The Important but Rarely Studied Cascade of Care

Mandrola, John; Morgan, Daniel J.

doi:10.1001/jamanetworkopen.2019.13315

Cited by 15 publications

(17 citation statements)

References 7 publications

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“…Overuse of laboratory tests not only increases length of stay in the ED but also may have a negative downstream effect on patient care, triggering a potential cascade of additional, unjustified, and even invasive investigations, which may in turn lead to potentially harmful interventions. 39,40 We observed a high level of variation in testing, specifically in the use of glucose, C-reactive protein, liver function test, and CaMgP04, with up to 43.5% differences in the rate of ordering these tests between the clusters. This could have been due to potential differences in either patient population that was not captured in the case mix adjustment or differences in coding of the presenting problem.…”

Section: Sensitivity Analysesmentioning

confidence: 92%

The NSW Pathology Atlas of Variation: Part II—The Association of Variation in Emergency Department Laboratory Investigations With Outcomes for Patients Presenting With Chest Pain

Wabe

Scowen

Eigenstetter

et al. 2021

Annals of Emergency Medicine

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Study objective: Laboratory test use varies across emergency departments (EDs), yet little is known about the effect of this variation on outcomes. The aim of this study is 2-fold: to stratify EDs into clusters based on similar test use, and to determine whether the clusters differ in patient operational outcomes among patients presenting to EDs with undifferentiated chest pain.Methods: We conducted a retrospective cohort study of 222,788 patients presenting with undifferentiated chest pain at 44 EDs across New South Wales, Australia, from January 2017 to September 2018. The operational outcomes measured in this study included ED length of stay, hospital admission, the Emergency Treatment Performance target, and 7-and 15-day all-cause and same-cause ED revisit rates. We performed a hierarchic cluster analysis to identify ED clusters and mixed-effects models to determine the association between the clusters and the operational outcomes.Results: Two ED clusters, moderate users (18 EDs) and high users (26 EDs), were identified. After adjustment for confounders, the median ED length of stay was greater by 15.7% (equivalent to 33.4 minutes) in high versus moderate users (95% confidence interval 6.62 to 25.52 minutes), and high users were less likely to achieve the Emergency Treatment Performance target versus moderate users (odds ratio 0.66; 95% confidence interval 0.50 to 0.86). There were no significant differences between the users in hospital admission and ED revisit rates. Conclusion:Our findings suggest that reducing test use may reduce ED length of stay and improve the chance of achieving the Emergency Treatment Performance target. [

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Section: Sensitivity Analysesmentioning

confidence: 92%

The NSW Pathology Atlas of Variation: Part II—The Association of Variation in Emergency Department Laboratory Investigations With Outcomes for Patients Presenting With Chest Pain

Wabe

Scowen

Eigenstetter

et al. 2021

Annals of Emergency Medicine

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“…The objectives of this study are to evaluate whether a data-driven approach (ie, using Atlas Analytical Model to engage with LHDs) is associated with: (1) a reduction in test order variation; (2) improvements in patient outcomes through a reduction in ED LOS and a reduction in hospital admission rates [16][17][18] and (3) cost benefits (total pathology costs per ED encounter).…”

Section: Objectivesmentioning

confidence: 99%

“… 16 Overutilisation of pathology tests can also have a negative impact on patient care, triggering a potential cascade of additional, unjustified and even invasive investigations, which may in turn lead to potentially harmful interventions. 17 18 …”

Section: Introductionmentioning

confidence: 99%

Evaluating the long-term effects of a data-driven approach to reduce variation in emergency department pathology investigations: study protocol for evaluation of the NSW Health Pathology Atlas of variation

et al. 2020

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IntroductionVariation in test ordering is a major issue in Australia and globally with significant financial and clinical impacts. There is currently a lack of research identifying and remediating variation in the use of pathology tests in emergency departments (EDs). In 2019, NSW Health Pathology introduced the Pathology Atlas of Variation that uses a data-driven tool (the Atlas Analytical Model) to investigate test order variation across New South Wales (NSW) and engage with local health districts (LHDs) to reduce variation. The objectives of this study are to evaluate whether this data-driven approach is associated with: (1) a reduction in test order variation; (2) improvements in patient outcomes and (3) cost benefits, for the five most frequent ED presentations.Methods and analysisThis is a large multisite study including 45 major public hospitals across 15 LHDs in NSW, Australia. The Atlas Analytical Model is a data analytics and visualisation tool capable of providing analytical insights into variation in pathology investigations across NSW EDs, which will be used as feedback to inform LHDs efforts to reduce variation. Interrupted time series analyses using 2 years pre Atlas (2017–2018) and 2 years post Atlas (2021–2022) data will be conducted. Study data will be obtained by linking hospital and laboratory databases. Funnel plots will be used to identify EDs with outlying pathology test ordering practices. The outcome measures include changes in test ordering practices, ED length of stay, hospital admission and cost benefits (total pathology costs per ED encounter).Ethics and disseminationThe study has received ethical approval from the NSW Population and Health Service Research Ethics Committee (reference, 2019/ETH00184). The findings of the study will be published in peer-reviewed journals and disseminated via presentations at conferences. We will also engage directly with key stakeholders to disseminate the findings and to inform policies related to pathology testing in the ED.

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“…[3][4][5] When used inappropriately or excessively, neuroimaging is of low yield 6 and can result in unnecessary radiation exposure, 7 use of sedation, 8 and downstream cascades of care. 9,10 The economic impact is substantial, with annual US health care expenses for neuroimaging in headache patients approaching $1 billion. 1 Evidence-based guidelines addressing imaging utilization in pediatric and adult patients with headaches have been developed by the American Headache Society, American Academy of Neurology, American Board of Internal Medicine Foundation, and the American College of Radiology.…”

Section: Introductionmentioning

confidence: 99%

“…In the emergency department (ED) setting, neuroimaging is commonly utilized in patients with headaches to assist with patient triage, differential diagnosis, and to exclude life‐threatening conditions, such as stroke, bleed, or neoplasm 3–5 . When used inappropriately or excessively, neuroimaging is of low yield 6 and can result in unnecessary radiation exposure, 7 use of sedation, 8 and downstream cascades of care 9,10 . The economic impact is substantial, with annual US health care expenses for neuroimaging in headache patients approaching $1 billion 1…”

Section: Introductionmentioning

confidence: 99%

Increasing and disparate use of neuroimaging for adults and children with non‐traumatic headaches in the US emergency departments: Opportunities for improvement

et al. 2020

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Background: Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. Objective: To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. Methods: Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346. xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. Results: In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. Conclusion: Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, How to cite this article: Trofimova AV, Duszak R, Kadom N, Sadigh G. Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement.

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The Important but Rarely Studied Cascade of Care

Abstract: While technology has greatly improved health care, its advances are not free of downsides. A + Related articleAuthor affiliations and article information are listed at the end of this article.

Cited by 15 publications

References 7 publications

The NSW Pathology Atlas of Variation: Part II—The Association of Variation in Emergency Department Laboratory Investigations With Outcomes for Patients Presenting With Chest Pain

The NSW Pathology Atlas of Variation: Part II—The Association of Variation in Emergency Department Laboratory Investigations With Outcomes for Patients Presenting With Chest Pain

Evaluating the long-term effects of a data-driven approach to reduce variation in emergency department pathology investigations: study protocol for evaluation of the NSW Health Pathology Atlas of variation

Increasing and disparate use of neuroimaging for adults and children with non‐traumatic headaches in the US emergency departments: Opportunities for improvement

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