Background Overuse of diagnostic testing substantially contributes to healthcare expenses and potentially exposes patients to unnecessary harm. Our objective was to systematically identify and examine studies that assessed the prevalence of diagnostic testing overuse across healthcare settings to estimate the overall prevalence of low-value diagnostic overtesting. Methods PubMed, Web of Science and Embase were searched from inception until 18 February 2020 to identify articles published in the English language that examined the prevalence of diagnostic testing overuse using database data. Each of the assessments was categorised as using a patient-indication lens, a patient-population lens or a service lens. Results 118 assessments of diagnostic testing overuse, extracted from 35 studies, were included in this study. Most included assessments used a patient-indication lens (n=67, 57%), followed by the service lens (n=27, 23%) and patient-population lens (n=24, 20%). Prevalence estimates of diagnostic testing overuse ranged from 0.09% to 97.5% (median prevalence of assessments using a patient-indication lens: 11.0%, patient-population lens: 2.0% and service lens: 30.7%). The majority of assessments (n=85) reported overuse of diagnostic testing to be below 25%. Overuse of diagnostic imaging tests was most often assessed (n=96). Among the 33 assessments reporting high levels of overuse (≥25%), preoperative testing (n=7) and imaging for uncomplicated low back pain (n=6) were most frequently examined. For assessments of similar diagnostic tests, major variation in the prevalence of overuse was observed. Differences in the definitions of low-value tests used, their operationalisation and assessment methods likely contributed to this observed variation. Conclusion Our findings suggest that substantial overuse of diagnostic testing is present with wide variation in overuse. Preoperative testing and imaging for non-specific low back pain are the most frequently identified low-value diagnostic tests. Uniform definitions and assessments are required in order to obtain a more comprehensive understanding of the magnitude of diagnostic testing overuse.

https://qualitysafety.bmj.com/content/qhc/early/2021/05/09/bmjqs-2020-012576.full.pdf

Overuse of diagnostic testing in healthcare: a systematic review.

Adherence to evidence-based antibiotic therapy guidelines for treatment of upper respiratory tract infections (URIs) varies widely among clinicians. Understanding this variability is key for reducing inappropriate prescribing. To measure how emergency department (ED) clinicians’ perceptions of antibiotic prescribing risks affect their decision-making. Clinician survey based on fuzzy-trace theory, a theory of medical decision-making, combined with retrospective data on prescribing outcomes for URI/pneumonia visits in two EDs. The survey predicts the categorical meanings, or gists, that individuals derive from given information. ED physicians, residents, and physician assistants (PAs) who completed surveys and treated patients with URI/pneumonia diagnoses between August 2014 and December 2015. Gists derived from survey responses and their association with rates of antibiotic prescribing per visit. Of 4474 URI/pneumonia visits, 2874 (64.2%) had an antibiotic prescription. However, prescribing rates varied from 7% to 91% for the 69 clinicians surveyed (65.2% response rate). Clinicians who framed therapy-prescribing decisions as a categorical choice between continued illness and possibly beneficial treatment (“why not take a risk?” gist, which assumes antibiotic therapy is essentially harmless) had higher rates of prescribing (OR 1.28 [95% CI, 1.06–1.54]). Greater agreement with the “antibiotics may be harmful” gist was associated with lower prescribing rates (OR 0.81 [95% CI, 0.67–0.98]). Our results indicate that clinicians who perceive prescribing as a categorical choice between patients remaining ill or possibly improving from therapy are more likely to prescribe antibiotics. However, this strategy assumes that antibiotics are essentially harmless. Clinicians who framed decision-making as a choice between potential harms from therapy and continued patient illness (e.g., increased appreciation of potential harms) had lower prescribing rates. These results suggest that interventions to reduce inappropriate prescribing should emphasize the non-negligible possibility of serious side effects.

/pdf/categorical-risk-perception-drives-variability-in-antibiotic-3xsmwdsfkf.pdf

Categorical Risk Perception Drives Variability in Antibiotic Prescribing in the Emergency Department: A Mixed Methods Observational Study

After more than three decades of free medicines for the elderly in Spain, in the context of heavy austerity reforms of public financing, a set of cost-sharing reforms on pharmaceutical prescriptions with regional variants have been established in Spain since July 2012 The purpose of this analysis is to present the first attempt to provide accurate estimates of the overall impact at the regional level of these cost-sharing reforms We estimated the impact of the reforms on the quantity of dispensed medicines during the first 14 months We estimated 17 autoregressive integrated moving average (ARIMA) time series models of the monthly number of prescriptions dispensed in pharmacies for the period January 2003–May 2012 in each one of the 17 regions (Autonomous Communities) of Spain We calculated dynamic forecasts for the horizon June 2012–July 2013 in order to estimate the counterfactual (number of prescriptions that would had been observed without the intervention), and we estimated the impact of cost-sharing changes as the difference between the observed number of accumulated prescriptions at 3, 6, 12, and 14 months and the number predicted by our time-series models (in percentages) During the last decade the number of dispensed prescriptions has experienced rapid and continuous increases In the first 14 months after the co-payment reform, the total number of prescriptions decreased dramatically, by more than 20 % in Catalunya, Valencia, and Galicia, by more than 15 % in nine other regions, and by more than 10 % in 15 of the 17 Spanish regions The results of our model suggest that the new co-payment caused an abrupt shift in the mean level of the time series No shift in trend has been detected; the previous positive trend remains unchanged in most of the Autonomous Communities After decades of unsuccessfully trying to reduce drug spending in the Spanish National Health System through actions on prices and on prescribers, the co-payment established in mid-2012 led to a dramatic reduction in the use of drugs The health effects of this reduction are not known

Paying for Formerly Free Medicines in Spain After 1 Year of Co-Payment: Changes in the Number of Dispensed Prescriptions

Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.

/pdf/patients-and-clinicians-perceptions-of-antibiotic-2luq0dqxgk.pdf

Patients’ and Clinicians’ Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting

Background Antibiotic prescriptions at emergency departments (ED) could be a primary contributing factor to the overuse of antimicrobial agents and subsequently antimicrobial resistance. The aim of this study was to describe the pattern of antibiotic prescriptions at an emergency department of a tertiary care hospital in Saudi Arabia. Methods A cross-sectional study, based on a review of antibiotic prescriptions was conducted. All cases who visited the emergency department over a three-month period with a complaint of infection were analyzed in terms of patient characteristics (age, sex, infection type, and number of visits) and prescription characteristics (antibiotic category, spectrum, course and costs). The World Health Organization and International Network of Rational Use of Drugs prescribing indicators were presented. Descriptive and analytic statistics were applied. Results A total of 36,069 ED visits were recorded during the study period, of which 45,770 drug prescriptions were prescribed, including 6,354 antibiotics. The average number of drugs per encounter was 1.26, while the percentage of encounters with a prescribed antibiotic was 17.6%. Among antibiotic prescriptions, the percentage of encounters with injection antibiotics was 15.2%. Almost 77% of antibiotics were prescribed by their generic names, and the percentage of antibiotics prescribed from the essential list was 100%. Conclusion The average number of drugs per encounter in general and antibiotics per encounter in specific at this setting was lower than the standard value. However, the percentage of antibiotics prescribed by its generic name was less than optimal.

/pdf/an-evaluation-of-antibiotics-prescribing-patterns-in-the-2k0arsjjxy.pdf

An Evaluation Of Antibiotics Prescribing Patterns In The Emergency Department Of A Tertiary Care Hospital In Saudi Arabia.

Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers’ compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US. Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age  64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies. In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors. Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.

https://link.springer.com/content/pdf/10.1186%2F1471-227X-13-7.pdf

Over-prescribing of antibiotics and imaging in the management of uncomplicated URIs in emergency departments

OBJECTIVES The optimal timing of coronary artery bypass grafting (CABG) following an acute myocardial infarction (AMI) is a topic of debate. The present study was designed to evaluate patients undergoing CABG both early ( 5 days) after AMI in the era of percutaneous coronary intervention. METHODS The medical records at our institution from 2008 through 2012 were reviewed. A total of 128 patients underwent CABG after AMI during this time period and fulfilled criteria for the study. Death, stroke, renal failure, need for intraaortic balloon pump, postoperative ventilator days, and length of stay were examined. RESULTS Patients undergoing early CABG had an increased need for an intraaortic balloon pump. There were no other correlations that we could discern between early and late CABG. CONCLUSIONS Our data demonstrate no statistical difference in mortality or in the factors of morbidity studied between either early or late CABG after AMI.

Is Early Reperfusion a Good Thing? Optimal Timing of CABG Surgery Postacute Myocardial Infarction.

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Over-prescribing of antibiotics and imaging in the management of uncomplicated URIs in emergency departments

Is Early Reperfusion a Good Thing? Optimal Timing of CABG Surgery Postacute Myocardial Infarction.