31

NEHI CompendiumOveruse

33

Evidence Table—OveruseStudy Outcome

Revisiting The Appropriateness Of CarotidEndarterectomyHalm, E.A., Chassin, M.R., Tuhrim, S.,Hollier, L.H., Popp, A.J. Ascher, E.,Dardik, H., Faust, G., Riles, T.S.; 2003;Stroke

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 TractInfections In Ambulatory Practice In The UnitedStates, 1997-1999: Does Physician SpecialtyMatter?Rutschmann, O.T., Domino, M.E.;2004; J Am Board Fam Pract

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 ForHysterectomyBroder, M.S., Kanouse, D.E., Mittman,B.S., Bernstein, S.J.; 2000; ObstetGynecol

This study retrospectively reviewed therecords of women who underwent hysterec-tomy in nine capitated medical groups inCalifornia 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.

There are 14,000 inappropriate cases ofcarotid endarterectomy annually. 84.9% ofcases were judged to be appropriate, anincrease from earlier studies (35% ofMedicare cases judged appropriate). 10.6%judged inappropriate, primarily due to high co-morbid conditions.

Antibiotics are overused for URI. Patientswere less likely to receive antibiotic pre-scriptions from general internists than fami-ly practitioners. Rate of prescriptions writ-ten for URI decreased over the study peri-od from 52.1% to 41.5%.

Chart reviews revealed that 70% of chartsdid not completely meet all indications forhysterectomy. The most common failureswere lack of adequate diagnostic testingand failure to try alternative treatmentsprior to hysterectomy. The ultimate signifi-cance, however, is questionable, as thepanel estimated that only 14% of proce-dures were actually inappropriate.

34

Overuse

Overuse Of Transthoracic Echocardiography InThe Diagnosis Of Native Valve EndocarditisKuruppu, J.C., Corretti, M.,Mackowiak, P., Roghmann, M.C.; 2002;Arch Intern Med

This study reviewed hospital records of 98patients with suspected infective endocardi-tis who underwent TransthoracicEchocardiography (TTE) to determine theimpact that the study had on treatmentdecisions.

Antibiotic Treatment Of Children With SoreThroatKuruppu, J.C., Corretti, M.,Mackowiak, P., Roghmann, M.C.; 2005;JAMA

The study used National AmbulatoryMedical Care Survey (NAMCS) andNational Hospital Ambulatory Medical CareSurvey (NHAMCS) data to measure rates ofantibiotic prescribing and Group AHemolytic Streptococcus (GABHS) testingand to evaluate the association betweentesting and antibiotic treatment in childrenwith sore throat.

Study Outcome

TTE is overused in cases of infective endo-carditis (IE). The diagnosis of IE is a clini-cal diagnosis, and the results of the TTEdid not significantly affect the duration ofantibiotic therapy. The authors propose anew algorithm that would result in elimina-tion of 53% of the TTEs done in this study,which can be avoided by treating patientsempirically until the blood culture resultsare negative.

Antibiotics are generally overused, and thewrong antibiotics are prescribed (and mis-used) 27% of the time. Testing for GABHSis underused. Antibiotics were prescribed in53% of visits for sore throats in childrenaged 3-17. Antibiotics are indicated for sorethroats due to Group A Beta HemolyticStreptocci infection, which accounts foronly 15-36% of sore throats. When antibi-otics are prescribed, the correct antibiotic isprescribed 73% of the time. Only 57% ofchildren with a diagnosis of tonsillitis, strepsore throat, and pharyngitis had the GABHStest.

35

Overuse

Study Outcome

Use Of Adenosine In Patients Hospitalized In AUniversity Medical CenterKnight, B.P., Zivin, A., Souza, J.,Goyal, R., Man, K.C., Strickberger, A.,Morady, F.; 1998; Am J Med

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: ACase 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.

40% of hospitalized patients receivedadenosine for arrhythmias where adenosineis not indicated. 26 patients from the serieswere excluded because there was no evi-dence of their specific arrhythmia.

Costs were significantly higher in the ED.

36

Overuse

Study Outcome

Effectiveness Of A Medical Priority DispatchProtocol For Abdominal PainKennedy, J.D., Sweeney, T.A., Roberts,D., O’Connor, R.E.; 2003; PrehospEmerg Care

This study retrospectively reviewed therecords 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 AndAccurate Use Of Antibiotics: The Council ForAppropriate And Rational Antibiotic Therapy(CARAT) CriteriaSlama, T.G., Amin, A., Brunton, S.A.,File, T.M., Jr., Milkovich, G., Rodvold,K.A., Sahm, D.F., Varon, J., Weiland,D., Jr.; 2005; Am J Med

This study reviews literature regardingappropriate use of antibiotics.

Antibiotic Prescribing For Children With Colds,Upper Respiratory Tract Infections AndBronchitisNyquist, A.C., Gonzales, R., Steiner,J.F., Sande, M.A.; 1998; JAMA

This study drew upon the responses ofphysicians to the 1992 National AmbulatoryCare 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.

Hospital records were available for 86% ofcases, of which 12 were potentially life-threatening, requiring ALS intervention.Seventeen were non-life-threatening, butpotentially benefited from ALS interven-tion. The remaining 157 were classified asnot requiring ALS.

The rate of misuse and overuse of antibioticprescriptions might be lowered if clinicianswere to use the 5 Council for Appropriateand Rational Antibiotic Therapy (CARAT)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 considerwhen choosing an appropriate and accurateantibiotic therapy.

Overuse and underuse of antibiotics mayresult because some provider groups aremore inclined to prescribe than others; alsosome patient groups are more likely toreceive antibiotics than others. Pediatricianswere 0.57 times less likely to prescribeantibiotics to children with otitis, sinusitis,or pharyngitis than non-pediatricians.

37

Overuse

Study Outcome

Ceftriaxone Use In The Emergency Department:Are We Doing It Right?Jain, S., Sullivan, K.; 2002; PediatrEmerg Care

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 CareConsumers’ Use Of Emergency Departments:Has Managed Care Made A Difference?Speck, S.K., Peyrot, M., Hsiao, C.W.;2003; J Hosp Mark Public Relations

This study used National HospitalAmbulatory Medical Care Survey (NAHMCS) data from 1992 and1996 todetermine the effect of managed care onappropriateness of emergency department(ED) utilization.

Prospective Determination Of Medical NecessityFor Ambulance Transport By ParamedicsGratton, M.C., Ellison, S.R., Hunt, J.Ma, O.J.; 2003; Prehosp Emerg Care

This study prospectively assessed the med-ical necessity of emergency transport by alarge urban EMS system.

Based on published guidelines, ceftriaxoneuse in the PED was not justified in themajority of cases (66.4%, with an additional17% representing questionable use).

The proportion of non-urgent ED visitsdecreased from 57.1% of visits in 1992 to55.8% in 1996. However, over- and misuseof the ED did not decrease more for man-aged care patients compared with fee-for-service patients, nor for insured comparedwith uninsured patients.

Paramedics and emergency physiciansagreed that a significant percentage ofpatients (30% for paramedics, 29% forphysicians) did not require ambulancetransport (76.2% agreement) to the emer-gency department.

38

Overuse

Study Outcome

Cervical Cancer Screening Among Women WithAnd Without Hysterectomies.Eaker, E.D., Vierkant, R.A., Konitzer,K.A., Remington, P.L.; 1998; ObstetGynecol

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 ExperienceBell, N; 2002; Am J Manag Care

This study reviews the literature andreports on the prevalence of drug-resistantStrep pneumonia in Iowa. The Depart-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, AndPreventable Hospitalization Of Children In ALarge StateFriedman, B., Basu, J.; 2001; Am JManag Care

This study was a retrospective recordreview of 1994 hospital discharge data forNew York resident children withAmbulatory-Care Sensitive (ACS) condi-tions. Relationship between ACS admissionrates and several factors were analyzed.

Pap testing rates vary by type and reasonfor hysterectomy. Women with hysterecto-my for malignancy have 1 more test a yearthan women without, and women with hys-terectomy for benign reasons have 1 fewertest (potential overuse).

The profiling and educational interventionsled to a substantial decrease in both overallantibiotic prescribing and drug costs. Otherstates may want to undertake similar pro-grams to help protect their citizens frominfections caused by resistant pathogens.

Admission rates for ACS conditions in NewYork children were higher in locationswhere there were fewer primary care physi-cians, lower percents of children with pri-vate health maintenance organization(HMO) insurance, and higher proportions ofnon-white ethnic groups.

39

Overuse

Study Outcome

Lansoprazole Overutilization: Methods ForStep-Down TherapyPohland, C.J., Scavnicky, S.A., Lasky,S.S., Good, C.B.; 2003; Am J ManagCare

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 ForBronchitis And Upper Respiratory InfectionsAmong Adults And ChildrenMainous, A.G., III Hueston, W.J.,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.

46% (n = 60) of recommended step-downtherapies were accepted, resulting in an$85,000 savings per year.

Inappropriate use of antibiotics for viralURI has decreased, but 10% of children and20% of adults still receive inappropriatetreatment.

40

Overuse

Study Outcome

The Impact Of Peer Management On Test-Ordering BehaviorNeilson, E.G., Johnson, K.B.,Rosenbloom, S.T., Dupont, W.D.,Talbert, D., Giuse, D.A., Kaiser, A.,Miller, R.A.; 2004; Ann Intern Med

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 InNuclear CardiologyShaw, L.J., Miller, D.D., Berman, D.S.,Hachamovitch, R.; 2000; Q J Nucl Med

This article reviews the current state of theevidence on the clinical and economic dataregarding different nuclear cardiology imag-ing tests. A synthesis of current economicevidence for gated, Single-Photon EmissionComputed Tomography (SPECT) is alsopresented.

Peer management reduced provider vari-ability. Hospitals with growing health carecosts can improve resource utilizationthrough peer management by using CPOEsystems.

The overuse of diagnostic angiographyoften leads to unnecessary revascularizationthat does not lead to improvement in out-come. Thus, the potential exists that stressSPECT imaging, a highly effective diagnos-tic tool, could reduce the inappropriate useof an invasive procedures resulting in cost-effective cardiac care.

41

Overuse

Study Outcome

Self-Reported Papanicolaou Smears AndHysterectomies Among Women In The UnitedStatesSaraiya, M., Lee, N.C., Blackman, D.,Smith, M.J., Morrow, B., McKenna,M.A.; 2001; Obstet Gynecol

This study used 1992-1997 BRFSS, 1993-1994 NHIS, and 1980-1997 NHDS data toestimate the rates of Papanicolaou smears inwomen post hysterectomy.

Antimicrobial Use For Pediatric UpperRespiratory Tract Infections (URI): ReportedPractice, Actual Practice, Parental BeliefsWatson, R.L., Dowell, S.F., Jayaraman,M., Keyserling, H., Kolczak, M.,Schwartz, B.; 1999; Pediatrics

This study surveyed 336 pediatricians andfamily physicians in Georgia regarding opin-ions of the treatment of URIs. Randomchart reviews and parent interviews wereperformed in 25 randomly selected prac-tices in order to examine the factors thatrelate to the over-prescribing of antibioticsin children 5 years of age and younger.

There is significant overuse of pap smearsfollowing hysterectomy. 74.2-78.3% ofwomen who have had a hysterectomy self-reported that they had a pap smear withinthe 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.Only 6.7-15.4% of women who had a hys-terectomy need to have a pap smear due tosupracervical 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.

The overuse of antibiotics is prevalent forthe 5 conditions studied in pediatricpatients, despite stated beliefs that over-prescribing contributes to antibiotic resist-ance. The reasons cited included parentalpressure, desire to avoid a follow-up visit inmanaged care patients, and a belief thatparents could elect to obtain antibioticsfrom colleagues. Despite survey resultsindicating that pediatricians and familypractitioners recognize the problems associ-ated with overuse of antibiotics for URI,survey results (including both pediatriciansand family physicians) and chart reviews(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.

42

Overuse

Study Outcome

Factors Affecting Prescription Of Ultra-HighPotency Topical Corticosteroids In Skin Disease:An Analysis Of US National Practice DataBalkrishnan, R., Camacho, F.T.,Pearce, D.J., Kulkarni, A.S., Spencer,L., Fleischer, A.B., Jr. Feldman, S.R.;2005; J Drugs Dermatol

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 EmergencyDepartment Use In The First 3 Months Of LifePomerantz, W.J., Schubert, C.J.,Atherton, H.D. Kotagal, U.R.; 2002;Pediatr Emerg Care

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 OnUtilization Of Low-Yield Bacterial StoolCultures In A Children’s HospitalZaidi, A.K., Macone, A., Goldmann,A.D.; 1999; Pediatrics

This study used a retrospective analysis ofhospital laboratory records to estimate theappropriateness of stool cultures and todevelop guidelines for reducing unwarrant-ed stool cultures for Salmonella, Shigella,Campylobacter, Yersinia enterocolitica, andE. coli 0157:H7 (SSCYE).

Class I topical corticosteroids were pre-scribed in 3% of all skin disease-related vis-its, with prescription rates being highest inpsoriasis (22%). There were a large numberof questionable prescriptions for other con-ditions, which could be construed asimproper use of these medications.

60.1% of all visits were nonurgent. Of allpatients with non-urgent visits, 24.1% hadmore than 1. Younger maternal age,Medicaid, maternal parity, and non-whiterace all resulted in increased nonurgentemergency department (ED) use.

Guidelines for tests such as stool culturescan reduce overuse, particularly through theeducation of physicians about when suchtests are appropriate. Using guidelines tolimit stool cultures for SSCYE for inpatientsreduced cultures by 43% (689)—primarilyby reducing the number of tests ordered(497) rather than through a dramatic num-ber of tests being rejected (192)—and savedthe hospital of over $50,000 per year.

43

Overuse

Study Outcome

Keeping Children Out Of Hospitals: Parents’And Physicians’ Perspectives On How PediatricHospitalization For Ambulatory Care-SensitiveConditions Can Be AvoidedFlores, Glenn; 2003; Pediatrics

This study used a survey of parents, primary care physicians (PCPs) and inpa-tient attending physicians about pediatrichospital admissions concerning whether theadmission was avoidable.

Provider And Practice Characteristics AssociatedWith Antibiotic Use In Children With PresumedViral Respiratory Tract Infections.Gaur, A.H., Hare, M.E., Shorr, R.I.;2005; Pediatrics

This study used data from the 1995-2000National Hospital Ambulatory Medical CareSurvey (NHAMCS) to assess antibiotic pre-scribing to children in hospital outpatientclinics for 4 ICD-9 code diagnoses sugges-tive of viral respiratory infection acutenasopharyngitis.

Use Of Open Access In GI Endoscopy At AnAcademic Medical CenterCharles, R.J., Chak, A., Cooper, G.S.,Wong, R.C., Sivak, M.V., Jr.; 1999;Gastrointest Endosc

This study examined records from 5months 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.

About 50% of hospitalizations for childrenwith 6 diagnoses may be avoidable throughbetter parent education and follow-up clini-cal care. The most common diagnoses foravoidable hospitalization (AH) as agreed toby two of the three sources, were asthma(27%), skin infections (20%), and dehydra-tion/gastroenteritis (15%). Overall, theagreement rate varied from 68% for parentsand attending physicians to 79% for PCPsand attending physicians. Variables mostassociated with AH were being over the ageof 10, and having a diagnosis of asthma.

Potential overuse of antibiotics in childrenis related to both provider and facility char-acteristics. Although there seems to be adownward 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 inteaching or non-teaching hospitals (39.6%).Other factors associated with increased like-lihood of antibiotic prescribing includeddiagnosis of bronchitis (unspecified), beingseen in a non-pediatric clinic, and beingseen before the 1998 publication of theCDC/AAP guidelines.

86% of endoscopies after consultation withgastroenterologists were performed foraccepted indications compared with 65% ofopen access procedures. Significant patho-logic findings were present in 40% of theformer group compared with 28% of thoseundergoing open-access endoscopy.

44

Overuse

Study Outcome

Trends In Operative Management Of PediatricSplenic Injury In A Regional Trauma SystemDavis, D.H., Localio, A.R., Stafford,P.W., Helfaer, M.A., Durbin, D.R.;2005; Pediatrics

This study used state hospital dischargedata to identify patients <19 years of agewho 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 DepartmentUtilization For Nonurgent Pediatric ProblemsPhelps, K., Taylor, C., Kimmel, S.,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.

Hospitals that specialized in treating pedi-atric trauma were less likely to perform sur-gery for blunt splenic injury. At all types ofhospitals, the rate of surgery was low fromthe years 1991 to 1993, rose in the years1994 to 1997 (more in the less specializedhospitals), and declined to an intermediatelevel from 1998 to 2000.

65% of ED visits in this study were classi-fied as nonurgent by qualified medical per-sonnel.

45

Overuse

Study Outcome

National Trends In The Use Of Antibiotics ByPrimary Care Physicians For Adult PatientsWith CoughMetlay, J.P., Stafford, R.S., Singer,D.E.; 1998; Arch Intern Med

This study analyzed data from serialNational Ambulatory Medical Care Survey(NAMCS) beginning in 1980 to examinenational trends in the prescription of antibi-otics by primary care physicians (PCPs) toadult patients with cough, and to identifyfactors influencing prescription.

Beta-Blocker Dosages And Mortality AfterMyocardial Infarction: Data From A LargeHealth Maintenance OrganizationBarron, H.V,.Viskin, S., Lundstrom,R.J., Swain, B.E., Truman, A.F., Wong,C.C., Selby, J.V.; 1998; Arch InternMed

This study reviewed the clinical records of1165 Northern California Permanentepatients surviving Acute MyocardialInfarction (AMI) to examine a potentialassociation between dosage of beta-blockerreceived at hospital discharge (for MI) andmortality.

Evaluating The Appropriateness Of DigoxinLevel MonitoringCanas, F.,Tanasijevic, M.J., Ma’luf, N.,Bates, D.W.; 1999; Arch Intern Med

This study used a retrospective recordreview to determine the appropriateness ofa random sample of inpatient and outpa-tient digoxin levels at Brigham & Women’sHospital.

The high rate of antibiotic prescription forsymptoms of cough (66%) suggests overuseof antibiotics. However, there is no goldstandard on this topic and the appropriate-ness of prescription may be confounded bythe subjectivity of diagnosis. The percent-age of outpatients receiving antibiotic pre-scriptions for cough increased modestlyfrom 1980 to 1994 (1.05 per year). Overall,antibiotics were prescribed 66% of the timefor adult patients with cough, rising from59% in 1980 to 70% in 1994. Being underage 65, being white, visiting for the firsttime to complain of cough, and being diag-nosed with bronchitis were associated withsignificantly increased odds of prescription.

Large doses of beta-blockers may be over-prescribed, because smaller doses can bejust as effective. Treatment with lowerdoses of beta-blockers (less than 50% of thedose used in RCTs) was associated with atleast as much improvement in survival ashigher doses. In fact, in this study, treat-ment with lower doses resulted in signifi-cantly improved mortality compared withtreatment with higher doses.

Digoxin blood tests are overused. Only 16%of tests on inpatients and 52% in outpa-tients were appropriate. The vast majorityof inappropriate tests (76%) were for earlyroutine monitoring, i.e., a test repeated lessthan 10 days after a previous test for inpa-tients, and less than 10 months for outpa-tients.

46

Overuse

Study Outcome

Understanding Physician Adherence With APneumonia Practice Guideline: Effects OfPatient, System, And Physician FactorsHalm, E.A., Atlas, S.J., Borowsky,L.H., Benzer, T.I., Metlay, J.P., Chang,Y.C., Singer, D.E.; 2000; Arch InternMed

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 InHospitalized Patients: Current Patterns OfMisuse With An Emphasis On TheAntianaerobic Spectrum Of ActivityHecker, M.T., Aron, D.C., Patel, N.P.,Lehmann, M.K., Donskey, C.J.; 2003;Arch Intern Med

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 CareUnit: Understanding The ProblemHoughton, Douglas; 2002; AACN ClinIssuesThis article reviews the literature pertainingto antibiotic resistance and the role ofantibiotic misuse in its development.

Nonadherence occurred in 43.6% of casesand was associated with patient age (>65),gender (male), employment, multilobar dis-ease, or comorbid conditions. PCP involve-ment and increasing physician experiencewith pneumonia management both con-tributed to increased non-compliance.

Antimicrobials were overused in hospital-ized patients, either through prescriptionwhere antibiotics are not necessary, or mis-application of drugs where antibiotics arenecessary. Approximately 30% of the thera-py days were deemed unnecessary.

The overuse and misuse of antibiotics isdangerous and costly. Treatment of nosoco-mial infections are estimated to cost nearly$5 billion per year. While this article is moreof a discussion, it takes the numbers ofpatients in an intensive care unit with noso-comial infections and shows the percentageincrease of antimicrobial resistant pathogenswhich have increased across the spectrumsince 1994-1998.

47

Overuse

Study Outcome

Inappropriate Use Of Emergency MedicalServices Transport: Comparison Of ProviderAnd Patient PerspectivesRichards, J.R., Ferrall, S.J.; 1999; AcadEmerg Med

This study prospectively surveyed patientsand emergency medical services (EMS)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, AndFactors Related To Nonurgent VisitsLiu, 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 EmergencyDepartmentFong, Christina; 1999; Acad EmergMed

This study used a subset of 1994 NationalHospital Ambulatory Medical Care Survey(NHAMCS) data (age <16) to investigatethe overall rate of non-urgent visits was58%, 51% for HMO, 56% for privatelyinsured, and 60% for government insuredpediatric patients.

Inappropriate ambulance use is a significantproblem from both EMS provider andpatient perspectives. Approximately 43% oftransports were not true emergencies,diverting resources from true emergencies.41-50 year olds, whites, men and peoplewithout medical insurance or Medi-Cal aremore likely to use EMS.

54% of ED visits in 1996 were non urgentin nature.

Nonurgent emergency department (ED)visits can lead to inefficient utilization ofresources. Patients with HMOs used theED less often with nonurgent complaintsthan those with private health insurance.While 58% of visits were considered non-urgent, 10% of those visits were HMO-insured patients. Males make up more than50% of the caseload in both urgent and non-urgent care.

48

Overuse

Study Outcome

Parental Use And Misuse Of Antibiotics: AreThere Differences In Urban Vs. SuburbanSettings?Edwards, D.J., Richman, P.B., Bradley,K., Eskin, B., Mandell, M.; 2002; AcadEmerg Med

This was a prospective survey of parents ofchildren 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 NonurgentEmergency Department UseSarver, J.H., Cydulka, R.K., Baker,D.W.; 2002; Acad Emerg Med

This study used 1996 MEPS data to exam-ine whether patient dissatisfaction with theusual source of care (USC) and perceivedaccess difficulties to that USC were associ-ated with nonurgent emergency department(ED) use.

Repeat Patients To The Emergency DepartmentIn A Statewide DatabaseCook, L.J. Knight, S. Junkins, E.P., Jr.Mann, N.C. Dean, J.M. Olson, L.M.;2004; Acad Emerg Med

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.

Parents in both settings are misusing andoverusing antibiotics. However, the misusein suburbia is different from urban misuse.Parents in suburban settings were morelikely to have misused antibiotics for theirchildren. Parents in urban settings weremore likely to seek a prescription frommore than one physician.

Patients are more likely to use the ED fornonurgent visits when they believe thattheir usual source of care is not meetingtheir needs. Most participants reported highlevels of satisfaction with their USC. Accessto care items were also associated withnonurgent ED use.

ED visits increased as the percentage ofpatients using government insuranceincreased. While repeat and serial EDpatients made up one third of patients, theyaccumulated more than 60% of all ED visitsand ED charges.

49

Overuse

Study Outcome

Ineffective Use Of Radiology: The Hidden CostCascade, P.N., Webster, E.W.Kazerooni, E.A.; 1998; AJR Am JRoentgenol

This narrative review describes the extentof overuse of radiologic procedures, andprovides a brief description of the causesand the costs in terms of radiation-induceddeaths.

Long Term Use Of Acid Suppression StartedInappropriately During HospitalizationZink, D.A., Pohlman, M., Barnes, M.Cannon, M.E.; 2005; AlimentPharmacol Ther

This study is a retrospective chart review ofpatients admitted to a general medicineinpatient teaching service to determine theappropriateness of using proton pumpinhibitors (PPI) and Histamine ReceptorAntagonists (H2RA) in inpatient generalmedicine service; to characterize patientsdischarged on PPI/H2RA; and to test thehypothesis that use of PPI/H2RA continuesfor an inappropriately long time.

Diagnosis And Management Of Acute BronchitisKnutson, D., Braun, C.; 2002; Am FamPhysician

This is a general review of the diagnosisand treatment of acute bronchitis.

The authors estimate that 10-30% of diag-nostic radiologic procedures are unneces-sary. They cite self-referral by doctors whoown equipment, fear of litigation and “wor-ried well” as causes. Based on variousassumptions, they hypothesize that thereare 5,540-7,200 radiation-induced deathsper year of in the US. They further esti-mate that 1,108-1,440 severe hereditarydefects 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%).

196 out of 324 (60%) of general medical in-patients on acid-suppression therapy didnot have an appropriate indication for themedication. 67 out of 196 (34%) were dis-charged on the medication with an appro-priate indication. 84% were discharged onPPI, 15% were discharged on H2RA. At 3months, 80% of those available for follow-up (31 out of 39) were still on it inappropri-ately. At 6 months, 50% of those availablefor follow-up (fifteen out of twenty-six)were still on it. Current costs of PPI are$115 per month, generic H2RA costs $35per month, and brand H2RA costs $112month.

The study discusses several studies thatoffer mixed evidence of symptomaticimprovement resulting from antibiotic ther-apy.

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Vulnerable Populations At Risk Of PotentiallyAvoidable Hospitalizations: The Case OfNursing Home Residents With Alzheimer’sDiseaseCarter, M.W., Porell, F.W.; 2005; Am JAlzheimers Dis Other Demen

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 ForEvaluating Patients With Right LowerQuadrant Pain?Safran, D.B., Pilati, D., Folz, E., Oller,D.; 2001; Am J Emerg Med

This is a series of 4 cases to illustrate thecontroversy surrounding the routine use ofcomputed tomography (CT) for suspectedappendicitis.

Overuse Of Parenteral Antibiotics For WoundCare In An Urban Emergency DepartmentWaldrop, R.D. Prejean, C. Singleton,R.; 1998; Am J Emerg Med

This study retrospectively reviewed recordsof 72 patients who received parenteralantibiotics in emergency departments(EDs) for wound care but were not admit-ted, and assessed discrepancy with currentrecommendations derived from the litera-ture.

Dementia patients are at higher risk ofadmission for pneumonia, urinary tractinfection (UTI), and gastroenteritis, butthere is significant variation in ACSCadmissions between nursing homes regard-less of dementia status, suggesting animportant quality issue.

CT scans can prevent avoidable laparotomyin equivocal cases, but routine scanning incases with low likelihood of appendicitiscan, as shown in this report, lead to extend-ed hospitalizations and unnecessary costs.

Antibiotic use in about one-fifth (18%) ofwounds was incorrect according to theguidelines (although the authors themselvesdescribe their criteria as “arbitrary in theface of no accepted consensus among infec-tion disease experts”). Some wounds wereunnecessarily treated with Ceftriaxone andCefazolin.

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An Evidence-Based Clinical Pathway ForBronchiolitis Safely Reduces Antibiotic OveruseWilson, S.D., Dahl, B.B., Wells, R.D.;2002; Am J Med Qual

This study reviewed the charts of 181 chil-dren admitted to an academic hospital andestimated the extent to which antibioticswere overused.

Nesiritide, Not VerifiedTopol, Eric; 2005; N Engl J Med

A perspective piece expressing concernabout the approval and use of nesiritide(recombinant human brain natriuretic pep-tide), a costly vasodilator used in congestiveheart failure (CHF).

Antibiotic Prescribing Practices In A TeachingClinic: Comparison Of Resident And StaffPhysiciansMincey, B.A., Parkulo, M.A.; 2001;South Med J

This study employed a record review of allpatients in an academic practice presentingwith acute sinusitis to determine the rela-tionship between inappropriate antibioticprescribing and years of training.

Patients who were treated according to theevidence-based clinical pathway receivedmore antibiotics than those not treated onthe pathway (9% vs. 35%) and received nosystemic steroids (0% vs. 10%) significantlyless often. The cost of hospitalization wassignificantly less ($2,241 vs. $3,257), lengthof stay was lower (2.09 vs. 2.55 days), andthere was no statistically significant increasein return for unplanned care within 72hours (3.3% vs. 2.7% NS).

The author points out that the drug hasbeen shown to increase mortality by 81% or24% (two different studies) and cause 3times as much deterioration in renal func-tion as placebo. Mild efficacy in decreasingcapillary wedge pressure was shown in onestudy. The author suggests that the drugshould not have been approved, and notesthat it is being heavily marketed.

Residents adopted attending physicians’prescribing behavior over time. In this case,attending physicians’ behavior was morelikely to be wasteful. First- and second-yearresidents were significantly more likely toprescribe narrow spectrum antibiotics foracute sinusitis (56%) compared with attend-ing physicians (34%).

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Association Between Medication Supplies AndHealthcare Costs In Older Adults From AnUrban Healthcare SystemStroupe, K.T,. Murray, M.D., Stump,T.E., Callahan, C.M.; 2000; J AmGeriatr Soc

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 WomenWith A Cytological Diagnosis Of AtypicalSquamous Cells Of Undetermined Significance(ASCUS)?Lousuebsakul, V., Knutsen, S.M.,Singh, P.N., Gram, I.T.; 2003; JWomen’s Health (Larchmt )

This study evaluated a cohort of 651women with a Pap diagnosis of atypicalsquamous cells of undetermined signifi-cance (ASCUS) who received follow-up toanalyze determinants of the type of follow-up received (colposcopic biopsy v. repeatPap).

The Impact Of Drug Coverage On COX-2Inhibitor Use In MedicareDoshi, J.A., Brandt, N., Stuart, B.;2004; Health Aff (Millwood)

Data from the 2000 Medicare CurrentBeneficiary Survey were used to assess theimpact of drug coverage on COX-2 inhibitoruse among elderly people with osteoarthri-tis, taking into account risk for adverse gas-trointestinal events.

16% had an under-supply and 47% had anover-supply of medications. Both over-andunder-supply resulted in an increasedchance of emergency room visits and hospi-tal admission.

Women with high income, private insur-ance, and women aged 36-45 were morelikely to undergo colposcopic biopsy for fol-low-up of ASCUS. In a multivariate model,women with income greater than approxi-mately $47,000 had an 8.5 times higherodds 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-upby colposcopic biopsy than women withMedicaid. Women ages 36-45 had 3.1 timesgreater odds of follow-up by colposcopicbiopsy than women older than 55.

Among patients with the most generouscoverage, gastrointestinal risk had no inde-pendent effect on whether patients wereprescribed this class of medications. Drugusage was higher in Medicare beneficiarieswith coverage compared with no coverage.COX-2 use was twice as high in those withthe most generous coverage compared withno third-party coverage. Among patientswith the most generous coverage, patientswith increased gastrointestinal risk are nomore likely to be prescribed COX-2inhibitors.

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Study Outcome

Acetaminophen Overuse In The Ohio MedicaidPopulationHeaton, P.C., Cluxton, Jr., R.J.,Moomaw, C.J.; 2003; J Am PharmAssoc (Wash DC )

This was a retrospective review of OhioMedicaid claims data to examine potentialacetaminophen overuse in patients with andwithout risk factors for hepatotoxicity.

Preventable Hospitalization Among ElderlyMedicare Beneficiaries With Type 2 DiabetesNiefeld, 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 PotentiallyInappropriate Prescribing Among AmbulatoryOlder Patients In The Year 2001: ComparisonOf Three Explicit CriteriaViswanathan, H., Bharmal, M.,Thomas, III, J.; 2005; Clin Ther

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.

A relatively small, but significant, numberof patients were prescribed doses of aceta-minophen that were too high. 3% ofpatients were prescribed an average dose ofacetaminophen greater than or equal to4g/day or greater than or equal to 3g/daywith an ICD-9 code suggesting liver dys-function.

7% of all hospitalizations in this cohort wereavoidable.

13.4% of patient visits involved PIMs basedon the 2002 Beers criteria (and 4.2% visitsinvolved PIMs based on the Zhan criteria).Factors associated with receiving a PIMincluded: a visit occurring in a metropolitanarea, and a visit receiving higher number ofmedications during a single visit.

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Study Outcome

Nonurgent Pediatric Emergency DepartmentVisits: Care-Seeking Behavior And ParentalKnowledge Of InsuranceDoobinin, K.A.,Heidt-Davis, P.E.,Gross, T.K., Isaacman, D.J.; 2003;Pediatr Emerg Care

This study surveyed 251 parents of childrenattending a pediatric emergency depart-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.

Income, Race, And PreventableHospitalizations: A Small Area Analysis InNew 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 PreventableHospitalizations Among The ElderlyCuller, S.D., Parchman, M.L.,Przybylski, M.; 1998; Med Care

This study examined inpatient claims datafrom Medicare beneficiaries in order toexamine what factors are associated withhaving a hospitalization due to an ambulato-ry care-sensitive condition.

The primary reason chosen by the parentfor the ED visit was convenience (62.8% ofcases). 38.7% stated that they were educat-ed as to what problems are consideredemergencies by their insurance. ED refer-rals for nonurgent complaints are requiredby the insurance carrier for 74.9%, but only37.2% of the parents said referrals were nec-essary.

High rates of preventable hospitalizationswere associated with low income and race.

Higher odds of preventable hospitalizationswere 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. Factorsassociated with lower odds included: havingattended college, or having only Medicareinsurance coverage.

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Study Outcome

Pap Screening In A U.S. Health PlanInsinga, R.P., Glass, A.G., Rush, B.B.;2004; Cancer Epidemiol BiomarkersPrev

This study analyzed claims data from150,052 female members of KaiserPermanente Northwest to estimate compli-ance with U. S. Preventive Services TaskForce guidelines for cervical cancer screen-ing.

Inappropriate Prescribing For ElderlyOutpatientsAparasu, R.R., Sitzman, S.J.; 1999; AmJ Health Syst Pharm

This study extracted data from the 1994National Hospital Ambulatory Medical CareSurvey (NHAMCS) to determine: (1) thefrequency of potentially inappropriate pre-scribing for elderly outpatients; and (2) fac-tors predicting inappropriate prescribing.

Nosocomial Infections In The ICU: The GrowingImportance Of Antibiotic Resistant PathogensWeber, D.J., Raasch, R., Rutala, W.A.;1999; Chest

This article reviews the literature concern-ing nosocomial infections in intensive careunits.

Of the enrolled women, 31% received a Papsmear in 1998. The highest utilization rateswere among 25-29 year olds, of whom 62%received a Pap smear in 1998. Ratesdeclined with increasing age: 26% of 65-69year old women received a Pap smear in1998. Of women who were routinelyscreened during the follow-up period, 36%received annual smears, 22% received bien-nial smears, and 13% received triennialsmears. This study, using administrativedata, found lower utilization rates than simi-lar studies using self-report.

Potentially inappropriate medications wereprescribed at 4.45% of elderly outpatientvisits involving medications. Patients weremore likely to be given potentially inappro-priate medications if they had beenreferred; had a number of medications pre-scribed; had a prescription for certain typesof medications; or had a medication pre-scribed by a provider from a nonmetropoli-tan area.

Studies have shown that patients infectedwith resistant strains of bacteria are morelikely than control patients to have previ-ously received antimicrobials, and hospitalareas that have the highest prevalence ofresistance also have the highest rates ofantibiotic use. Additional interventionsinclude hand washing and surveillance pro-tocols, isolation measures, and occupationalhealth services for employees.

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Study Outcome

Inappropriate Medication Prescribing InHomebound Older AdultsGolden, A.G., Preston, R.A., Barnett,S.D., Llorente, M., Hamdan, K.,Silverman, M.A.; 1999; J Am GeriatrSoc

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 ForOsteoarthritis Of The KneeMoseley, J.B., O’Malley, K., Petersen,N.J., Menke, T.J., Brody, B.A.,Kuykendall, D.H., Hollingsworth, J.C.,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.

9.9% of prescriptions were inappropriate.39.7% of the residents had at least one inap-propriate prescription. Inappropriate drugsincluded: temazepam and zoldipem.

Arthroscopic lavage or debridement was nomore effective than a placebo procedure onpain or function. At 1-and 2-year follow-up,mean pain scale scores were not significant-ly different in the three groups.

57

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Study Outcome

Patterns And Correlates Of Local Therapy ForWomen With Ductal Carcinoma-In-SituKatz, S.J., Lantz, P.M., Janz, N.K.,Fagerlin, A., Schwartz, K., Liu, L.,Deapen, D., Salem, B., Lakhani, I.,Morrow, M.; 2005; J Clin Oncol

This study interviewed 659 patients withDuctal 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 ForPrescription Drug Benefit PlansFischer, M.A., Avorn, J.; Economic2003; Health Serv Res

This study used 2000 state-level Medicaiddata to estimate the rate of underuse ofgeneric drugs and calculate potential costsavings.

Support Of Evidence Based Guidelines For TheAnnual Physical Examination: A Survey OfPrimary Care ProvidersProchazka, A.V., Lundahl, K., Pearson,W., Oboler, S.K., Anderson, R.J.; 2005;Arch Intern Med

This study used a mailed survey to assessthe attitudes of 783 primary care physiciansregarding annual physical exams.

Only 14% of patients at lowest risk of recur-rence received a mastectomy comparedwith 22.8% and 52.6% of patients at inter-mediate and highest risk. Between-site dif-ferences in receipt of radiation after breastconserving surgery (BCS) were consistentwith patient recall of surgeon discussionsabout treatment.

In 2000, Medicaid could have savedbetween $229 and $450 million dollars ifgeneric drugs were used instead of thebrand-name versions of the same agents.The majority of the unrealized savings wereconcentrated in a small group of medica-tions, including clozapine, alprazolam, andlevothyroxine.

Despite evidence to the contrary, 65% feltthat an annual exam was necessary, 55% dis-agreed with evidence that exams wereunnecessary, and 88% perform annualexams and screenings, including CBC, UA,lipid panel, glucose, and mammography.

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Study Outcome

Distributional Issues In The Analysis OfPreventable HospitalizationsDeLia, D.; 2003; Health Serv Res

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 NoninvasiveDiagnostic ImagingWeiner, S.N., Komarow, M.; 2005;Manag Care Interface

This study compared imaging ratesbetween 2 plans that adopted proprietaryimaging management systems and 2unmanaged plans in the same geographicarea.

Safety And Cost-Effectiveness Of EarlyDischarge After Primary Angioplasty In Low-Risk Patients With Acute Myocardial Infarction.PAMI-II Investigators. Primary Angioplasty InMyocardial InfarctionGrines, C.L., Marsalese, D.L., Brodie,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.

ACS admissions are geographically concen-trated and have increased to 12.2% of alladmissions.

Utilization rates for nuclear imaging were 2-3 times higher in unmanaged plans. PETrates were comparable, and computedtomography (CT) rates 30% higher inunmanaged plans. Utilization Managementconsisted of both review and facility cre-dentialing.

Low-risk patients treated with PTCA ran-domized to an accelerated hospital coursedid not have inferior outcomes to thosetreated traditionally. The acceleratedapproach reduced hospital costs by $2,000per patient.

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Study Outcome

The Cost-Effective Use Of Nebulized RacemicEpinephrine In The Treatment Of CroupThomas, L.P., Friedland, L.R.; 1998;Am J Emerg Med

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 MayImprove Patient Satisfaction With AppropriateAntibiotic UsePhillips, T.G., Hickner, J.; 2005; J AmBoard Fam Pract

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 TestsDuring Routine Preventive Health ExamsMerenstein, D., Daumit, G.L., Powe,N.R.; 2006; Am J Prev Med

This study compared data from 1997 to2002 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.

Several ED medical directors (7/23, 30%)responded that they would automaticallyadmit a child with croup despite recentstudies suggesting safe discharge to home ispossible.

26% of those that were told they had bron-chitis were dissatisfied with their treatment,compared with 13% and 17% for colds andviral illness, respectively. Educationalattainment, age, and gender did not affectsatisfaction rates.

Tests for which there is no documented evi-dence were routinely ordered during annualpreventive health exams (43% of the time).The frequency of ordering specific testsranged from 7% to 37% of visits for x-raysand urinalysis, respectively.

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Cervical Cancer Screening Among WomenWithout A CervixSirovich, B.E., Welch, H.G.; 2004;JAMA

This study used behavioral risk factor surveillance system (BRFSS) and nationalimmunization survey (NIS) data to estimatethe number of women with a history of hys-terectomy who reported a current Papsmear.

Excessive Antibiotic Use For Acute RespiratoryInfections In The United StatesGonzales, R., Malone, D.C., Maselli,J.H., Sande, M.A.; 2001; Clin Infect Dis

This study used data from the 1998National Ambulatory Medical Care Survey(NAMCS) to estimate primary care officevisits and antibiotic prescription rates foracute respiratory infections.

Trends In Antimicrobial Prescribing Rates ForChildren And AdolescentsMcCaig, L.F., Besser, R.E., Hughes,J.M.; 2002; JAMA

This study used physician providedNational Ambulatory Medical Care Survey(NAMCS) data to assess antibiotic prescrib-ing rates for respiratory infections in chil-dren < age 15.

The proportion of women who had under-gone a hysterectomy and reported a Papsmear in the prior 3 years did not changeover the course of the study. In both 1992(before the U.S. Preventive Services TaskForce recommendation) and 2002 (after therecommendation), approximately 69% ofhysterectomized women reported havingundergone a recent Pap smear. The authorsestimate that 10 million women, or half ofall women who have undergone hysterecto-my, are receiving Pap smears unnecessarily.

In 1998, antibiotic prescriptions in excess ofexpectations amounted to 55% of all antibi-otics prescribed for acute respiratory infec-tions. Associated costs of this unnecessaryprescription totaled approximately $726million.

Although the average annual rate of antibi-otic prescription for children and adoles-cents decreased from 838 per 1,000 in 1989to 503 per 1,000 in 1999, the authors con-clude that it is important to continue effortsto improve appropriate antimicrobial pre-scribing.

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Study Outcome

Desire For Antibiotics And AntibioticPrescribing For Adults With Upper RespiratoryTract InfectionsLinder, J.A., Singer, D.E.; 2003; J GenIntern Med

This is a prospective cohort study in adultswith 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 ProlongedHospitalizations On A General MedicineTeaching ServiceCarey, M.R., Sheth, H., Braithwaite,R.S.; 2005; J Gen Intern Med

This study collected data from 16 seniorresidents 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 AcuteCystitis On Unnecessary Antibiotic UseMcIsaac, W.J., Low, D.E., Biringer, A.,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.

39% of adults seeking care for upper respi-ratory tract infections wanted antibiotics,which is less than in previous studies.Predictors of wanting antibiotics were priorantibiotic use and current smoking.Wanting antibiotics was an independentpredictor of antibiotic prescribing.

13.5% of all hospital days were judgedunnecessary for acute inpatient care andoccurred because of delays in needed serv-ices. The majority of nonmedical servicedelays were due to difficulty finding a bedin a skilled nursing facility. Medical servicedelays were more common on weekenddays.

Empiric antibiotic use without testing fornitrites and pyuria increases antibiotic usage41%.

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Study Outcome

Antibiotic Use For Upper Respiratory TractInfections: How Well Do Pediatric ResidentsDo?Nambiar, S., Schwartz, R.H., Sheridan,M.J.; 2002; Arch Pediatr Adolesc Med

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 UpperRespiratory Tract Infections For Children InDay 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 ChemotherapyTreatment For Cancer Patients?Jacobson, M., O’Malley, A.J., Earle,C.C., Pakes, J., Gaccione, P.,Newhouse, J.P.; 2006; Health Aff(Millwood)

This study sought to determine if physicianreimbursement rates for chemotherapydrugs affected the frequency of usingchemotherapy in metastatic cancer patientsduring 1995 and 1998.

Residents’ knowledge of the guidelinesincreased with level of training, from 16%(first year) to 36% (second year) to 50%(third/fourth year).

Staff does not influence parental care seek-ing.

A physician’s decision to administerchemotherapy to metastatic cancer patientswas not measurably affected by higherreimbursement. Providers who were moregenerously reimbursed, however, prescribedmore costly chemotherapy regimens tometastatic breast, colorectal, and lung can-cer patients.

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Study Outcome

Trends In Antibiotic Prescribing For Adults InThe United States—1995 To 2002Roumie, C.L., Halasa, N.B., Grijalva,C.G., Edwards, K.M., Zhu, Y., Dittus,R.S., Griffin, M.R.; 2005; J Gen InternMed

This study used data from the NationalAmbulatory Medical Care Survey(NAMCS) to estimate the impact of effortsto limit antibiotic prescribing in adults.

Measuring The Quality Of Care For Group AStreptococcal Pharyngitis In 5 US Health PlansMangione-Smith, R. Elliott, M.N. Wong,L., McDonald, L., Roski, J.; 2005; ArchPediatr Adolesc Med

This study used claims data from 5 healthplans 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 NegativeRelationship Between Physician Supply AndHospitalization For Ambulatory Care SensitiveConditionsLaditka, J.N., Laditka, S.B., Probst,J.C.; 2005; Health Serv Res

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.

From 1996 to 2002, the percentage of out-patient visits resulting in an antibiotic pre-scription decreased from 18% to 15%. Thereduction was completely attributable to adecrease in antibiotic prescription for acuterespiratory infections (ARIs). However, thepercentage of broad-spectrum antibioticsprescribed for ARIs increased from 41% to77%.

There is substantial variability in GAS test-ing rates between health plans. Overall, therate of GAS testing was 74%, but rangedfrom 59% to 83% among the 5 health plansstudied. Rates of antibiotic prescription alsovaried tremendously by health plan, rangingfrom 9% to 61%.

In urban settings, increased physician sup-ply was associated with lower rates ofpotentially preventable hospitalizations. Inrural areas, there was no associationbetween physician supply and potentiallypreventable hospitalizations.

64

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Study Outcome

Is Routine Postoperative Chest RadiographyNeeded After Open Nephrectomy?Latchamsetty, K.C., La Rochelle, J.C.,Hoeksema, J., Coogan, C.L.; 2005;Urology

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 VersusMagnetic Resonance Imaging In The DiagnosisOf Meniscal Tears And Anterior CruciateLigament RuptureKocabey, 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 ToClear Cervical Spines In Blunt TraumaPatients With Normal Computed TomographicResults And No Motor DeficitsSchuster, 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.

Of the 150 patients undergoing nephrecto-my, 92 (61%) underwent postoperativeCXR, and 4 of these had a pneumothorax.Only 1 of these 4 needed a chest tube.

There was no statistical difference betweenMRI and clinical examination in diagnosingmeniscal or anterior cruciate ligamentinjuries suggesting overuse of MRI.

Out of the 93 patients with no motordeficits, a negative CT, and persistent cervi-cal pain, none had evidence of fracture onMRI.

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Study Outcome

Health Insurance, Neighborhood Income, AndEmergency Department Usage By Utah Children1996-1998Suruda, A., Burns, T.J., Knight, S.,Dean, J.M.; 2005; BMC Health ServRes

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 OfCancerDillman, R.O., Chico, S.; 2000; Eff ClinPract

In this study, records of newly diagnosedbreast cancer patients were retrospectivelyreviewed to determine the frequency withwhich radiologic tests are used in womenwith newly diagnosed breast cancer and theyield of such tests in these patients.

Analysis Of Medication Use Patterns: ApparentOveruse Of Antibiotics And Underuse OfPrescription Drugs For Asthma, Depression AndCHFGilberg, K.; 2003; J Manag Care Pharm

This study used claims data from 3California Managed Care Organizations(MCOs) to assess the appropriateness ofprescription medication use based uponguidelines for various conditions.

The majority of usage for Medicaid anduninsured children (65%) was for non-trau-matic conditions. Children with Medicaidhad approximately 50% greater ED utiliza-tion rates than children with commercialhealth insurance or uninsured children.

A total of 1,910 radiologic tests, including646 bone scans, 637 chest radiographs, and627 other tests, were obtained in 1,167patients with a known TN status.Radiologic tests were performed in 42% ofpatients with carcinoma in situ, but none ofthe 183 tests detected metastases. 828 radi-ologic tests were performed in patients whowere classified as having stage I disease onthe basis of TN criteria. Only 3 of thesetests (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.

Of patients with cold or upper respitoryinfection (URIs), conditions for whichantibiotics are not indicated, 35.7% receivedanitbiotics.

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Study Outcome

The Cost Of Antibiotics In Treating UpperRespiratory Tract Infections In A MedicaidPopulationMainous, A.G., III Hueston, W.J.; 1998;Arch Fam Med

This study examined Kentucky Medicaidclaims in order to examine the use and costof the nonindicated antibiotics for upperrespiratory tract infections (URIs).

Prescribing Potentially InappropriatePsychotropic Medications To The AmbulatoryElderlyMort, 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.

60% of outpatient episodes and 48% ofemergency department episodes resulted inan antibiotic prescription being filled. Inoutpatient settings, secondary diagnoses ofeither otitis media or acute sinusitisaccounted for less than 6% of the episodesthat resulted in an antibiotic prescriptionbeing filled. The most frequently filledantibiotic was amoxicillin, although second-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.

Potentially inappropriate psychotropicagents were overused (27.2% of visitsinvolving psychotropics).

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Resource Utilization Of Patients WithHypochondriacal Health Anxiety AndSomatizationBarsky, A.J., Ettner, S.L., Horsky, J.,Bates, D.W.; 2001; Med Care

876 patients attending an academic primarycare 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 ResonanceImaging As A Diagnostic Screening Tool InPatients With Chronic Shoulder PainBradley, M.P., Tung, G., Green, A.;2005; J Shoulder Elbow Surg

This study examined 101 patients withchronic shoulder pain to see if magnetic res-onance imaging (MRI) done before beingevaluated by a shoulder specialist improvedoutcomes.

Musculoskeletal Imaging In Physical TherapistPracticeDeyle, Gail; 2005; J Orthop Sports PhysTher

This article reviews literature pertinent toevidence-based use of diagnostic imagingand overuse of imaging for musculoskeletalconditions.

Patients with healthcare-related anxiety usemore services than those without it. Thestudy found that patients with hypochon-dria or somatization have more outpatientvisits (approximately 9 vs. 6), more outpa-tient costs (approximately $1,300 vs. $950),and greater likelihood of hospitalization(24% vs. 17%) than others.

The study concludes that MRI is overused,based on two main outcomes: (1) Therewere no differences (in age, sex, insurancestatus, range of motion, or mechanism ofinjury) among patients who received a pre-evaluation MRI and those who did not. (2)There was no difference in outcomesbetween patients who did or did not have apre-evaluation MRI. The first outcomecould 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.

This paper suggests that physical therapistsuse 50% less imaging than physicians inlow-back-pain patients.

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Current Antibiotic Therapy For IsolatedUrinary Tract Infections In WomenKallen, A.J, Welch, H.G, Sirovich, B.E.;2006; Arch Intern Med

This study used data from 2000-2002National Hospital Ambulatory Medical CareSurvey (NHAMCS) to estimate the rate ofantibiotic prescribing for women with isolat-ed uncomplicated urinary tract infections(UTIs).

Unnecessary Cesarean Delivery In Louisiana:An Analysis Of Birth Certificate DataKabir, A.A., Steinmann, W.C., Myers,L., Khan, M.M., Herrera, E.A., Yu, S.Jooma, N.; 2004; Am J Obstet Gynecol

This study used the Louisiana birth certifi-cate database to determine temporal trendsand factors that are associated withCesarean deliveries and potentially unnec-essary Cesarean deliveries.

Geographic Variation In PreventableHospitalizations Of Older Women And Men:Implications For Access To Primary HealthCareLaditka, S.B. Laditka, J.N.; 1999; JWomen Aging

This study reviewed hospital discharge datain five upstate New York counties todemonstrate how readily available data andsmall area analysis can be used to identifypotential problems of access to primary careservices for older women and men.

The study found that quinolones were pre-scribed more commonly than sulfa drugs forisolated outpatient UTIs, despite recom-mended guidelines. The former were pre-scribed for 44% of UTIs compared with30% for the latter, and nitrofurantoin for18%. There were few significant predictorsof quinolone use, and more frequentquinolone prescription (e.g., in theNortheast) did not reflect geographicallyhigher rates of sulfa-resistant organisms.

The average potentially unnecessary pri-mary and repeat Cesarean deliveries were17 and 43, respectively, per 100 cesareandeliveries. The primary Cesarean deliveryrate decreased and the repeat Cesareandelivery rate increased during the study.But neither the absence nor the presence ofpotential risk factors accounted for thesechanges.

Using hospital discharge data, 5 county and24 intracounty areas in Upstate New Yorkare studied. There is significant variation inpreventable hospitalization within counties.Areas having significantly higher rates ofthese hospitalizations tend to have higherrates for both women and men. Problems ofaccess are associated with lower incomeareas for women and men.

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Estimating The Proportion Of UnnecessaryCesarean Sections In Ohio Using BirthCertificate DataKoroukian, S.M., Trisel, B., Rimm,A.A.; 1998; J Clin Epidemiol

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 AndVisit Duration In Adults With UpperRespiratory Tract InfectionsLinder, 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? TheInfluence Of Community Radiologists’ MedicalMalpractice Perceptions And Experience OnScreening MammographyElmore, J.G. Taplin, S.H., Barlow,W.E., Cutter, G.R., D’Orsi, C.J.,Hendrick, R.E., Abraham, L.A., Fosse,J.S., Carney, P.A.; 2005; Radiology

This study surveyed radiologists who inter-pret mammograms to determine whetherthe 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.

Using the authors’ methods, nearly 40% ofrepeat C-sections had no documentedabnormalities on the birth certificate to jus-tify a C-section.

Antibiotic use was marginally associatedwith a shorter visit duration (0.7 minutesshorter).

There was no correlation between concernabout or experience of malpractice andhigher rates of re-examination; howevermore than half of the radiologists (59%)reported that concerns about malpracticeclaims increased their rate of recommenda-tion for breast biopsies, and 76% expressedconcern about the impact of malpractice onmammography practice. About one-thirdwere considering withdrawing from inter-pretation of mammograms.

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How Are Age And Payors Related To AvoidableHospitalization Conditions?Guo, L., MacDowell, M., Levin, L.,Hornung, R.W., Linn, S.; 2001; ManagCare Q

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 AndThe Role Of The Emergency DepartmentMalone, Ruth E.; 1998; J Health PolitPolicy Law

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 PediatricRespiratory Tract Infections: Clinical ChallengesJacobs, M.R., Dagan, R.; Antimicrobial;2004; Semin Pediatr Infect Dis

This study reviews the literature pertinentto the development of antibiotic resistanceamong upper respiratory infection (URI)pathogens and discusses both the overuseof antibiotics and the inadequate dosing ofantibiotics.

This study demonstrates that age andage/gender adjustments for AHC are need-ed for privately insured and Medicarepatients while additional adjustment forcommunity characteristics is needed forMedicaid and self-pay patients.

70% of heavy ED users were either home-less or sufficiently poor or disabled to quali-fy for government assistance.

The challenge for rational antibiotic use isto determine which patients can be treatedconservatively and which require antimicro-bial intervention. Different antibiotics arediscussed. The pneumococcal vaccine intro-duced in 2000 has not had a major impacton decreasing antimicrobial resistance.

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Triage Services: A Profile Of High UtilizationBerg-Weger, M., Gockel, J. Rubio,D.M., Douglas, R.; 1998; Soc WorkHealth Care

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 OnPrimary And Repeat Cesarean Rates AmongU.S. Department Of Defense Health CareBeneficiaries In Military And CivilianHospitals Worldwide, 1999-2002Linton, A., Peterson, M.R.; 2004; Birth

This study used Department of Defense(DOD) hospital records for 365,648 single-ton deliveries to assess the impact of enroll-ment in TRICARE prime, the department’smanaged care plan, on C-section rates.Rates among TRICARE Prime beneficiar-ies were compared to those for non-Primebeneficiaries.

Antibiotic Prescribing Rates In The USAmbulatory Care Setting For PatientsDiagnosed With Influenza, 1997-2001Ciesla, G., Leader, S., Stoddard, J.;2004; Respir Med

This study used National AmbulatoryMedical 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.

Factors associated with high utilization ofambulatory care triage clinic servicesinclude: patient perception of health status;number of prescription medications; andsocial needs.

The study found that primary C-sectionrates were significantly lower for TRICAREPrime enrollees when compared to non-TRICARE Prime enrollees. No significantdifferences in repeat C-section rates werefound. Primary and repeat C-section rateswere lower in military hospitals than incivilian hospitals.The study suggests that tolower C-section rates (which shoulddecrease morbidity and decrease costs) weneed to understand better why differenthealth care plans have different C-sectionrates. Patients under the TRICARE Primehealth plan had lower primary C-sectionrates, but it is not clearly understood why.

Antibiotic prescribing for influenza is wide-spread; 38% of visits where the diagnosis ofinfluenza was made led to an antibiotic pre-scription of which one-third were for broadspectrum antibiotics. Inappropriate antibi-otics cost $18.5 million annually and maycontribute to resistance.

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Study Outcome

Regional Air Transport Of Burn Patients: ACase For Telemedicine?Saffle, J.R., Edelman, L., Morris, S.E.;2004; J Trauma

225 cases of patients transported by air forburn injuries were reviewed to determine iftelemedicine could have been used to assistin evaluation and treatment of burnpatients.

Improving Quality Through IdentifyingInappropriate Care: The Use Of Guideline-Based Utilization Review Protocols In TheWashington State Workers’ Compensation SystemWickizer, T.M., Franklin, G., Gluck,J.V., Fulton-Kehoe, D.; 2004; J OccupEnviron Med

This study examined patterns of deniedrequests through an analysis of the 100,005utilization 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 OrganizationsOn Cost And Utilization Of HysterectomiesCurrier, C.A., Smith, D.G., Wheeler,J.R., Hirth, R.A., Walker, D.S.; 2004;Nurs Econ

This study used claims data to comparehysterectomy rates for beneficiaries ofemployer sponsored PPO and indemnityplans between 1988 and 1990.

In 92 out of 225 cases, overestimation orunderestimation of burn size by referringphysicians or performance of endotrachealincubation suggested that telemedicineevaluation before transport might have sig-nificantly altered transport decisions or care.

The authors conclude that their programshows that “guideline-based utilizationreview protocols” can be used to identifyinappropriate care, and improve quality.When “guideline-based review criteria”were used during a utilization review, denialrates were 7.9%. When “proprietary reviewcriteria” were used, denial rates were 4.9%.When “other criteria” were used, denialrates were 1.8%.

Utilization rates among PPO participantswere lower for TAH and (12% lower) forvaginal hysterectomy, suggesting overuse ofthese procedures in indemnity plan benefi-ciaries.

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Radiograph Use In Low Back Pain: A UnitedStates Emergency Department DatabaseAnalysisIsaacs, D.M., Marinac, J., Sun, C.;2004; J Emerg Med

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 BronchitisAt An Academic Teaching ClinicHall, K.K., Philbrick, J., Nadkarni, M.;2003; Am J Med Sci

This study examined the medical records of160 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 MildTo Moderate Pediatric Trauma: Are WeOverusing It?Jindal, A. Velmahos, G.C. Rofougaran,R.; 2001; World J Surg

A retrospective case control study thatexamined 102 cases of pediatric trauma todetermine if children with mild to moderatetrauma are evaluated by more computedtomography (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.

Based upon published guidelines, the studyidentified over 3 million patients withuncomplicated low back pain, of whom17.8% received an unnecessary radiograph.

66% of patients diagnosed with bronchitisreceived an antibiotic. Increasing age, puru-lent cough, abnormal exam, and comorbidi-ties were associated with higher likelihoodof antibiotic use. Smoking, duration ofsymptoms, gender, and race did not predictantibiotic use.

Comparing pediatric and adult traumapatients the number of patients who need-ed CT scans were equal. More CT scanswere done in pediatric patients, due tomore pediatric patients receiving scans ofmultiple body areas. The higher number ofCT scans did not improve outcomes sincethey did not identify more injuries, and didnot decrease morbidity, mortality, length ofhospital or length of ICU stay.

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Overuse Of Acid-Suppressive Therapy InHospitalized PatientsNardino, R.J., Vender, R.J. Herbert,P.N.; 2000; Am J Gastroenterol

A chart review of 226 patients admitted tothe general adult wards to determine thefrequency of use and indications of acid-suppressive mediations, and to determine ifpatients who were prescribed them forstress ulcer prophylaxis were also prescribedthem on discharge.

Patient Characteristics And Patterns Of Use ForLumbar Patient Characteristics And Patterns OfUse For Lumbar Spine Radiographs: ResultsFrom The Veterans Health StudySelim, A.J., Fincke, G., Ren, X.S.Deyo, R.A., Lee, A., Skinner, K., Kazis,L.; 2000; Spine

To identify patient characteristics that pre-dict different patterns in the use of lumbarspine X-rays, a prospective cohort studyover 12 months of 401 patients who presentto Veterans Administration clinics for low-back pain.

At this hospital, acid-suppressant medica-tions were inappropriately used among out-patient adults and inpatients. The studyfound that among patients who entered thehospital already on acid-suppressant med-ications, 54% were deemed to be takingthem unnecessarily. Among patients whobegan acid-suppressant medication duringtheir hospitalization, 75% of these caseswere deemed unnecessary. When thesemedications were started during a hospital-ization, 55% of low-risk patients were dis-charged with a prescription for these med-ications.

Lumbar X-rays for low-back pain are over-used in patients who scored worse on sur-veys of mental health. The study found thathigher rates of new lumbar spine X-rayswere associated with both physical examand psychological factors. Higher rates ofrepeat lumbar spine X-rays were associatedwith worse mental health, but they werenot associated with worse physical health.There was no association between patternsof X-ray use and the following factors: age,income, education, alcohol or drug use, ornumber of medical and mental conditions.

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Healthcare Utilization And Referral Patterns InThe Initial Management Of New-Onset,Uncomplicated, Low Back Workers’Compensation Disability ClaimsTacci, J.A., Webster, B.S., Hashemi, L.,Christiani, D.C.; 1998; J OccupEnviron Med

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 OfAntipsychotic Use In Residential Treatment: AFour-State ComparisonRawal, P.H., Lyons, J.S., MacIntyre,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:What Do They Really Expect?Haltiwanger, K.A. Hayden, G.F. Weber,T. Evans, B.A. Possner, A.B.; 2001; JAm Coll Health

129 university students with upper respira-tory symptoms were evaluated to determineif receiving an antibiotic prescription influ-enced patients’ satisfaction with visits to aclinician.

The study found that urgent care and emer-gency rooms were used more than what isprobably indicated: only 56% of patientssaw their primary care physician first.Specialist care was provided more common-ly than would be expected: 36% were seenby specialists. Referral to specialists wasmade sooner than expected: the median forreferrals was 13 days.

There was significant regional variation. Ofthe children taking antipsychotic medica-tion, 42.9% had no history of or current psy-chosis.

A clear diagnosis, an explanation of therationale for treatment, and an antibioticprescription were significantly associatedwith patient satisfaction. Clinicians pre-scribed an antibiotic for 36% of the stu-dents.

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Infantile Hypertrophic Pyloric Stenosis: DelaysIn Diagnosis And Overutilization Of ImagingModalitiesAbbas, A.E., Weiss, S.M., Alvear, D.T.;1999; Am Surg

This study is a retrospective chart review of93 patients with infantile hypertrophicpyloric stenosis (IHPS) to determine ifunnecessary and redundant diagnostic stud-ies were done and to propose an algorithmfor the management of patients with sus-pected IHPS.

Propensity Of HIV Patients To Seek Urgent AndEmergent Care. HIV Cost And ServicesUtilization Study ConsortiumGifford, A.L., Collins, R., Timberlake,D., Schuster, M.A., Shapiro, M.F.,Bozzette, S.A., Kanouse, D.E.; 2000; JGen Intern Med

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 SuspectedTuberculosis In A New York City HospitalGriffiths, R.I., Hyman, C.L.,McFarlane, S.I., Saurina, G.R.,Anderson, J.E., O’Brien, T,. Popper, C.,McGrath, M.M., Herbert, R.J., Sierra,M.F.; 1998; Infect Control HospEpidemiol

This study analyzed 151 adult admissionsfor suspected Tuberculosis (TB) at oneNew York hospital, in order to compareresource use by diagnostic outcome.

Many patients who had the diagnosis con-firmed on physical exam underwent unnec-essary studies. Unnecessary studies wereassociated with delay in diagnosis, and pos-sibly with adverse health problems. Theauthors propose an algorithm to decreasethis waste; if there is clinical suspicion ofpyloric stenosis, the first step is promptreferral to a pediatric surgeon or an “experi-enced physician,” before doing testingwhich may be unnecessary.

Many patients reported that they would usethe Emergency Department (ED) insteadof same-day primary care for several com-mon symptoms of HIV disease. AfricanAmericans, the poor, and patients with psy-chological symptoms were more likely tosay they would use the ED.

Admissions without culture-proven TBaccounted for 36% of the days of TB isola-tion, and for 65% of the days of anti-TBtreatment. The vast majority of resourceconsumption occurred during the diagnosticperiod before a definitive culture result wasknown.

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Preventive Pharmacologic Therapy AmongAsthmatics Five Years After Publication OfGuidelinesJatulis, D.E., Meng, Y.Y., Elashoff,R.M., Schocket, A.L., Evans, R.M.,Hasan, A.G., Legorreta, A.P.; 1998;Annals of Allergy, Asthma, &Immunology

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?Prostate Cancer Diagnosis And PSA ScreeningPatterns For A Single Veterans Affairs MedicalCenterRichter, F., Dudley, A.W., Jr. Irwin,R.J., Jr. Sadeghi-Nejad, H.; 2001; JCancer Educ

This study retrospectively reviewed com-puterized records of a Veterans AffairsMedical Center (VAMC) to estimate theappropriateness of Prostate-SpecificAntigen (PSA) testing.

Analysis Of Chronic Emergency Department UseBond, T.K., Stearns, S., Peters, M.;1999; Nurs Econ

This is a retrospective chart review todetermine the relationship between acuitylevel of illness and type of insurance forpatients who visit an emergency depart-ment (ED) in Northern VA more than 6times a year. It was hypothesized that unin-sured/public aid chronic ED users wouldhave more visits for nonurgent needs.

In contrast to the recommendations of thenational guidelines, about half of moderateasthmatics and 40% of severe asthmaticsdid not fill any anti-inflammatory agents(AI) prescriptions. Approximately one-fourth of the asthmatics were relying onshort-acting bronchodilators without AI-rep-resenting overutilization of symptom reliefagents.

The study concludes that the findings raisethe “possibility of indiscriminate PSA test-ing or unnecessary repetition of testing.”The study found that the number of casesof prostate cancer per PSA test performeddecreased from 1.8% in 1997 to 0.8% in1998. There was a significant increase inthe number of PSA tests performedbetween 1997 (9,410 tests) and 1998 (23,684tests).

62% of the visits were nonurgent, and thepublic aid/uninsured (or equivalent)patients were more likely to have nonurgentvisits (70%). Looking at visits, a greater per-centage of these visits were from publicaid/uninsured (or equivalent) patients(61%), even though this group representedonly 57.4% of patients. The study alsofound that the age group with the highestfrequency of visits was the 24-64 year oldpatients, and that the peak visit period forthese patients was between 0800 and 1600and did not increase on weekends, leadingthe authors to conclude that these patientswere not first seeking care elsewhere.

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The Financial Burden Of EmergencyDepartment Congestion And Hospital CrowdingFor Chest Pain Patients Awaiting AdmissionBayley, M.D., Schwartz, J.S., Shofer,F.S., Weiner, M., Sites, F.D., Traber,K.B., Hollander, J.E.; 2005; Ann EmergMed

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 HospitalizationAmong Medicaid AdultsBasu, J. Friedman, B., Burstin, H.;2004; Health Serv Res

The study used data from the HealthcareCost and Utilization Project (HCUP) toexamine the association between managedcare enrollment and preventable hospital-ization patterns of adult Medicaid enrolleesin 4 states.

Non-Emergent And Preventable ED VisitsMassachusetts Division of Health CareFinance and Policy; 2004; Analysis inBrief

To estimate the proportion of non-emergentand preventable emergency department(ED) visits in Massachusetts.

Extended ED length of stay demonstratedno association with total hospital costs orrevenues, or total hospital length of stay.However, patients awaiting telemetry bedsprevented ER use for new patients, therebycausing a loss of potential revenue.

Private health maintenance organization(HMO) enrollment was associated withfewer preventable admissions, compared toprivate fee-for-service. However, Medicaidmanaged care enrollment was not associatedwith a reduction in preventable admissions,compared to Medicaid fee-for-service.

Approximately 21% of outpatient ED visitswere considered non-emergent. A further19% and 6% were deemed emergent butprimary-care treatable and emergent butpreventable with good primary care, respec-tively. Women, blacks, and the uninsuredwere more likely to visit the ED for non-emergent reasons.

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Extended Use Of Indwelling Urinary CathetersIn Postoperative Hip Fracture PatientsWald, H., Epstein, A., Kramer, A.;2005; Med Care

This study used data from Medicare admis-sions to skilled nursing facilities (SNFs)from acute care hospitals with a diagnosis ofhip fracture to estimate the probability andimpact of having an indwelling urinarycatheter.

Decreasing Overuse Of Therapies In TheTreatment Of Bronchiolitis By IncorporatingEvidence At The Point Of CareMuething, S., Schoettker, P.J.,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:Looking For Trouble?Anderiesz, C., Elwood, J.M., McAvoy,B.R., Kenny, L.M.; 2004; Med J Aust

This review article discusses the issue ofwhether or not whole-body computedtomography scans are appropriate. Theauthor discusses evidence from the US andother developed countries.

32% of hip fracture discharges to SNFs hadurinary catheters. At 30 days after operation,these patients had higher odds of death,and of rehospitalization for urinary tractinfection. Western region and urban loca-tion were associated with a higher likeli-hood of having an indwelling urinarycatheter.

Bronchodilator and chest radiograph usedecreased, although 53.7% of patients stillreceived bronchodilators and 46.5% a chestradiograph.

Despite the growth in demand for whole-body computed tomography scans, there isno evidence that they are effective indetecting serious, treatable disease withoutundue cost or undesirable effects.

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Estimated Risks Of Radiation-Induced FatalCancer From Pediatric CTBrenner, D., Elliston, C., Hall, E.,Berdon, W.; 2001; AJR Am JRoentgenol

This article discusses biologic responses toionizing radiation and estimates potentialcancer deaths attributable to current levelsof pediatric computed tomography (CT)use.

The Clinical And Economic Correlates OfMisdiagnosed Appendicitis: Nationwide AnalysisFlum, D.R., Koepsell, T.; 2002;Archives of Surgery

This study used data from the 1997 healthcost and utilization project (HCUP)National Inpatient Sample to estimate thefrequency and cost of negative appendecto-my.

An Evaluation Of Statewide Strategies ToReduce Antibiotic OveruseMainous, A.G., III, Hueston, W.J.,Love, M.M., Evans, M.E., Finger, R.;2000; Fam Med

This article tested the hypothesis that inter-ventions will decrease antibiotic overuse intreatment of upper respiratory infection(URI) in pediatric populations. There werethree intervention groups: patient educationonly, provider education only, and bothpatient and provider education.

In the U.S., of approximately 600,000abdominal and head CT examinationsannually performed in children under theage of 15 years, a rough estimate is that 500of these individuals might ultimately diefrom cancer attributable to the CT radia-tion.

Nationwide, 15.3% of appendectomies areestimated to be negative appendectomies.Patients in whom negative appendectomieswere suspected had longer lengths of stay(5.8 vs. 3.6 days), higher total charge-admis-sion ($18,780 vs. $10,584), higher case fatal-ity rate (1.5% vs. 0.2%), and higher rate ofinfectious complications (2.6% vs. 1.8%).

There is over- and misuse of antibiotics forthe 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-cated/provider feedback) increased at aslower rate.

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Urban Emergency Department Utilization ByAdolescentsGrove, D.D., Lazebnik, R., Petrack,E.M.; 2000; Clin Pediatr (Phila)

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 ChildrenAfter A Community-Wide CampaignPerz, J.F., Craig, A.S., Coffey, C.S.,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: TheEffect Of Having A Regular Doctor.Petersen, L.A., Burstin, H.R., O’Neil,A.C., Orav, E.J., Brennan, T.A.; 1998;Med Care

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.

Adolescents on public assistance or withoutinsurance may frequently utilize an urbanED for nonurgent medical problems. Themajority of triage codes for ED visits werenonurgent (n=140; 93%).

Antibiotic prescription rates declined 19%in the intervention county compared with8% in the control counties.

Lack of a PCP predicted overuse of theemergency department (ED) (odds ration1.6). Half of the ED visits were deemedunnecessary.

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Emergency Department Use By Family PracticePatients 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 EmergencyDepartment During The DayKini, N.M., Strait, R.T.; 1998; PediatrEmerg Care

This was a prospective study of non-urgentpatients presenting to a pediatric emer-gency department (PED) to evaluate thepattern and reasons for nonurgent use of thepediatric emergency department during reg-ular office hours.

Resource Utilization And Its Management InSplenic TraumaCochran, A., Mann, N.C., Dean, J.M.,Cook, L.J., Barton, R.G.; 2004; Am JSurg

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.

Calling ahead was not associated with moreappropriate ED use (63% vs. 61%).

Most Health Maintenance Organization(HMO) (62%) and non-HMO enrollees(86%) did not call their Primary CarePhysician (PCP) prior to arrival in the PED.Comparing the reasons given by thesepatients (HMO enrollees vs. non-HMO) fornot calling, we found: convenience (HMO17% vs. non-HMO 42%) “no identifiedPCP”, (HMO 17% vs. non-HMO 42%), and“felt problem was an emergency” (HMOl9% 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.”

Splenic injury cases managed at pediatricreferral centers and trauma centers hadlonger hospital stays and higher total costswhen compared to cases managed at otherfacilities, even when controlled for injurytype and severity.

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Indigent Men’s Use Of Emergency DepartmentsOver Primary Care Settings (Letter)Schanzer, B.M., Morgan, J.A.; 2004;Am J Public Health

This letter to the editor commented on astudy that surveyed 2 Bronx hospitals toexamine the factors leading to emergencydepartment (ED) overuse by men.

Emergency Department Management Of AcuteRespiratory InfectionsWard, M.A.; 2002; Semin Respir Infect

This study reviews common respiratoryinfections and considers the overuse ofantibiotics.

Practical Considerations When TreatingChildren With Antimicrobials In The OutpatientSettingWerk, L.N., Bauchner, H.; 1998; Drugs

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 DepartmentIs Medically Nonurgent: Provider IdeologiesAnd Patient AdviceGuttman, N., Nelson, M.S.,Zimmerman, D.R.; 2001; Qual HealthRes

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.

Factors including a lack of insurance, unem-ployment, and low income (less than$20,000 a year) were associated with a high-er rate of ED utilization. Lower incomepatients visited the ED 2.5 times the fre-quency of higher income patients.

Careful selection of antimicrobial agents isessential to maximize benefit and preventoveruse.

By avoiding inappropriate use of antimicro-bials, we can avoid antiobitic resistance.Simple strategies can improve compliancewith therapeutic regimens and improveparental satisfaction

Three provider ideologies regarding theappropriateness of medically nonurgent EDuse were identified and found to be linkedto particular communication strategies thatproviders employed with ED users: restric-tive, pragmatic, and all-inclusive.

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Reducing Antibiotic Use In Children: ARandomized Trial In 12 PracticesFinkelstein, J.A., Davis, R.L., Dowell,S.F., Metlay, J.P., Soumerai, S.B., Rifas-Shiman, S.L., Higham, M., Miller, Z.,Miroshnik, I., Pedan, A., Platt, R.;2001; Pediatrics

This study utilized educational outreachregarding antibiotics for upper respiratoryinfection (URI) in 12 pediatric practices inMassachusetts and Washington State.

The Beginning Of The End Of The AntibioticEra? Part I. The Problem: Abuse Of The“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 InebriatesThornquist, L., Biros, M., Olander, R.,Sterner, S.; 2002; Acad Emerg Med

Chronic inebriates often use emergencyservices 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.

Educational efforts targeting physicians andparents can contribute to the declining rateof antibiotic misuse and overuse in childrenbetween the ages of 3 months and 6 years.The educational interventions reducedantibiotic prescribing by 16% in childrenaged 3-36 months, and 12% in children 36-72 months compared to a control group ofpractices. These represented 0.23 fewerantibiotics per-patient per-year for ages 3-36months, and 0.13 fewer antibiotics per-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%).

Antibiotic overuse is one factor in the emer-gence of significant antibiotic resistance.

These programs reduce health care use formost patients; however serious medical ill-ness and injury in a small number ofpatients contributed heavily to resource uti-lization.

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Use And Misuse Of CorticosteroidsBorchers, A.T., Keen, C.L., Gershwin,M.E.; 2003; Compr Ther

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 AndRevascularization for Acute CoronarySyndromesLange, R.A., Hillis, L.D.; 1998; N EnglJ Med

This is an editorial commenting on theVeterans Affairs Non-Q-Wave InfarctionStrategies in Hospital (VANQWISH) Trial,published in the same issue. The study isthe fourth large randomized clinical trial(RCT) looking at aggressive versus conser-vative management of acute coronary syn-dromes.

Preventing The Spread Of AntimicrobialResistance Among Bacterial RespiratoryPathogens In Industrialized Countries: The CaseFor Judicious Antimicrobial UseSchwartz, B.; 1999; Clin Infect Dis

This article reviews the literature and dis-cusses the joint Centers for Disease Control(CDC)/American Academy of Pediatrics(AAP)/American Academy of FamilyPhysicians (AAFP) program to promoterational antibiotic use.

Corticosteroids appear to be either overusedor over-prescribed in each of the conditionsstudied.

“Angiography, percutaneous transluminalcoronary angioplasty (PTCA), and coronaryartery bypass grafting (CABG) done rou-tinely following myocardial infarction,rather than on the basis of ischemia, do notimprove outcomes. All four studies showthat routine angiography and revasculariza-tion do not reduce the incidence of nonfatalreinfarction or death as compared with themore conservative, ischemia-guidedapproach. Physicians who work in hospitalswith catheterization facilities are more like-ly to recommend coronary angiography thanthose without easy access to such a facility.”

Patient pressure and suboptimal diagnosisand treatment contribute to antibiotic over-use. Curricula for doctors have been devel-oped to describe the optimal managementof respiratory infections. Patient educationmaterials and strategies to improve doctor-patient communication have been devel-oped. Studies are underway to evaluateinterventions.

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The Annual Physical: Are Physicians AndPatients Telling Us Something?O’Malley, P.G., Greenland, P.; 2005;Arch Intern Med

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 AntibioticsPlonczynski, D.J.; 2005; AORN J

This article examines the relationshipbetween microbial resistance and the over-use of antibiotics.

A Simple, Focused, Computerized Query ToDetect Overutilization Of Laboratory TestsWeydert, J.A., Nobbs, N.D., Feld, R.,Kemp, J.D.; 2005; Arch Pathol LabMed

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.

Although there is no evidence for the utilityof the annual physical, this editorial sug-gests that it may persist because it providesa forum to build and nurture the physician-patient relationship.

This article supports the use of prophylacticantibiotics for specific cardiac, colorectal,gynecologic, ophthalmologic, orthopedic, orurologic procedures when given as a singledose prior to incision.

A focused query of data derived from a clin-ical data repository can detect and docu-ment overutilization of a common laborato-ry test in a convincing fashion within agiven institution.

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Resource Utilization And Outcome In GravelyIll Intensive Care Unit Patients With PredictedIn-Hospital Mortality Rates Of 95% Or HigherBy APACHE III Scores: The Relationship WithPhysician And Family ExpectationsBerge, K.H. Maiers, D.R., Schreiner,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 PrescriptionIn New York CityLarson, E., Grullon-Figueroa, L.; 2004;J Urban Health

This article describes a survey of the avail-ability of non-prescription antibiotics in 101independent stores in Manhattan, NewYork.

Combating Antimicrobial Resistance:Intervention Programs To Promote AppropriateAntibiotic UseEmmer, 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.

23% of patients in the cohort survived tohospital discharge; all but one were moder-ately or severely disabled. 10% were alive at1 year. Resource utilization was extensive,but costs were not calculated. Survival was5 times that predicted by the tool.

Antibiotics were available in all stores in theHispanic neighborhood, but in none of thestores in non-Hispanic neighborhoods.

It appears that these interventions are suc-cessfully reducing the inappropriate use ofantibiotics.

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Cost-Utility Analysis Of Screening Intervals ForDiabetic Retinopathy In Patients With Type 2Diabetes MellitusVijan, S., Hofer, T.P., Hayward, R.A.;2000; JAMA

This study performed a Markov cost-effec-tiveness model using data from the ThirdNational Health and Nutrition ExaminationSurvey 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 RespiratoryTract Infections In The Primary Care SettingFendrick, A.M., Saint, S., Brook, I.,Jacobs, M.R., Pelton, S., Sethi, S.; 2001;Clin Ther

This paper reviews the literature and theresults 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 TransportationTo A Suburban Pediatric EmergencyDepartmentKost, S., Arruda, J.; 1999; PrehospEmerg Care

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.

Patients in the high-risk group cost an addi-tional $40,530 per quality-adjusted life year(QALY) gained, while those in the low-riskgroup cost an additional $211,570 per QALYgained. Retinal screening annually vs. everyother year for patients with type 2 diabetescosts $107,510 per QALY gained, whilescreening every other year vs. every thirdyear costs $49,760 per QALY gained.

Guidelines for the management of AECB,AOM, and ABRS emphasize the importanceof differentiating between bacterial andnonbacterial infections, choosing an antibi-otic based on the likelihood of infectionwith resistant pathogens, and providing cov-erage against the predominant pathogens.

28% of patients who arrived by ambulancewere judged to have used the ambulancetransportation unnecessarily. Of the unnec-essary transports, 60% were insured byMedicaid.

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Medication Overuse Headache FromAntimigraine Therapy Clinical Features,Pathogenesis And ManagementSmith, T.R., Stoneman, J.; 2004; Drugs

This study is an examination of the litera-ture on medication-overuse headaches (alsotermed analgesia rebound headaches) todescribe a number of theories on cause anda number of suggestions for treatment.

Transformed Migraine And Medication OveruseIn A Tertiary Headache Centre—ClinicalCharacteristics And Treatment OutcomesBigal, M.E., Rapoport, A.M., Sheftell,F.D., Tepper, S.J., Lipton, R.B.; 2004;Cephalalgia

To compare the outcomes for patients withmedication-overuse headaches (transformedmigraines) who were able to stop overusinganalgesics to those who were not.

Use Of Antihypertensive Drug Therapy In OlderPersons In An Academic Nursing HomeZiesmer, V., Ghosh, S., Aronow, W.S.;2003; J Am Med Dir Assoc

This study analyzed the charts of all resi-dents of an academic nursing home toexamine the prevalence of hypertensionand appropriate treatment of hypertensionin a nursing home population.

Patients are overusing analgesics formigraine headaches, leading to moreheadaches. According to the study, treat-ments for medication-overuse headachesshould include replacement of analgesicswith prophylactic and headache-abortingmedications and the use of alternative treat-ments, such as biofeedback.

By overusing analgesics, patients worsentheir illness. The study found that the fre-quency of headaches decreased by 74% inpatients who were able to stop analgesicoveruse (“detox”), and 17% in those whowere not. The duration of headache painwas reduced by 61% (detox) vs. 15% (nodetox).

A significant minority of patients (16%) haduncontrolled hypertension. Among patientswith hypertension and concomitant dia-betes, coronary artery disease, and/or heartfailure, a specific recommended class ofdrugs (e.g., ACE inhibitors for diabetics)was often not being prescribed (3-47% ofthe time, depending on condition and drugclass).

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Prevalence Of Subacute Patients In Acute Care:Results Of A Study Of VA HospitalsWeaver, F.M., Guihan, M., Hynes,D.M., Byck, G. ,Conrad, K.J., Demakis,J.G.; 1998; J Med Syst

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 HysterectomyShwayder, J.M.; 1999; Obstet GynecolClin North Am

This article is a review about the topic of“laparoscopically assisted vaginal hysterec-tomy” (LAVH). The review discusses thehistory, challenges, and future of this tech-nique.

Pediatric Emergency Room Visits ForNontraumatic Dental DiseaseGraham, D.B., Webb, M.D., Seale,N.S.; 2000; Pediatr Dent

This study reviewed 149 visits to an emer-gency room (ER) of a children’s hospitalwhich had a diagnosis of dental caries, peri-apical abscess or facial cellulitis. The pur-pose was to determine “the incidence andpredisposing, enabling, and need factors ofoutpatients” and to analyze the hospitalcharges.

Over one-third of hospitalized patients hadat least 1 subacute day; with an averagelength of stay of 12.7 days; of which 6.8days were subacute.

The growth and, at times, overuse of thelaparoscopic approach have waned some-what as physicians reevaluate LAVH, adoptnew techniques such as arterial emboliza-tion and myolysis, and rediscover old tech-niques such as uterine morcellation at vagi-nal hysterectomy.

During 1996-97, 149 patients made 159 ERvisits. The most common diagnoses wereICD-9 codes 521.0 for dental carie (48%)and 522.5 for periapical abscess (47%).Medicaid recipients used the ER at anintermediate level between patients withno payor source and those with privateinsurance. Almost one-half of the accountschanged status during the billing process,with the majority being entered as private-pay upon admission, but changing to baddebt or charity after the registration recordswere processed and collection was attempt-ed. Most patients were treated empiricallyby the ER physicians according to their pre-senting signs/symptoms.

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Propoxyphene Use By Community-Dwelling AndInstitionalized Elderly Medicare BeneficiariesKamal-Bahl, S.J., Doshi, J.A., Stuart,B.C., Briesacher, B.A.; 2003; J AmGeriatr Soc

This study was conducted to provide thefirst 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 ThePopulation Of Individuals Who Seek HealthCare At Emergency DepartmentsMacLean, S.L., Bayley, E.W., Cole,F.L., Bernardo, L., Lenaghan, P.,Manton, A.; 1999; J Emerg Nurs

This study employed a retrospective recordreview of 12,422 randomly selected emer-gency department (ED) visits at 89 EDs in35 states to describe the population ofpatients who seek care in EDs.

Variation In Psychotropic Drug Use In NursingHomesCastle, Nicholas; 1999; J Health SocPolicy

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.

The results show that propoxyphene use byU.S. community-dwelling seniors is high,but is much higher in the institutionalizedpopulation. These findings suggest thatprescribing for older adults with pain couldbe improved, especially for vulnerable long-term care residents.

Most patients had insurance (80%) and 78%of patients had a primary care physician(PCP), but only 51% of self-pay patientshad 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(4.5% of diagnoses). It was also noted thatmost visits were NOT related to alcohol ordrugs (77%), and 16% of patients wereadmitted to the hospital.

Homes with high levels of antipsychoticdrug use are less likely to be hospital-based,are less likely to have special care units, butare more likely to have Alzheimer’s special-care units.

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Overcrowding In The Nation’s EmergencyDepartments: Complex Causes And DisturbingEffectsDerlet, R.W., Richards, J.R.; 2000; AnnEmerg Med

This study reviews the literature regardingovercrowding of emergency department(EDs) and describes root causes and conse-quences of overcrowding.

1998 ARRS Executive Council Award.Radiology In The Emergency Department:Technique For Quantitative Description Of UseAnd ResultsLee, S.I., Chew, F.S.; 1998; AJR Am JRoentgenol

This article describes how one hospitaldeveloped a method to analyze theirrecords from the radiology department inorder to describe the use and results ofimaging studies in emergency department(ED) patients.

Root causes include increased complexityand acuity of patients using EDs; overallincreases in populations; unintended effectsof managed care; scarcity of inpatient beds;increasing intensity of ED interventions toavoid hospitalization; delays in providingancillary services; nursing, clerical, andphysician shortages; shortages of on-callspecialty 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.

ED admissions and imaging studies werestable from 1991 to 1997, averaging 60,000and 52,000 per year, respectively. Bone radi-ographs comprised 45.1% of examinations;chest radiographs, 44.6%; and abdominalradiographs, 10.4%. The percentages ofradiographs interpreted as normal were75.9% 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.The number of CT studies of the bodyincreased 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.

Overuse

Care In The Emergency Department: HowCrowded Is Overcrowded?Hwang, U., Concato, J.; 2004; AcadEmerg Med

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 TheUnited States: An Emerging Threat To PatientSafety And Public HealthTrzeciak, S., Rivers, E.P; 2003; EmergMed J

This is a systematic review that describeshow emergency department (ED) over-crowding threatens patient safety and pub-lic health.

Frequent Overcrowding In U.S. EmergencyDepartmentsDerlet, R., Richards, J., Kravitz, R.;2001; Acad Emerg Med

This study employed a survey methodologyto assess the frequency, determinants, andconsequences of ED overcrowding.

43% of the articles had explicit definitionsof crowding or overcrowding. The defini-tions varied widely in content and focus,including emergency department, hospital,or external (non-hospital) factors.

The study reports three findings: 1) the EDis a vital part of the safety net, 2) over-crowding threatens public health, 3) themain cause is inadequate inpatient capacity.

91% of ED directors reported overcrowdingas a problem. Common definitions of over-crowding (greater than 70%) included thefollowing: patients in hallways, all ED bedsoccupied, full waiting rooms longer than 6hours a day, and acutely ill patients whowait longer than 60 minutes to see a physi-cian.

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Ethnic Differences In Past Hysterectomy ForBenign ConditionsPowell, L.H., Meyer, P., Weiss, G.,Matthews, K.A., Santoro, N.,Randolph, J.F., Jr., Schocken, M.,Skurnick, J., Ory, M.G., Sutton-Tyrrell,K.; 2005; Womens Health Issues

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 EmergencyDepartment Headache “Repeater”Maizels, M; 2002; Headache

This study employed retrospective emer-gency department (ED) and urgent carecenter chart reviews to analyze the healthcare utilization of patients who use EDsrepeatedly for recurrent headaches.

The Health Economics Of Asthma And Rhinitis.I. Assessing The Economic ImpactWeiss, K.B., Sullivan, S.D.; 2001; JAllergy Clin Immunol

This paper is a narrative review that lookedat 128 articles about asthma and allergicrhinitis in order to estimate the amount ofdirect and indirect costs of these 2 diseasesin the U.S.

The highest rates of hysterectomy occurredin the disadvantaged African American andHispanic subgroups, and could not beexplained by known risk factors. Therefore,overuse of hysterectomy in these disadvan-taged groups may exist.

Over a 6-month period, 502 patients made1004 visits. 54 patients accounted for 502visits. Retrospectively, the ED charges forthis group of patients in the previous 12months was $183,760, 41/52 used narcotics,and 30/52 benzodiazepines.

In 1998, asthma in the U.S. cost 12.7 billiondollars annually (for direct and indirectcosts). In 1994, allergic rhinitis cost $1.2 billion. Most of the costs were due to directmedical expenditures (especially medica-tions).

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Helicopter Transport Of Pediatric TraumaPatients In An Urban Emergency MedicalServices System: A Critical AnalysisEckstein, M., Jantos, T., Kelly, N.,Cardillo, A.; 2002; J Trauma

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 TractInfectionTrautner, B.W., Hull, R.A., Darouiche,R.O.; 2005; Current opinion in infec-tious diseases

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 PrescribingIn Nursing HomesBriesacher, B.A., Limcangco, M.R.,Simoni-Wastila, L., Doshi, J.A., Levens,S.R., Shea, D.G., Stuart, B.; 2005; ArchIntern Med

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.

Out of 175 patients transported by helicop-ter, 14% were incubated in the emergencydepartment (ED), 18% were admitted tothe intensive care unit (ICU), 4% weretaken directly to the operating room (OR),33% were discharged home from the ED.

The underlying cause of catheter-associatedUTIs is biofilm formation by pathogens onthe urinary catheter. Research is ongoingregarding biofilm formation, and ways toprevent and treat these infections.

27% of all Medicare beneficiaries in nursinghomes received antipsychotics. Patientsreceiving antipsychotic therapy withinguidelines were no more likely to achievestability or improved behavioral symptomsthan were those taking antipsychotics out-side the guidelines.

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Economic Evaluation Of Four Treatments ForLow Back Pain: Results From A RandomizedControlled TrialKominski, G.F., Heslin, K.C.,Morgenstern, H., Hurwitz, E.L.,Harbor, P.L.; 2005; Med Care

This study examined 18-month costs for 4treatments for low-back pain.

Medical Care- Is More Always Better?Fisher, E.S.; 2003; N Engl J Med

This editorial discusses the effect of theVeterans Adminstration’s reform of itshealth care system on patients with chronicdisease.

Responsible Use Of CT [Letter]Frush, D.P.; 2003; Radiology

This letter to the editor discusses theoreti-cal risks and benefits of computed tomogra-phy (CT) scans in terms of the trade-offbetween low-level radiation exposure andincreased diagnostic certainty

The adjusted outpatient costs (not includ-ing pharmaceuticals) for the 4 modalities forlow-back pain were $369 for medical careonly, $560 for chiropractic care only, $579for chiropractic care with physical modali-ties, and $760 for medical care and physicaltherapy.

High-intensity practice patterns are associ-ated with lower quality of care and worseoutcomes than more conservative practicepatterns.

CT results in low level radiation exposure.The cumulative effect of repeated examscan lead to significant exposure which couldpredispose to a variety of malignancies.