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Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments.

ABSTRACT: Importance:Overuse of medical tests and treatments is an increasingly recognized problem across health systems; best practices for reducing overuse are not clear. Framing the problem in terms of the spectrum of potential patient harm is likely to be an effective strategy for clinician and patient engagement in efforts to reduce overuse, but the scope of negative consequences of overuse for patients has not been well described. Observations:We sought to generate a comprehensive conceptual map documenting the processes through which overused tests and treatments lead to multiple domains of negative consequences for patients. For map development, an iterative consensus process was informed by structured review of the literature on overuse using PubMed and input from a panel of 6 international experts. For map verification, a systematic review was performed of case reports involving overused services, identified through literature review and manual review of relevant article collections. The conceptual map documents that overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop. Case reports on overuse confirmed the processes and domains of the conceptual map. Cases also revealed strengths and weaknesses in published communication about overuse: they were dominated by physical harms, with other negative consequences receiving far less attention. Conclusions and Relevance:This evidence-based conceptual map clarifies the processes by which overused tests and treatments result in negative consequences for patients; it also documents multiple domains of negative consequences experienced by patients. The map will be useful for facilitating comprehensive communication about overuse, estimating harms and costs associated with overused services, and informing health system efforts to reduce overuse.

SUBMITTER: Korenstein D

PROVIDER: S-EPMC7505335 | biostudies-literature | 2018 Oct

REPOSITORIES: biostudies-literature

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Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments.

Korenstein Deborah D Chimonas Susan S Barrow Brooke B Keyhani Salomeh S Troy Aaron A Lipitz-Snyderman Allison A

JAMA internal medicine 20181001 10

<h4>Importance</h4>Overuse of medical tests and treatments is an increasingly recognized problem across health systems; best practices for reducing overuse are not clear. Framing the problem in terms of the spectrum of potential patient harm is likely to be an effective strategy for clinician and patient engagement in efforts to reduce overuse, but the scope of negative consequences of overuse for patients has not been well described.<h4>Observations</h4>We sought to generate a comprehensive con ...[more]

PMID: 30105371

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Project description:ImportanceOveruse of health care services exposes patients to unnecessary risk of harm and costs. Distinguishing patterns of overuse among hospitals requires hospital-level measures across multiple services.ObjectiveTo describe characteristics of hospitals associated with overuse of health care services in the US.Design, setting, and participantsThis retrospective cross-sectional analysis used Medicare fee-for-service claims data for beneficiaries older than 65 years from January 1, 2015, to December 31, 2017, with a lookback of 1 year. Inpatient and outpatient services were included, and services offered at specialty and federal hospitals were excluded. Patients were from hospitals with the capacity (based on a claims filter developed for this study) to perform at least 7 of 12 investigated services. Statistical analyses were performed from July 1, 2020, to December 20, 2020.Main outcomes and measuresOutcomes of interest were a composite overuse score ranging from 0 (no overuse of services) to 1 (relatively high overuse of services) and characteristics of hospitals clustered by overuse rates. Twelve published low-value service algorithms were applied to the data to find overuse rates for each hospital, normalized and aggregated to a composite score and then compared across 6 hospital characteristics using multivariable regression. A k-means cluster analysis was used on normalized overuse rates to identify hospital clusters.ResultsThe primary analysis was performed on 2415 cohort A hospitals (ie, hospitals with capacity for 7 or more services), which included 1 263 592 patients (mean [SD] age, 72.4 [14] years; 678 549 women [53.7%]; 101 017 191 White patients [80.5%]). Head imaging for syncope was the highest-volume low-value service (377 745 patients [29.9%]), followed by coronary artery stenting for stable coronary disease (199 579 [15.8%]). The mean (SD) composite overuse score was 0.40 (0.10) points. Southern hospitals had a higher mean score than midwestern (difference in means: 0.06 [95% CI, 0.05-0.07] points; P < .001), northeast (0.08 [95% CI, 0.06-0.09] points; P < .001), and western hospitals (0.08 [95% CI, 0.07-0.10] points; P < .001). Nonprofit hospitals had a lower adjusted mean score than for-profit hospitals (-0.03 [95% CI, -0.04 to -0.02] points; P < .001). Major teaching hospitals had significantly lower adjusted mean overuse scores vs minor teaching hospitals (difference in means, -0.07 [95% CI, -0.08 to -0.06] points; P < .001) and nonteaching hospitals (-0.10 [95% CI, -0.12 to -0.09] points; P < .001). Of the 4 clusters identified, 1 was characterized by its low counts of overuse in all services except for spinal fusion; the majority of major teaching hospitals were in this cluster (164 of 223 major teaching hospitals [73.5%]).Conclusions and relevanceThis cross-sectional study used a novel measurement of hospital-associated overuse; results showed that the highest scores in this Medicare population were associated with nonteaching and for-profit hospitals, particularly in the South.

Project description:This study explores the impact of the extensive use of an oral device since infancy (pacifier) on the acquisition of concrete, abstract, and emotional concepts. While recent evidence showed a negative relation between pacifier use and children's emotional competence (Niedenthal et al., 2012), the possible interaction between use of pacifier and processing of emotional and abstract language has not been investigated. According to recent theories, while all concepts are grounded in sensorimotor experience, abstract concepts activate linguistic and social information more than concrete ones. Specifically, the Words As Social Tools (WAT) proposal predicts that the simulation of their meaning leads to an activation of the mouth (Borghi and Binkofski, 2014; Borghi and Zarcone, 2016). Since the pacifier affects facial mimicry forcing mouth muscles into a static position, we hypothesize its possible interference on acquisition/consolidation of abstract emotional and abstract not-emotional concepts, which are mainly conveyed during social and linguistic interactions, than of concrete concepts. Fifty-nine first grade children, with a history of different frequency of pacifier use, provided oral definitions of the meaning of abstract not-emotional, abstract emotional, and concrete words. Main effect of concept type emerged, with higher accuracy in defining concrete and abstract emotional concepts with respect to abstract not-emotional concepts, independently from pacifier use. Accuracy in definitions was not influenced by the use of pacifier, but correspondence and hierarchical clustering analyses suggest that the use of pacifier differently modulates the conceptual relations elicited by abstract emotional and abstract not-emotional. While the majority of the children produced a similar pattern of conceptual relations, analyses on the few (6) children who overused the pacifier (for more than 3 years) showed that they tend to distinguish less clearly between concrete and abstract emotional concepts and between concrete and abstract not-emotional concepts than children who did not use it (5) or used it for short (17). As to the conceptual relations they produced, children who overused the pacifier tended to refer less to their experience and to social and emotional situations, use more exemplifications and functional relations, and less free associations.

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

Project description:BACKGROUND:Overuse of healthcare is pervasive in the United States, often exposing patients to harm with little likelihood of benefit. Older Americans are particularly vulnerable to overuse and impacted by it, yet it is unknown whether older patients perceive overuse as a consequential problem. OBJECTIVE:To explore the experiences and perspectives of older adults with respect to healthcare overuse in order to develop a framework for understanding and reducing overuse in older adults. DESIGN:Qualitative study using focus group methodology. PARTICIPANTS:Five focus groups were held with people ?65 years of age (N?=?38) in four senior centers in Baltimore, Maryland, in 2016. APPROACH:Transcripts were analyzed using qualitative content analysis to identify major themes. KEY RESULTS:Of the 38 participants, 28 were women and 29 were African-American; 31 had at least a 12th grade education. While virtually all reported experience with what they perceived to have been healthcare overuse, some expressed concern that they had been denied appropriate care. They perceived overuse to have occurred when interventions were applied in the absence of symptoms (excluding cancer screening), did not improve symptoms, were discordant with their preferences, or were duplicative. Some defined overuse as interventions that were offered before less intensive options or too early in the course of disease. Suggested contributors to overuse were poor quality communication between patients and healthcare providers, and between different healthcare providers. Participants reported suffering from treatment effects, high costs, worry, and inconvenience from what they perceived to be overuse. They suggested that overuse may be reduced when the patient is involved in decision making and has a trusted primary care doctor. CONCLUSIONS:The experience of older adults highlights potential sites of intervention to reduce healthcare overuse. Engaging patients in shared decision making and enhancing communication and knowledge transfer should be tested as interventions to reduce perceived overuse.

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Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments.

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Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments.

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