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Journal articles

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21 July 2021 | EMA

Effect of a clinical flowchart incorporating Wells score, PERC rule and age-adjusted D-dimer on pulmonary embolism diagnosis, scan rates and diagnostic yield


Objective: To assess the association between the use of a flowchart incorporating Wells score, PERC rule and age-adjusted D-dimer and subsequent imaging and yield rates of computed tomography pulmonary angiogram and nuclear medicine ventilation perfusion scans being ordered in the ED for the assessment of pulmonary embolism.

Methods: A flowchart governing ED pulmonary embolism investigation was introduced across three EDs in Melbourne, Australia for a 12 month period. Comparison of pulmonary embolism imaging rates and yield with the preceding 12 months was performed.

Results: A total of 1815 pre-implementation scans were performed compared with 1116 scans post-implementation. Because of growth in patient attendances over this time, this equated to an imaging rate of 14.5 per 1000 presentations pre-implementation and 8.6 per 1000 presentations post-implementation (P < 0.001). Overall pulmonary embolism imaging yield rates rose from 9.9% to 16.5% (P < 0.001). A total of 179 pre-implementation pulmonary embolisms were identified, with an incidence of 1.4 per 1000 presentations. This compared to 184 pulmonary embolisms post-implementation, with an incidence of 1.4 per 1000 presentations (P = 0.994).

Conclusion: The introduction of a clinical flowchart incorporating Wells score, PERC rule and age-adjusted D-dimer was associated with an increase in ED computed tomography pulmonary angiogram and nuclear medicine ventilation perfusion yield rate from 9.9% to 16.5% across the three enrolment hospitals when investigating possible pulmonary embolism. This corresponded to a 40% relative reduction in pulmonary embolism imaging. Diagnosis rates remained unchanged and no cases of missed pulmonary embolism attributable to the flowchart were identified.

Key words: computed tomography, D-dimer, emergency department, pulmonary angiogram, ventilation perfusion scan.

19 July 2021

Low value care is a health hazard that calls for patient empowerment

To protect themselves from the potential harms of low value care, patients must take an active role in clinical decision making.

Low value care is care that is ineffective, harmful or confers marginal benefit at disproportionately high cost. Professionally‐led campaigns such as Choosing Wisely Australia and the Royal Australasian College of Physicians’ EVOLVE program aim to reduce the prevalence of such care. However, similar overseas campaigns have been marred by selective focus on infrequent, low impact, or less financially lucrative practices; uncertainty about the most effective de‐adoption strategies; and limited success to date in reducing overuse. While clinician‐targeted education programs, audit and feedback, and decision support feature prominently, evidence appears stronger and impact seems greater for strategies directed to, or mediated by, patients.

26 February 2021 | Health Policy

Physicians’ views and experiences of defensive medicine: An international review of empirical research

This study systematically maps empirical research on physicians’ views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English‐language publications in health, legal and multi-disciplinary databases. The extraction framework covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions.

79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investigation. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels.

Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care.

2 September 2020 | International Journal of Medical Informatics

A systematic literature review on unnecessary diagnostic testing: The role of ICT use


Background: The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests.

Method: A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol.

Results: 92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies.

Conclusions: This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.

1 Apr 2019 | The Commonwealth Fund

Choosing Wisely: An international movement toward appropriate medical care

A hot dog with too much mustard on it. A washing machine overflowing with soap suds. A suitcase with clothes spilling out of it. These images aren’t what you expect to see when you go to your doctor — but in primary care waiting rooms across Canada, posters with these images hang on the walls. The posters, accompanied with the message “More Is Not Always Better,” are intended to prompt patients to talk to their physicians about what kind of care is right for them.

Behind the eye-catching posters is Choosing Wisely, an international movement that began in the United States and has since spread around the world. It was launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation to advance a national dialogue on how to avoid unnecessary medical tests, treatments, and procedures. Today, more than 20 countries have developed campaigns based on a simple but compelling premise: conversations between doctors and patients can help patients choose care that is based on evidence, truly necessary, not duplicative, and free from harm.

Stewardship toolkit for clinical educators

The Health Resource Stewardship for Clinical educators contains educational material about the Choosing Wisely initiative for use in universities, hospitals and health professional colleges

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5 Questions

5 questions to ask your doctor or other healthcare provider to make sure you end up with the right amount of care.

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