitan or a rural area, assess- ing oneself as having poor status, or havingcertain diseases such as diabetes. Factors This study examined inpatient claims data associated with lower odds included: having attended college, or having only Medicare having a hospitalization due to an ambulato-ry care-sensitive condition.
Study Outcome
Pap Screening In A U.S. Health Plan Of the enrolled women, 31% received a Pap smear in 1998. The highest utilization rates received a Pap smear in 1998. Ratesdeclined with increasing age: 26% of 65-69 screened during the follow-up period, 36% received annual smears, 22% received bien- Force guidelines for cervical cancer screen- smears. This study, using administrativedata, found lower utilization rates than simi-lar studies using self-report.
Inappropriate Prescribing For Elderly Potentially inappropriate medications were prescribed at 4.45% of elderly outpatient visits involving medications. Patients were more likely to be given potentially inappro-priate medications if they had been referred; had a number of medications pre- National Hospital Ambulatory Medical Care scribed; had a prescription for certain types frequency of potentially inappropriate pre- scribed by a provider from a nonmetropoli- scribing for elderly outpatients; and (2) fac- tors predicting inappropriate prescribing.
Nosocomial Infections In The ICU: The Growing Studies have shown that patients infected Importance Of Antibiotic Resistant Pathogens with resistant strains of bacteria are more likely than control patients to have previ- ously received antimicrobials, and hospitalareas that have the highest prevalence of This article reviews the literature concern- resistance also have the highest rates of ing nosocomial infections in intensive care include hand washing and surveillance pro-tocols, isolation measures, and occupationalhealth services for employees.
Study Outcome
Inappropriate Medication Prescribing In 9.9% of prescriptions were inappropriate.
39.7% of the residents had at least one inap- propriate prescription. Inappropriate drugs This study extracted data from records of2,193 elderly patients in a managed careplan who were homebound and met nursinghome eligibility. The objective of the studywas to report on the prevalence and patternof inappropriate medications in this popula-tion.
A Controlled Trial Of Arthroscopic Surgery For Arthroscopic lavage or debridement was no more effective than a placebo procedure on pain or function. At 1-and 2-year follow-up, mean pain scale scores were not significant- Ashton, C.M., Wray, N.P.; 2002; NEngl J Med This prospective randomized trial studied180 patients with osteoarthritis of the kneeto determine whether arthroscopic kneelavage and debridement resulted in greatersymptomatic relief than a sham procedure.
Study Outcome
Patterns And Correlates Of Local Therapy For Only 14% of patients at lowest risk of recur- Women With Ductal Carcinoma-In-Situ with 22.8% and 52.6% of patients at inter- mediate and highest risk. Between-site dif- ferences in receipt of radiation after breast conserving surgery (BCS) were consistentwith patient recall of surgeon discussions Ductal Carcinoma In-Situ (DCIS) inDetroit and Los Angeles in order to deter-mine if rates of mastectomy and radiationtherapy are due to overuse or underuse ofthese treatments, or if they are due topatient preferences and physician recom-mendations.
Consequences Of Underuse Of Generic Drugs: Evidence From Medicaid And Implications For brand-name versions of the same agents.
The majority of the unrealized savings wereconcentrated in a small group of medica- This study used 2000 state-level Medicaid tions, including clozapine, alprazolam, and generic drugs and calculate potential costsavings.
Support Of Evidence Based Guidelines For The Despite evidence to the contrary, 65% felt Annual Physical Examination: A Survey Of that an annual exam was necessary, 55% dis- lipid panel, glucose, and mammography.
This study used a mailed survey to assessthe attitudes of 783 primary care physiciansregarding annual physical exams.
Study Outcome
Distributional Issues In The Analysis Of ACS admissions are geographically concen- trated and have increased to 12.2% of all This study used New York State hospitaldischarge data to describe patterns in therates of ambulatory care sensitive (ACS)admissions and preventable hospitalizations.
Utilization Management And Noninvasive Utilization rates for nuclear imaging were 2- tomography (CT) rates 30% higher inunmanaged plans. Utilization Management consisted of both review and facility cre- imaging management systems and 2unmanaged plans in the same geographicarea.
Safety And Cost-Effectiveness Of Early Discharge After Primary Angioplasty In Low- domized to an accelerated hospital course Risk Patients With Acute Myocardial Infarction. PAMI-II Investigators. Primary Angioplasty In approach reduced hospital costs by $2,000 B., Griffin, J., Donohue, B., Costantini,C.R., Balestrini, C., Stone, G.,Wharton, T., Esente, P., Spain, M.,Moses, J., Nobuyoshi, M., Ayres, M.,Jones, D., Mason, D., Sachs, D.,Grines, L.L., O’Neill, W.; 1998; Journalof the American College of Cardiology This prospective RCT study conducted in34 centers evaluated the hypothesis thatprimary Percutaneous TransluminalCoronary Angioplasty (PTCA), with subse-quent discharge from the hospital 3 dayslater, is safe and cost-effective in low-riskpatients.
Study Outcome
The Cost-Effective Use Of Nebulized Racemic Epinephrine In The Treatment Of Croup studies suggesting safe discharge to home ispossible. This study used a survey of emergencydepartment (ED) medical directors inKentucky, Indiana, and Ohio to examinewhether ED medical directors are adheringto guidelines which demonstrate that, underspecific circumstances, it is safe to dischargeto home many patients presenting withcroup.
Calling Acute Bronchitis A Chest Cold May 26% of those that were told they had bron- Improve Patient Satisfaction With Appropriate chitis were dissatisfied with their treatment, attainment, age, and gender did not affectsatisfaction rates.
459 people were given a written scenariodescribing a typical acute respiratory infec-tion where they were given 1 of 3 differentdiagnostic labels: chest cold, viral upper res-piratory infection, or bronchitis, followed bya treatment plan that excluded antibiotictreatment. Satisfaction levels were ana-lyzed.
Use And Costs Of Nonrecommended Tests Tests for which there is no documented evi- During Routine Preventive Health Exams dence were routinely ordered during annual preventive health exams (43% of the time).
The frequency of ordering specific testsranged from 7% to 37% of visits for x-rays 2002 National Ambulatory Medical CareSurvey (NAMCS) to U.S. PreventiveServices Task Force (USPSTF) recommen-dations to estimate the frequency and asso-ciated costs of nonrecommended tests dur-ing routine preventive health exams from1997 to 2002.
Study Outcome
Cervical Cancer Screening Among Women smear in the prior 3 years did not change over the course of the study. In both 1992(before the U.S. Preventive Services Task Force recommendation) and 2002 (after the immunization survey (NIS) data to estimate the number of women with a history of hys- undergone a recent Pap smear. The authors estimate that 10 million women, or half of all women who have undergone hysterecto-my, are receiving Pap smears unnecessarily.
Excessive Antibiotic Use For Acute Respiratory In 1998, antibiotic prescriptions in excess of expectations amounted to 55% of all antibi- otics prescribed for acute respiratory infec- tions. Associated costs of this unnecessaryprescription totaled approximately $726 National Ambulatory Medical Care Survey(NAMCS) to estimate primary care officevisits and antibiotic prescription rates foracute respiratory infections.
Trends In Antimicrobial Prescribing Rates For Although the average annual rate of antibi- otic prescription for children and adoles- cents decreased from 838 per 1,000 in 1989 to 503 per 1,000 in 1999, the authors con-clude that it is important to continue efforts to improve appropriate antimicrobial pre- (NAMCS) data to assess antibiotic prescrib-ing rates for respiratory infections in chil-dren < age 15.
Study Outcome
Desire For Antibiotics And Antibiotic 39% of adults seeking care for upper respi- Prescribing For Adults With Upper Respiratory ratory tract infections wanted antibiotics, which is less than in previous studies.
Predictors of wanting antibiotics were prior antibiotic use and current smoking.
Wanting antibiotics was an independent This is a prospective cohort study in adults predictor of antibiotic prescribing.
with upper respiratory tract infections. Thestudy sought to: (1) determine what propor-tion of patients wanted antibiotics, and (2)identify factors associated with wantingantibiotics and antibiotic prescribing.
A Prospective Study Of Reasons For Prolonged Hospitalizations On A General Medicine occurred because of delays in needed serv- delays were due to difficulty finding a bedin a skilled nursing facility. Medical service residents at a tertiary care, university-affili- ated teaching hospital in order to quantifyand characterize delays in care which pro-long hospitalizations for general medicineinpatients.
The Impact Of Emprical Management Of Acute Empiric antibiotic use without testing for Cystitis On Unnecessary Antibiotic Use nitrites and pyuria increases antibiotic usage Pimlott, N., Evans, M., Glazier, R.;2002; Arch Intern Med This study evaluated the appropriateness ofempiric antibiotic use in a cohort of 231women presenting to family physicians withsymptoms of cystitis.
Study Outcome
Antibiotic Use For Upper Respiratory Tract Infections: How Well Do Pediatric Residents increased with level of training, from 16% This study surveyed residents in pediatricsabout their familiarity with guidelines toavoid the unnecessary use of antibiotics inupper respiratory infection (URI).
Acute Care And Antibiotic Seeking For Upper Staff does not influence parental care seek- Respiratory Tract Infections For Children In Day CareFriedman, J.F., Lee, G.M., Kleinman,K.P., Finkelstein, J.A.; 2003; ArchPediatr Adolesc Med This study surveyed 211 parents of childrenattending day care in 36 Massachusetts cen-ters, and day care staff, to determine bothparental and day care level predictors ofacute care and antibiotic seeking for upperrespiratory infections (URIs).
Does Reimbursement Influence Chemotherapy chemotherapy to metastatic cancer patients generously reimbursed, however, prescribed more costly chemotherapy regimens tometastatic breast, colorectal, and lung can- This study sought to determine if physician reimbursement rates for chemotherapydrugs affected the frequency of usingchemotherapy in metastatic cancer patientsduring 1995 and 1998.
Study Outcome
Trends In Antibiotic Prescribing For Adults In From 1996 to 2002, the percentage of out- patient visits resulting in an antibiotic pre- reduction was completely attributable to a decrease in antibiotic prescription for acute respiratory infections (ARIs). However, thepercentage of broad-spectrum antibiotics prescribed for ARIs increased from 41% to (NAMCS) to estimate the impact of effortsto limit antibiotic prescribing in adults.
Measuring The Quality Of Care For Group A There is substantial variability in GAS test- Streptococcal Pharyngitis In 5 US Health Plans ing rates between health plans. Overall, the studied. Rates of antibiotic prescription alsovaried tremendously by health plan, ranging This study used claims data from 5 health plans to estimate the rate of Group AStreptococcal (GAS) testing in children witha diagnosis of pharyngitis who are pre-scribed antibiotics.
More May Be Better: Evidence Of A Negative In urban settings, increased physician sup- Relationship Between Physician Supply And Hospitalization For Ambulatory Care Sensitive potentially preventable hospitalizations. In This study analyzed data from 642 urbancounties and 306 rural counties to deter-mine the relationship between physiciansupply and ambulatory care sensitive condi-tions (ACSH). ACSHs are also called“potentially preventable hospitalizations”and are an indicator of accessibility andeffectiveness of primary health care.
Study Outcome
Is Routine Postoperative Chest Radiography Of the 150 patients undergoing nephrecto- CXR, and 4 of these had a pneumothorax.
Only 1 of these 4 needed a chest tube.
This study examined 150 retrospectivecases of open nephrectomy at 1 institutionin order to determine if routine postopera-tive chest X-ray is required after opennephrectomy for the detection and manage-ment of a pneumothorax.
The Value Of Clinical Examination Versus There was no statistical difference between Magnetic Resonance Imaging In The Diagnosis MRI and clinical examination in diagnosing Of Meniscal Tears And Anterior Cruciate Kocabey, Y., Tetik, O., Isbell, W.M.,Atay, O.A., Johnson, D.L.; 2004;Arthroscopy This study examined 50 patients in 1 ortho-pedic practice in order to compare the accu-racy of clinical examination versus magneticresidence imaging (MRI) in diagnosingmeniscal and ACL (anterior cruciate liga-ment) pathology.
Magnetic Resonance Imaging Is Not Needed To Clear Cervical Spines In Blunt Trauma deficits, a negative CT, and persistent cervi- Patients With Normal Computed Tomographic cal pain, none had evidence of fracture on Schuster, R., Waxman, K., Sanchez, B.,Becerra, S., Chung, R., Conner, S.,Jones, T.; 2005; Arch Surg This study reports results from 93 patientswith negative computed tomography (CT)scans who were also examined by magneticresonance imaging (MRI), in order to try todetermine if MRI testing was necessary.
Study Outcome
Health Insurance, Neighborhood Income, And Emergency Department Usage By Utah Children uninsured children (65%) was for non-trau- had approximately 50% greater ED utiliza- This study used ED discharge data report-ed in Utah to examine income, health insur-ance status, types of medical conditions,and whether introduction of managed careaffected utilization by Medicaid children.
Radiologic Tests After A New Diagnosis Of A total of 1,910 radiologic tests, including 646 bone scans, 637 chest radiographs, and patients with a known TN status.
Radiologic tests were performed in 42% of In this study, records of newly diagnosed patients with carcinoma in situ, but none of breast cancer patients were retrospectively the 183 tests detected metastases. 828 radi- ologic tests were performed in patients who were classified as having stage I disease on with newly diagnosed breast cancer and the the basis of TN criteria. Only 3 of these yield of such tests in these patients.
tests (0.4%) detected metastatic disease,and all 3 were performed in 1 patient withbone pain. For patients, who were classifiedas having stage IIA, stage IIB, or stage IIIdisease on the basis of TN criteria, 5 of 410tests (1.2%), 20 of 294 tests (6.8%), and 33of 195 tests (17%), respectively, yieldedpositive results.
Analysis Of Medication Use Patterns: Apparent Overuse Of Antibiotics And Underuse Of Prescription Drugs For Asthma, Depression And antibiotics are not indicated, 35.7% received This study used claims data from 3California Managed Care Organizations(MCOs) to assess the appropriateness ofprescription medication use based uponguidelines for various conditions.
Study Outcome
The Cost Of Antibiotics In Treating Upper Respiratory Tract Infections In A Medicaid emergency department episodes resulted in an antibiotic prescription being filled. In outpatient settings, secondary diagnoses of either otitis media or acute sinusitisaccounted for less than 6% of the episodes that resulted in an antibiotic prescription claims in order to examine the use and cost of the nonindicated antibiotics for upper antibiotic was amoxicillin, although second- respiratory tract infections (URIs).
and third-generation cephalospoirins werethe second most frequently occurringantibiotic class. 23% and 9% of outpatientemergency department episodes, respec-tively, resulted in a prescription filled forantihistamines. In outpatient episodes,antibiotics account for 23% of the total costof care or $9.91 for each episode of care. Inemergency department visits, antibioticsaccount for 8% of the cost of URIs. An esti-mate of the cost of antibiotics for URIs in ayear for the Kentucky Medicaid program is$1.62 million.
Prescribing Potentially Inappropriate Psychotropic Medications To The Ambulatory Mort, J.R., Aparasu, R.R.; 2000; ArchIntern Med This study analyzed public use files fromthe 1996 National Ambulatory MedicalCare Survey (NAMCS) and NationalHospital Ambulatory Medical Care Survey(NHAMCS) for inappropriate prescriptionof psychotropic medications for the elderlyin office-based settings and outpatientdepartments.
Study Outcome
Resource Utilization Of Patients With Patients with healthcare-related anxiety use Hypochondriacal Health Anxiety And dria or somatization have more outpatient visits (approximately 9 vs. 6), more outpa-tient costs (approximately $1,300 vs. $950), 876 patients attending an academic primary and greater likelihood of hospitalization care clinic were randomly selected to com- plete surveys designed to examine theresource utilization of patients with highlevels of somatization and health-relatedanxiety.
Overutilization Of Shoulder Magnetic Resonance The study concludes that MRI is overused, Imaging As A Diagnostic Screening Tool In Patients With Chronic Shoulder Pain were no differences (in age, sex, insurance injury) among patients who received a pre-evaluation MRI and those who did not. (2) chronic shoulder pain to see if magnetic res- between patients who did or did not have a evaluated by a shoulder specialist improved could imply that there are no consistent cri- teria that doctors use to decide whichpatients should get a “pre-evaluation MRI”before being referred to a shoulder special-ist.
Musculoskeletal Imaging In Physical Therapist This paper suggests that physical therapists This article reviews literature pertinent toevidence-based use of diagnostic imagingand overuse of imaging for musculoskeletalconditions.
Study Outcome
Current Antibiotic Therapy For Isolated The study found that quinolones were pre- scribed more commonly than sulfa drugs for mended guidelines. The former were pre-scribed for 44% of UTIs compared with 30% for the latter, and nitrofurantoin for National Hospital Ambulatory Medical Care 18%. There were few significant predictors antibiotic prescribing for women with isolat- ed uncomplicated urinary tract infections Northeast) did not reflect geographically higher rates of sulfa-resistant organisms.
Unnecessary Cesarean Delivery In Louisiana: An Analysis Of Birth Certificate Data 17 and 43, respectively, per 100 cesarean L., Khan, M.M., Herrera, E.A., Yu, S.
deliveries. The primary Cesarean delivery rate decreased and the repeat Cesareandelivery rate increased during the study.
This study used the Louisiana birth certifi- But neither the absence nor the presence of cate database to determine temporal trends potential risk factors accounted for these Cesarean deliveries and potentially unnec-essary Cesarean deliveries.
Geographic Variation In Preventable Using hospital discharge data, 5 county and Hospitalizations Of Older Women And Men: Implications For Access To Primary Health are studied. There is significant variation in preventable hospitalization within counties.
Areas having significantly higher rates of these hospitalizations tend to have higherrates for both women and men. Problems of This study reviewed hospital discharge data demonstrate how readily available data andsmall area analysis can be used to identifypotential problems of access to primary careservices for older women and men. Study Outcome
Estimating The Proportion Of Unnecessary Using the authors’ methods, nearly 40% of Cesarean Sections In Ohio Using Birth abnormalities on the birth certificate to jus- This study examined data from 262,013patients in databases of Ohio birth certifi-cates and Medicaid eligibility files in orderto validate a method that can be used toestimate the proportion of unnecessaryCesarean sections.
Association Between Antibiotic Prescribing And Visit Duration In Adults With Upper with a shorter visit duration (0.7 minutes Linder, J.A., Singer, D.E., Stafford,R.S.; 2003; Clin Ther 3,764 patient visits from the NationalAmbulatory Medical Care Survey(NAMCS) database were analyzed to deter-mine the association between antibioticprescribing and visit duration in adults withupper respiratory tract infections.
Does Litigation Influence Medical Practice? The Influence Of Community Radiologists’ Medical Malpractice Perceptions And Experience On claims increased their rate of recommenda- tion for breast biopsies, and 76% expressed concern about the impact of malpractice onmammography practice. About one-third This study surveyed radiologists who inter- the higher rate of repeat mammography andbreast biopsy by U.S. radiologists relates toperceptions of, and experience with, mal-practice claims for failing to identify breastcancer by mammography.
Study Outcome
How Are Age And Payors Related To Avoidable community characteristics is needed forMedicaid and self-pay patients.
This study used hospital discharge data col-lected in Cincinnati Ohio to investigatehow age and payor types were related to therates of avoidable hospital conditions.
Whither The Almshouse? Overutilization And The Role Of The Emergency Department less or sufficiently poor or disabled to quali- Interviews with frequent emergency depart-ment (ED) patients (i.e., those with morethan four visits per year) and ED staff wereused at 2 urban hospitals to determine whatfactors (traditional, medical and social) wererelated to their frequent ED visits.
Antimicrobial Resistance Among Pediatric The challenge for rational antibiotic use is Respiratory Tract Infections: Clinical Challenges to determine which patients can be treated conservatively and which require antimicro- bial intervention. Different antibiotics arediscussed. The pneumococcal vaccine intro- This study reviews the literature pertinent to the development of antibiotic resistance on decreasing antimicrobial resistance.
among upper respiratory infection (URI)pathogens and discusses both the overuseof antibiotics and the inadequate dosing ofantibiotics.
Study Outcome
Triage Services: A Profile Of High Utilization Factors associated with high utilization of include: patient perception of health status; number of prescription medications; andsocial needs.
This study examined the utilization pat-terns of 189 veterans in order to identifyfactors that are related to high utilizationrates of ambulatory care triage clinic servic-es.
Effect Of Managed Care Enrollment On Primary And Repeat Cesarean Rates Among rates were significantly lower for TRICARE U.S. Department Of Defense Health Care Beneficiaries In Military And Civilian differences in repeat C-section rates were found. Primary and repeat C-section rateswere lower in military hospitals than in civilian hospitals.The study suggests that to (DOD) hospital records for 365,648 single- ton deliveries to assess the impact of enroll- decrease morbidity and decrease costs) we ment in TRICARE prime, the department’s managed care plan, on C-section rates.
health care plans have different C-section rates, but it is not clearly understood why.
Antibiotic Prescribing Rates In The US Antibiotic prescribing for influenza is wide- Ambulatory Care Setting For Patients spread; 38% of visits where the diagnosis of Diagnosed With Influenza, 1997-2001 influenza was made led to an antibiotic pre- scription of which one-third were for broad spectrum antibiotics. Inappropriate antibi-otics cost $18.5 million annually and may Medical Care Survey (NAMCS) andNational Hospital Ambulatory Medical CareSurvey (NHAMCS) data to document therate and cost of antibiotic prescribing topatients diagnosed with uncomplicatedinfluenza at ambulatory care visits from1997-2001.
Study Outcome
Regional Air Transport Of Burn Patients: A In 92 out of 225 cases, overestimation or underestimation of burn size by referring physicians or performance of endotracheal incubation suggested that telemedicineevaluation before transport might have sig- 225 cases of patients transported by air for nificantly altered transport decisions or care.
burn injuries were reviewed to determine iftelemedicine could have been used to assistin evaluation and treatment of burnpatients.
Improving Quality Through Identifying Inappropriate Care: The Use Of Guideline- shows that “guideline-based utilization Based Utilization Review Protocols In The review protocols” can be used to identify Washington State Workers’ Compensation System inappropriate care, and improve quality.
When “guideline-based review criteria” were used during a utilization review, denial rates were 7.9%. When “proprietary reviewcriteria” were used, denial rates were 4.9%.
When “other criteria” were used, denial requests through an analysis of the 100,005 utilization reviews that were done between1993 and 1998 by the workers’ compensa-tion program of the Washington StateDepartment of Labor and Industries.
The Effects Of Preferred Provider Organizations On Cost And Utilization Of Hysterectomies vaginal hysterectomy, suggesting overuse of these procedures in indemnity plan benefi- This study used claims data to comparehysterectomy rates for beneficiaries ofemployer sponsored PPO and indemnityplans between 1988 and 1990.
Study Outcome
Radiograph Use In Low Back Pain: A United Based upon published guidelines, the study States Emergency Department Database 17.8% received an unnecessary radiograph.
A retrospective analysis of data from theNational Hospital Ambulatory Medical CareSurvey (NHAMCS) from 1998-2000 todetermine what factors were associated withhaving an x-ray if a person presented to anemergency room for uncomplicated lowback pain.
Evaluation And Treatment Of Acute Bronchitis 66% of patients diagnosed with bronchitis received an antibiotic. Increasing age, puru- lent cough, abnormal exam, and comorbidi- ties were associated with higher likelihoodof antibiotic use. Smoking, duration of This study examined the medical records of symptoms, gender, and race did not predict 160 patients diagnosed with acute bronchi- tis to examine antibiotic prescribing pat-terns in a single university internal medi-cine clinic.
Computed Tomography For Evaluation Of Mild To Moderate Pediatric Trauma: Are We patients the number of patients who need- more pediatric patients receiving scans ofmultiple body areas. The higher number of examined 102 cases of pediatric trauma to they did not identify more injuries, and did determine if children with mild to moderate not decrease morbidity, mortality, length of tomography (CT) scans than adults withinjuries of similar severity. To look at mor-bidity, mortality, and lengths of hospital andICU stays, and to see if the number of CTscans was associated with outcomes.
Study Outcome
Overuse Of Acid-Suppressive Therapy In At this hospital, acid-suppressant medica- tions were inappropriately used among out- found that among patients who entered thehospital already on acid-suppressant med- A chart review of 226 patients admitted to frequency of use and indications of acid- suppressive mediations, and to determine if their hospitalization, 75% of these cases stress ulcer prophylaxis were also prescribed medications were started during a hospital- ization, 55% of low-risk patients were dis-charged with a prescription for these med-ications.
Patient Characteristics And Patterns Of Use For Lumbar X-rays for low-back pain are over- Lumbar Patient Characteristics And Patterns Of used in patients who scored worse on sur- Use For Lumbar Spine Radiographs: Results veys of mental health. The study found that and psychological factors. Higher rates of repeat lumbar spine X-rays were associatedwith worse mental health, but they were To identify patient characteristics that pre- not associated with worse physical health.
dict different patterns in the use of lumbar There was no association between patterns of X-ray use and the following factors: age, over 12 months of 401 patients who present income, education, alcohol or drug use, or to Veterans Administration clinics for low- number of medical and mental conditions.
Study Outcome
Healthcare Utilization And Referral Patterns In The study found that urgent care and emer- The Initial Management Of New-Onset, Uncomplicated, Low Back Workers’ saw their primary care physician first.
Specialist care was provided more common- by specialists. Referral to specialists wasmade sooner than expected: the median for To describe the utilization and physician- referral patterns for new-onset, uncompli-cated low back pain, an analysis of 415 casesof low back pain from the workman’s com-pensation claims data of an insurance com-pany that operates in 44 states in the U.S.
Regional Variation And Clinical Indicators Of There was significant regional variation. Of Antipsychotic Use In Residential Treatment: A the children taking antipsychotic medica- tion, 42.9% had no history of or current psy- J.C., Hunter, J.C.; 2004; J BehavHealth Serv Res The medical records of pediatric residentialtreatment patients in 4 states were retro-spectively reviewed to determine if regionalvariation exists in off-label prescription andwhat clinical factors predict use. The studyused clinical and pharmacological data col-lected via retrospective chart reviews(N=732).
Antibiotic-Seeking Behavior In College Students: rationale for treatment, and an antibiotic prescription were significantly associated with patient satisfaction. Clinicians pre- scribed an antibiotic for 36% of the stu-dents.
129 university students with upper respira-tory symptoms were evaluated to determineif receiving an antibiotic prescription influ-enced patients’ satisfaction with visits to aclinician.
Study Outcome
Infantile Hypertrophic Pyloric Stenosis: Delays In Diagnosis And Overutilization Of Imaging associated with delay in diagnosis, and pos- sibly with adverse health problems. Theauthors propose an algorithm to decrease This study is a retrospective chart review of this waste; if there is clinical suspicion of pyloric stenosis, the first step is prompt referral to a pediatric surgeon or an “experi- unnecessary and redundant diagnostic stud- ies were done and to propose an algorithm for the management of patients with sus-pected IHPS.
Propensity Of HIV Patients To Seek Urgent And Many patients reported that they would use Emergent Care. HIV Cost And Services of same-day primary care for several com- Americans, the poor, and patients with psy- This study interviewed HIV-infected adultsin order to determine if they said that theywould be more likely to seek care in the theemergency department (ED) or with theirprimary care provider.
Medical-Resource Use For Suspected Tuberculosis In A New York City Hospital accounted for 36% of the days of TB isola- Anderson, J.E., O’Brien, T,. Popper, C., consumption occurred during the diagnostic period before a definitive culture result was This study analyzed 151 adult admissionsfor suspected Tuberculosis (TB) at oneNew York hospital, in order to compareresource use by diagnostic outcome.
Study Outcome
Preventive Pharmacologic Therapy Among In contrast to the recommendations of the Asthmatics Five Years After Publication Of national guidelines, about half of moderate did not fill any anti-inflammatory agents short-acting bronchodilators without AI-rep- resenting overutilization of symptom reliefagents.
This study used pharmacy and survey datafor 7,423 asthmatic members of a CaliforniaHMO to examine the use of routine anti-inflammatory steroids and bronchodilators.
Are We Ordering Too Many PSA Tests? The study concludes that the findings raise Prostate Cancer Diagnosis And PSA Screening the “possibility of indiscriminate PSA test- Patterns For A Single Veterans Affairs Medical ing or unnecessary repetition of testing.” of prostate cancer per PSA test performed 1998. There was a significant increase inthe number of PSA tests performed between 1997 (9,410 tests) and 1998 (23,684 Medical Center (VAMC) to estimate theappropriateness of Prostate-SpecificAntigen (PSA) testing. Analysis Of Chronic Emergency Department Use 62% of the visits were nonurgent, and the patients were more likely to have nonurgentvisits (70%). Looking at visits, a greater per- determine the relationship between acuity level of illness and type of insurance for (61%), even though this group represented found that the age group with the highest times a year. It was hypothesized that unin- frequency of visits was the 24-64 year old patients, and that the peak visit period for have more visits for nonurgent needs.
these patients was between 0800 and 1600and did not increase on weekends, leadingthe authors to conclude that these patientswere not first seeking care elsewhere.
Study Outcome
Department Congestion And Hospital Crowding no association with total hospital costs or For Chest Pain Patients Awaiting Admission revenues, or total hospital length of stay.
However, patients awaiting telemetry beds prevented ER use for new patients, thereby causing a loss of potential revenue.
This study examined 904 emergency roomER visits for chest pain and admission to atelemetry bed in an urban university hospi-tal. The purpose was to determine theadditional cost of an extended emergencydepartment (ED) stay while awaiting non-Intensive Care Unit (ICU), monitored(telemetry) beds.
Managed Care And Preventable Hospitalization fewer preventable admissions, compared to private fee-for-service. However, Medicaidmanaged care enrollment was not associated with a reduction in preventable admissions, compared to Medicaid fee-for-service.
examine the association between managedcare enrollment and preventable hospital-ization patterns of adult Medicaid enrolleesin 4 states.
Non-Emergent And Preventable ED Visits Approximately 21% of outpatient ED visits primary-care treatable and emergent butpreventable with good primary care, respec- To estimate the proportion of non-emergent were more likely to visit the ED for non- Study Outcome
Extended Use Of Indwelling Urinary Catheters 32% of hip fracture discharges to SNFs had In Postoperative Hip Fracture Patients urinary catheters. At 30 days after operation, and of rehospitalization for urinary tractinfection. Western region and urban loca- This study used data from Medicare admis- tion were associated with a higher likeli- sions to skilled nursing facilities (SNFs) from acute care hospitals with a diagnosis of hip fracture to estimate the probability andimpact of having an indwelling urinarycatheter.
Decreasing Overuse Of Therapies In The Treatment Of Bronchiolitis By Incorporating decreased, although 53.7% of patients still received bronchodilators and 46.5% a chest Gerhardt, W.E., Atherton, H.D., Britto,M.T., Kotagal, U.R.; 2004; J Pediatr This study used a cohort of infants < age 1year admitted to an academic children’shospital with a first-time diagnosis of bron-chiolitis to assess the use of bronchodilatortherapy before and after guideline imple-mentation.
Whole-Body Computed Tomography Screening: detecting serious, treatable disease withoutundue cost or undesirable effects.
This review article discusses the issue ofwhether or not whole-body computedtomography scans are appropriate. Theauthor discusses evidence from the US andother developed countries.
Study Outcome
Estimated Risks Of Radiation-Induced Fatal age of 15 years, a rough estimate is that 500 of these individuals might ultimately diefrom cancer attributable to the CT radia- This article discusses biologic responses to ionizing radiation and estimates potentialcancer deaths attributable to current levelsof pediatric computed tomography (CT)use.
The Clinical And Economic Correlates Of Misdiagnosed Appendicitis: Nationwide Analysis estimated to be negative appendectomies.
were suspected had longer lengths of stay(5.8 vs. 3.6 days), higher total charge-admis- This study used data from the 1997 health sion ($18,780 vs. $10,584), higher case fatal- ity rate (1.5% vs. 0.2%), and higher rate of National Inpatient Sample to estimate the infectious complications (2.6% vs. 1.8%). frequency and cost of negative appendecto-my.
An Evaluation Of Statewide Strategies To There is over- and misuse of antibiotics for the treatment of viral pediatric illness.
Antibiotic use increased in all 3 interven- tion groups as well as in the control group, although the increases in 2 interventiongroups (patient educated and patient edu- This article tested the hypothesis that inter- ventions will decrease antibiotic overuse in treatment of upper respiratory infection(URI) in pediatric populations. There werethree intervention groups: patient educationonly, provider education only, and bothpatient and provider education.
Study Outcome
Urban Emergency Department Utilization By Adolescents on public assistance or without insurance may frequently utilize an urban majority of triage codes for ED visits werenonurgent (n=140; 93%).
This study is a retrospective chart review atan academic medical center to determineemergency department (ED) utilization andfollow-up referral patterns among adoles-cents.
Changes In Antibiotic Prescribing For Children Antibiotic prescription rates declined 19% Jorgensen, D.M., Mitchel, E., Hall, S.,Schaffner, W., Griffin, M.R.; 2002;JAMA To evaluate the effectiveness of a multi-faceted campaign to reduce unnecessaryantibiotic prescriptions to children. Theintervention included educational effortsdirected at health care practitioners, par-ents, and the public. Nonurgent Emergency Department Visits: The Effect Of Having A Regular Doctor. This study used interviews of patients pre-senting to 5 major Boston teaching hospitalswith diagnoses of abdominal pain, chestpain, or asthma, to assess the associationbetween having a regular doctor and pres-entation for nonurgent versus urgent emer-gency department.
Study Outcome
Emergency Department Use By Family Practice Calling ahead was not associated with more Patients In An Academic Health Center. Campbell, P.A., Pai, R.K., Derksen,D.J., Skipper, B.; 1998; Fam Med This retrospective review of emergencydepartment (ED) logs assessed whetherpatients who call the ED before visiting,and are thus triaged by telephone, hadfewer inappropriate ED visits.
Nonurgent Use Of The Pediatric Emergency Physician (PCP) prior to arrival in the PED.
Comparing the reasons given by these This was a prospective study of non-urgent pattern and reasons for nonurgent use of the pediatric emergency department during reg- l9% vs. non-HMO 10%) to be importantdifferences. HMO enrollees receivedapproval for the visit 79% of the time.
These approvals were mostly after noon,and due to “a full office schedule.” Resource Utilization And Its Management In Splenic injury cases managed at pediatric longer hospital stays and higher total costs facilities, even when controlled for injurytype and severity.
This study used emergency department(ED) and hospital discharge data to com-pare resource utilization and its manage-ment for splenic injury at 2 level-I traumacenters and a pediatric referral center withother facilities.
Study Outcome
Indigent Men’s Use Of Emergency Departments Factors including a lack of insurance, unem- Over Primary Care Settings (Letter) $20,000 a year) were associated with a high- er rate of ED utilization. Lower incomepatients visited the ED 2.5 times the fre- study that surveyed 2 Bronx hospitals toexamine the factors leading to emergencydepartment (ED) overuse by men.
Emergency Department Management Of Acute Careful selection of antimicrobial agents is essential to maximize benefit and prevent This study reviews common respiratoryinfections and considers the overuse ofantibiotics.
Practical Considerations When Treating By avoiding inappropriate use of antimicro- Children With Antimicrobials In The Outpatient bials, we can avoid antiobitic resistance.
with therapeutic regimens and improveparental satisfaction This article is an overview of practical con-siderations for providers when treating chil-dren with antimicrobials in the outpatientsetting, with special attention paid to acuteotitis media.
When The Visit To The Emergency Department Is Medically Nonurgent: Provider Ideologies appropriateness of medically nonurgent ED use were identified and found to be linked to particular communication strategies that providers employed with ED users: restric- This study employed interviews of 26emergency department (ED) providers inurban hospitals to determine their opinionsabout nonurgent pediatric ED visits andhow they advise parents on appropriate EDuse.
Study Outcome
Reducing Antibiotic Use In Children: A Educational efforts targeting physicians and parents can contribute to the declining rate of antibiotic misuse and overuse in children S.F., Metlay, J.P., Soumerai, S.B., Rifas- between the ages of 3 months and 6 years.
antibiotic prescribing by 16% in children aged 3-36 months, and 12% in children 36-72 months compared to a control group of regarding antibiotics for upper respiratory antibiotics per-patient per-year for ages 3-36 infection (URI) in 12 pediatric practices in patient per-year for patients 36-72 monthscompared to the controls which showedsmaller decreases in the intervention year.
Also, most of the antibiotics prescriptionswere for otitis media (62.1%).
The Beginning Of The End Of The Antibiotic Antibiotic overuse is one factor in the emer- Era? Part I. The Problem: Abuse Of The gence of significant antibiotic resistance.
“Miracle Drugs”Harrison, J.W., Svec, T.A.; 1998;Quintessence Int This study presents a comprehensivereview of the evolution of antibiotic resist-ance since WWII.
Health Care Utilization Of Chronic Inebriates These programs reduce health care use for most patients; however serious medical ill- ness and injury in a small number ofpatients contributed heavily to resource uti- services because they lack other resourcesor access to primary care. Three county pro-grams were developed to reduce emergencyresource utilization which would be meas-ured by medical visits, hospital visits, hospi-tal inpatient days, and total charges.
Study Outcome
Corticosteroids appear to be either overused or over-prescribed in each of the conditions This article provides a systemic review ofcorticosteroid use, focusing on evidencesupporting use in rheumatoid arthritis, asth-ma, COPD, and prematurity.
Use And Overuse Of Angiography And “Angiography, percutaneous transluminal Revascularization for Acute Coronary coronary angioplasty (PTCA), and coronary rather than on the basis of ischemia, do notimprove outcomes. All four studies show that routine angiography and revasculariza- tion do not reduce the incidence of nonfatal reinfarction or death as compared with the published in the same issue. The study is the fourth large randomized clinical trial approach. Physicians who work in hospitals (RCT) looking at aggressive versus conser- with catheterization facilities are more like- ly to recommend coronary angiography than those without easy access to such a facility.” Preventing The Spread Of Antimicrobial Patient pressure and suboptimal diagnosis Resistance Among Bacterial Respiratory and treatment contribute to antibiotic over- Pathogens In Industrialized Countries: The Case use. Curricula for doctors have been devel- of respiratory infections. Patient educationmaterials and strategies to improve doctor- This article reviews the literature and dis- cusses the joint Centers for Disease Control (AAP)/American Academy of FamilyPhysicians (AAFP) program to promoterational antibiotic use.
Study Outcome
The Annual Physical: Are Physicians And Although there is no evidence for the utility of the annual physical, this editorial sug- gests that it may persist because it provides a forum to build and nurture the physician-patient relationship.
This editorial addresses the attitudes of pri-mary care physicians regarding “annualphysicals” that are discordant with U.S.
Preventive Services Task Force (USPSTF)guidelines and evidence.
Wise Use Of Perioperative Antibiotics This article supports the use of prophylactic antibiotics for specific cardiac, colorectal,gynecologic, ophthalmologic, orthopedic, or urologic procedures when given as a single between microbial resistance and the over- A Simple, Focused, Computerized Query To A focused query of data derived from a clin- Detect Overutilization Of Laboratory Tests ical data repository can detect and docu- ment overutilization of a common laborato- This study tested a method for detectingrepetitive daily ordering of a commonlyordered laboratory test (serum sodium).
The results were followed by a chart reviewin order to determine the accuracy of thetest.
Study Outcome
Resource Utilization And Outcome In Gravely 23% of patients in the cohort survived to Ill Intensive Care Unit Patients With Predicted hospital discharge; all but one were moder- In-Hospital Mortality Rates Of 95% Or Higher ately or severely disabled. 10% were alive at By APACHE III Scores: The Relationship With 1 year. Resource utilization was extensive, but costs were not calculated. Survival was D.P., Jewell, S.M., Bechtle, P.S.,Schroeder, D.R., Stevens, S.R., Lanier,W.L.; 2005; Mayo Clin Proc This study evaluated APACHE III scores ofall patients admitted to the intensive careunit (ICU) at the Mayo Clinic between1994 and 2001. 248 had a predicted in-hos-pital mortality of 95% or higher, and thestudy evaluated the resource utilization andultimate outcome of this cohort.
Availability Of Antibiotics Without Prescription Antibiotics were available in all stores in the Hispanic neighborhood, but in none of the stores in non-Hispanic neighborhoods.
This article describes a survey of the avail-ability of non-prescription antibiotics in 101independent stores in Manhattan, NewYork.
Combating Antimicrobial Resistance: It appears that these interventions are suc- Intervention Programs To Promote Appropriate cessfully reducing the inappropriate use of Emmer, C.L., Besser, R.E.; 2002; InfectMed This article reviews current efforts to pro-mote the appropriate use of antibiotics, andreduce the spread of antibiotic resistance.
Study Outcome
Cost-Utility Analysis Of Screening Intervals For Patients in the high-risk group cost an addi- Diabetic Retinopathy In Patients With Type 2 tional $40,530 per quality-adjusted life year (QALY) gained, while those in the low-risk group cost an additional $211,570 per QALY gained. Retinal screening annually vs. everyother year for patients with type 2 diabetes This study performed a Markov cost-effec- screening every other year vs. every third National Health and Nutrition Examination Survey in order to examine the cost-effec-tiveness of various screening intervals foreye disease in patients with type 2 diabetes.
Diagnosis And Treatment Of Upper Respiratory Tract Infections In The Primary Care Setting Jacobs, M.R., Pelton, S., Sethi, S.; 2001; nonbacterial infections, choosing an antibi- otic based on the likelihood of infectionwith resistant pathogens, and providing cov- This paper reviews the literature and the erage against the predominant pathogens.
results of an industry-sponsored roundtablediscussion regarding the management ofacute exacerbations of chronic bronchitis(AECB), acute otitis media (AOM), andacute bacterial rhinosinusitis (ABRS).
Appropriateness Of Ambulance Transportation transportation unnecessarily. Of the unnec- This study examined emergency depart-ment (ED) records of all patients arriving toa suburban ED during 1 year in order toassess the appropriateness of ambulance usewith regard to both medical necessity andinsurance status.
Study Outcome
Antimigraine Therapy Clinical Features, headaches. According to the study, treat- ments for medication-overuse headachesshould include replacement of analgesics This study is an examination of the litera- ture on medication-overuse headaches (also medications and the use of alternative treat- describe a number of theories on cause anda number of suggestions for treatment.
Transformed Migraine And Medication Overuse In A Tertiary Headache Centre—Clinical their illness. The study found that the fre- Characteristics And Treatment Outcomes overuse (“detox”), and 17% in those who were not. The duration of headache painwas reduced by 61% (detox) vs. 15% (no To compare the outcomes for patients with medication-overuse headaches (transformedmigraines) who were able to stop overusinganalgesics to those who were not.
Use Of Antihypertensive Drug Therapy In Older A significant minority of patients (16%) had Persons In An Academic Nursing Home uncontrolled hypertension. Among patients betes, coronary artery disease, and/or heartfailure, a specific recommended class of This study analyzed the charts of all resi- drugs (e.g., ACE inhibitors for diabetics) the time, depending on condition and drug and appropriate treatment of hypertension Study Outcome
Prevalence Of Subacute Patients In Acute Care: Over one-third of hospitalized patients had Results Of A Study Of VA Hospitals length of stay of 12.7 days; of which 6.8 This study reviewed 858 medical and surgi-cal admissions from 43 VA hospitals in orderto determine the number of VA patientswith subacute needs being cared for inacute care.
Laparoscopically Assisted Vaginal Hysterectomy what as physicians reevaluate LAVH, adoptnew techniques such as arterial emboliza- This article is a review about the topic of tion and myolysis, and rediscover old tech- “laparoscopically assisted vaginal hysterec- niques such as uterine morcellation at vagi- history, challenges, and future of this tech-nique.
Pediatric Emergency Room Visits For and 522.5 for periapical abscess (47%).
Medicaid recipients used the ER at an This study reviewed 149 visits to an emer- gency room (ER) of a children’s hospital which had a diagnosis of dental caries, peri- insurance. Almost one-half of the accounts apical abscess or facial cellulitis. The pur- changed status during the billing process, pose was to determine “the incidence and with the majority being entered as private- predisposing, enabling, and need factors of outpatients” and to analyze the hospital debt or charity after the registration records were processed and collection was attempt-ed. Most patients were treated empiricallyby the ER physicians according to their pre-senting signs/symptoms.
Study Outcome
Propoxyphene Use By Community-Dwelling And The results show that propoxyphene use by Institionalized Elderly Medicare Beneficiaries but is much higher in the institutionalized prescribing for older adults with pain couldbe improved, especially for vulnerable long- first comparable national prevalence esti-mates on the use of propoxyphene by elder-ly Medicare beneficiaries living in the com-munity and in institutions, and to deter-mine whether institutionalized beneficiariesare at greater risk for receiving propozx-phene than community-dwelling beneficiar-ies.
The LUNAR Project: A Description Of The Most patients had insurance (80%) and 78% Population Of Individuals Who Seek Health had PCPs. 31% of visits were for injuries, and 52% were for nonurgent care. The spe- cific diagnoses were very varied, with themost frequent diagnosis being otitis media This study employed a retrospective record (4.5% of diagnoses). It was also noted that most visits were NOT related to alcohol or gency department (ED) visits at 89 EDs in Variation In Psychotropic Drug Use In Nursing drug use are less likely to be hospital-based, are less likely to have special care units, but are more likely to have Alzheimer’s special-care units.
This study uses self reported data in theOSCAR databases to provide a descriptiveanalysis of nursing homes with and withouthigh levels of psychotropic drug use and toprovide an analysis of the determinants ofhigh use.
Study Outcome
Overcrowding In The Nation’s Emergency Departments: Complex Causes And Disturbing and acuity of patients using EDs; overall increases in populations; unintended effects of managed care; scarcity of inpatient beds; increasing intensity of ED interventions toavoid hospitalization; delays in providing This study reviews the literature regarding ancillary services; nursing, clerical, and physician shortages; shortages of on-call (EDs) and describes root causes and conse- specialty physicians; difficulty arranging fol- low-up care, limited physical space; lan-guage barriers; and increased documenta-tion requirements. The results are: poorpatient satisfaction, ambulance diversion ofcritically ill patients, and poor outcomesrelated to delays in treatment.
1998 ARRS Executive Council Award. Radiology In The Emergency Department: stable from 1991 to 1997, averaging 60,000 Technique For Quantitative Description Of Use and 52,000 per year, respectively. Bone radi- radiographs, 10.4%. The percentages ofradiographs interpreted as normal were 75.9% in 1992 and 75.3% in 1996, with cer- vical spine (88.7%), thoracic spine (86.3%), and knee (86.3%) yielding the highest pro- portion of studies with normal findings.
increased from 1,840 in 1993 to 3,101 in1997. Studies of the abdomen accounted formost of this increase (52.3% in 1993 to66.0% in 1997). During evaluations for cer-vical spine injury, a mean of 6.5% of radi-ographic studies were followed by CT stud-ies, and the findings of 89.0% of those CTstudies were interpreted as normal.
Study Outcome
Care In The Emergency Department: How 43% of the articles had explicit definitions tions varied widely in content and focus, including emergency department, hospital,or external (non-hospital) factors.
This article examined 53 articles, whichincluded all articles on PubMed and MED-LINE databases (1966 to 2002) about over-crowding in emergency rooms, in order todetermine if there existed an explicit crite-ria for the term “emergency room over-crowding.” Emergency Department Overcrowding In The The study reports three findings: 1) the ED United States: An Emerging Threat To Patient is a vital part of the safety net, 2) over- main cause is inadequate inpatient capacity.
This is a systematic review that describeshow emergency department (ED) over-crowding threatens patient safety and pub-lic health.
Frequent Overcrowding In U.S. Emergency 91% of ED directors reported overcrowding as a problem. Common definitions of over- following: patients in hallways, all ED bedsoccupied, full waiting rooms longer than 6 hours a day, and acutely ill patients who to assess the frequency, determinants, and wait longer than 60 minutes to see a physi- Study Outcome
Ethnic Differences In Past Hysterectomy For The highest rates of hysterectomy occurred in the disadvantaged African American and explained by known risk factors. Therefore, overuse of hysterectomy in these disadvan- Using a phone survey of women in 7 differ-ent U.S. cities, this study attempted todetermine differences in hysterectomy ratesamong different ethnic groups.
Health Resource Utilization Of The Emergency Department Headache “Repeater” 1004 visits. 54 patients accounted for 502 visits. Retrospectively, the ED charges forthis group of patients in the previous 12 months was $183,760, 41/52 used narcotics, center chart reviews to analyze the healthcare utilization of patients who use EDsrepeatedly for recurrent headaches.
The Health Economics Of Asthma And Rhinitis. In 1998, asthma in the U.S. cost 12.7 billion dollars annually (for direct and indirect costs). In 1994, allergic rhinitis cost $1.2 billion. Most of the costs were due to directmedical expenditures (especially medica- This paper is a narrative review that looked at 128 articles about asthma and allergicrhinitis in order to estimate the amount ofdirect and indirect costs of these 2 diseasesin the U.S.
Study Outcome
Helicopter Transport Of Pediatric Trauma Out of 175 patients transported by helicop- Patients In An Urban Emergency Medical Services System: A Critical Analysis taken directly to the operating room (OR),33% were discharged home from the ED. This study was a retrospective review of175 pediatric patients transported by heli-copter to a single pediatric trauma center inorder to determine if helicopter transportwas necessary.
Prevention Of Catheter-Associated Urinary Tract The underlying cause of catheter-associated UTIs is biofilm formation by pathogens on the urinary catheter. Research is ongoing This article reviews the topic of catheter-associated urinary tract infections (UTIs).
The article discusses etiology and patholo-gy, and areas of research.
The Quality Of Antipsychotic Drug Prescribing 27% of all Medicare beneficiaries in nursing guidelines were no more likely to achieve stability or improved behavioral symptoms than were those taking antipsychotics out-side the guidelines.
This study retrospectively analyzed datafrom 1,096 nursing home patients in theMedicare Current Beneficiary Survey inorder to determine the pattern of antipsy-chotic use and the appropriateness ofantipsychotic use.
Study Outcome
Economic Evaluation Of Four Treatments For The adjusted outpatient costs (not includ- Low Back Pain: Results From A Randomized ing pharmaceuticals) for the 4 modalities for only, $560 for chiropractic care only, $579 for chiropractic care with physical modali- ties, and $760 for medical care and physicaltherapy. This study examined 18-month costs for 4treatments for low-back pain.
Medical Care- Is More Always Better? High-intensity practice patterns are associ- ated with lower quality of care and worseoutcomes than more conservative practice This editorial discusses the effect of the Veterans Adminstration’s reform of itshealth care system on patients with chronicdisease.
CT results in low level radiation exposure.
The cumulative effect of repeated examscan lead to significant exposure which could This letter to the editor discusses theoreti- predispose to a variety of malignancies.
cal risks and benefits of computed tomogra-phy (CT) scans in terms of the trade-offbetween low-level radiation exposure andincreased diagnostic certainty

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Manitowoc County Health Department Pertussis Case Report Form Name of Patient (Last, First, Middle Initial)  1 Native American / Alaskan Native  5 White  2 Asian / Pacific Islander  8 Other Culture/PCR Was patient tested for Bordetella pertussis ? PCR? ____Yes ____No Date: Culture? ____Yes ____No Date: (Both a PCR and culture are recommended when testing fo

Publicationpfe endoscopy information leaflet

You may experience fatigue, dizziness or If you have any questions please ask your headaches drink plenty of fluids to relieve Polyps are little growths which arise from the lining of the bowels. Some may progress and change as they grow, therefore removal is necessary to prevent them turning cancerous. Polyp removal is achieved by looping them with a snare and cutting through the lining

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