7 x 9 brochure evidence table overuse web.qxp
Revisiting The Appropriateness Of Carotid
carotid endarterectomy annually. 84.9% of
Dardik, H., Faust, G., Riles, T.S.; 2003;
Medicare cases judged appropriate). 10.6%
judged inappropriate, primarily due to high co-morbid conditions.
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 Tract
Antibiotics are overused for URI. Patients
Infections In Ambulatory Practice In The United
were less likely to receive antibiotic pre-
States, 1997-1999: Does Physician Specialty
scriptions from general internists than fami-
ly practitioners. Rate of prescriptions writ-
ten for URI decreased over the study peri-
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 For
Chart reviews revealed that 70% of charts
did not completely meet all indications for
and failure to try alternative treatmentsprior to hysterectomy. The ultimate signifi-
California 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.
Overuse Of Transthoracic Echocardiography In
TTE is overused in cases of infective endo-
The Diagnosis Of Native Valve Endocarditis
carditis (IE). The diagnosis of IE is a clini-
cal diagnosis, and the results of the TTE
did not significantly affect the duration of
antibiotic therapy. The authors propose anew algorithm that would result in elimina-
This study reviewed hospital records of 98
tion of 53% of the TTEs done in this study,
patients with suspected infective endocardi-
which can be avoided by treating patients
empirically until the blood culture results
impact that the study had on treatmentdecisions.
Antibiotic Treatment Of Children With Sore
Antibiotics are generally overused, and the
wrong antibiotics are prescribed (and mis-
is underused. Antibiotics were prescribed in
53% of visits for sore throats in childrenaged 3-17. Antibiotics are indicated for sore
National Hospital Ambulatory Medical Care
only 15-36% of sore throats. When antibi-
otics are prescribed, the correct antibiotic is
children with a diagnosis of tonsillitis, strep
sore throat, and pharyngitis had the GABHS
testing and antibiotic treatment in children
Use Of Adenosine In Patients Hospitalized In A
adenosine for arrhythmias where adenosine
is not indicated. 26 patients from the series
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: A
Costs were significantly higher in the ED.
Case Study Of Three Prevalent, Costly, AndNon-Emergent Diagnoses At A CommunityTeaching Hospital
Martin, 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.
Effectiveness Of A Medical Priority Dispatch
Hospital records were available for 86% of
cases, of which 12 were potentially life-
threatening, requiring ALS intervention.
potentially benefited from ALS interven-tion. The remaining 157 were classified as
records 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 And
The rate of misuse and overuse of antibiotic
Accurate Use Of Antibiotics: The Council For
prescriptions might be lowered if clinicians
Appropriate And Rational Antibiotic Therapy
were to use the 5 Council for Appropriate
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 consider
when choosing an appropriate and accurate
Antibiotic Prescribing For Children With Colds,
Upper Respiratory Tract Infections And
more inclined to prescribe than others; also
receive antibiotics than others. Pediatricianswere 0.57 times less likely to prescribe
antibiotics to children with otitis, sinusitis,
physicians to the 1992 National Ambulatory
or pharyngitis than non-pediatricians.
Care 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.
Ceftriaxone Use In The Emergency Department:
Based on published guidelines, ceftriaxone
majority of cases (66.4%, with an additional
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 Care
Consumers’ Use Of Emergency Departments:
decreased from 57.1% of visits in 1992 to
Has Managed Care Made A Difference?
aged care patients compared with fee-for-service patients, nor for insured compared
Ambulatory Medical Care Survey (NAHMCS) data from 1992 and1996 todetermine the effect of managed care onappropriateness of emergency department(ED) utilization.
Prospective Determination Of Medical Necessity
For Ambulance Transport By Paramedics
Gratton, M.C., Ellison, S.R., Hunt, J.
physicians) did not require ambulancetransport (76.2% agreement) to the emer-
This study prospectively assessed the med-
ical necessity of emergency transport by alarge urban EMS system.
Cervical Cancer Screening Among Women With
Pap testing rates vary by type and reason
my for malignancy have 1 more test a year
terectomy for benign reasons have 1 fewertest (potential overuse).
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 Experience
The profiling and educational interventions
led to a substantial decrease in both overallantibiotic prescribing and drug costs. Other
states may want to undertake similar pro-
reports on the prevalence of drug-resistant
grams to help protect their citizens from
infections caused by resistant pathogens.
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, And
Admission rates for ACS conditions in New
Preventable Hospitalization Of Children In A
where there were fewer primary care physi-
cians, lower percents of children with pri-
vate health maintenance organization(HMO) insurance, and higher proportions of
review of 1994 hospital discharge data forNew York resident children withAmbulatory-Care Sensitive (ACS) condi-tions. Relationship between ACS admissionrates and several factors were analyzed.
Lansoprazole Overutilization: Methods For
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 For
Inappropriate use of antibiotics for viral
Bronchitis And Upper Respiratory Infections
URI has decreased, but 10% of children and
20% of adults still receive inappropriate
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.
The Impact Of Peer Management On Test-
ability. Hospitals with growing health care
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 In
often leads to unnecessary revascularization
that does not lead to improvement in out-
come. Thus, the potential exists that stressSPECT imaging, a highly effective diagnos-
This article reviews the current state of the
tic tool, could reduce the inappropriate use
evidence on the clinical and economic data
of an invasive procedures resulting in cost-
regarding different nuclear cardiology imag-
ing tests. A synthesis of current economicevidence for gated, Single-Photon EmissionComputed Tomography (SPECT) is alsopresented.
Self-Reported Papanicolaou Smears And
There is significant overuse of pap smears
Hysterectomies Among Women In The United
reported that they had a pap smear within
the 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.
terectomy need to have a pap smear due to
estimate the rates of Papanicolaou smears in
supracervical 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.
Antimicrobial Use For Pediatric Upper
The overuse of antibiotics is prevalent for
Respiratory Tract Infections (URI): Reported
Practice, Actual Practice, Parental Beliefs
patients, despite stated beliefs that over-
prescribing contributes to antibiotic resist-
ance. The reasons cited included parental
pressure, desire to avoid a follow-up visit inmanaged care patients, and a belief that
This study surveyed 336 pediatricians and
parents could elect to obtain antibiotics
family physicians in Georgia regarding opin-
practitioners recognize the problems associ-
ated with overuse of antibiotics for URI,
tices in order to examine the factors that
survey results (including both pediatricians
relate to the over-prescribing of antibiotics
in children 5 years of age and younger.
(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.
Factors Affecting Prescription Of Ultra-High
Class I topical corticosteroids were pre-
Potency Topical Corticosteroids In Skin Disease:
scribed in 3% of all skin disease-related vis-
An Analysis Of US National Practice Data
its, with prescription rates being highest in
psoriasis (22%). There were a large number
of questionable prescriptions for other con-
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 Emergency
60.1% of all visits were nonurgent. Of all
Department Use In The First 3 Months Of Life
patients with non-urgent visits, 24.1% had
race all resulted in increased nonurgentemergency department (ED) use.
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 On
Guidelines for tests such as stool cultures
Utilization Of Low-Yield Bacterial Stool
can reduce overuse, particularly through the
Cultures In A Children’s Hospital
tests are appropriate. Using guidelines to
limit stool cultures for SSCYE for inpatientsreduced cultures by 43% (689)—primarily
This study used a retrospective analysis of
hospital laboratory records to estimate the
(497) rather than through a dramatic num-
ber of tests being rejected (192)—and saved
develop guidelines for reducing unwarrant-
the hospital of over $50,000 per year.
ed stool cultures for Salmonella, Shigella,Campylobacter, Yersinia enterocolitica, andE. coli 0157:H7 (SSCYE).
Keeping Children Out Of Hospitals: Parents’
About 50% of hospitalizations for children
And Physicians’ Perspectives On How Pediatric
with 6 diagnoses may be avoidable through
Hospitalization For Ambulatory Care-Sensitive
better parent education and follow-up clini-
avoidable hospitalization (AH) as agreed toby two of the three sources, were asthma
(27%), skin infections (20%), and dehydra-
tient attending physicians about pediatric
agreement rate varied from 68% for parents
hospital admissions concerning whether the
and attending physicians. Variables mostassociated with AH were being over the ageof 10, and having a diagnosis of asthma.
Provider And Practice Characteristics Associated
Potential overuse of antibiotics in children
With Antibiotic Use In Children With Presumed
is related to both provider and facility char-
Viral Respiratory Tract Infections.
acteristics. Although there seems to be a
downward 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 in
National Hospital Ambulatory Medical Care
teaching or non-teaching hospitals (39.6%).
Survey (NHAMCS) to assess antibiotic pre-
Other factors associated with increased like-
scribing to children in hospital outpatient
lihood of antibiotic prescribing included
clinics for 4 ICD-9 code diagnoses sugges-
diagnosis of bronchitis (unspecified), being
tive of viral respiratory infection acute
seen in a non-pediatric clinic, and being
seen before the 1998 publication of theCDC/AAP guidelines.
Use Of Open Access In GI Endoscopy At An
86% of endoscopies after consultation with
accepted indications compared with 65% of
open access procedures. Significant patho-
logic findings were present in 40% of theformer group compared with 28% of those
months 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.
Trends In Operative Management Of Pediatric
Hospitals that specialized in treating pedi-
Splenic Injury In A Regional Trauma System
atric trauma were less likely to perform sur-
gery for blunt splenic injury. At all types of
hospitals, the rate of surgery was low from
the years 1991 to 1993, rose in the years1994 to 1997 (more in the less specialized
hospitals), and declined to an intermediate
data to identify patients <19 years of age
who 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 Department
65% of ED visits in this study were classi-
Utilization For Nonurgent Pediatric Problems
fied as nonurgent by qualified medical per-
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.
National Trends In The Use Of Antibiotics By
The high rate of antibiotic prescription for
Primary Care Physicians For Adult Patients
of antibiotics. However, there is no gold
standard on this topic and the appropriate-
ness of prescription may be confounded bythe subjectivity of diagnosis. The percent-
age of outpatients receiving antibiotic pre-
from 1980 to 1994 (1.05 per year). Overall,
national trends in the prescription of antibi-
antibiotics were prescribed 66% of the time
otics by primary care physicians (PCPs) to
for adult patients with cough, rising from
adult patients with cough, and to identify
age 65, being white, visiting for the firsttime to complain of cough, and being diag-nosed with bronchitis were associated withsignificantly increased odds of prescription.
Beta-Blocker Dosages And Mortality After
Large doses of beta-blockers may be over-
Myocardial Infarction: Data From A Large
doses of beta-blockers (less than 50% of the
dose used in RCTs) was associated with at
higher doses. In fact, in this study, treat-ment with lower doses resulted in signifi-
This study reviewed the clinical records of
patients surviving Acute MyocardialInfarction (AMI) to examine a potentialassociation between dosage of beta-blockerreceived at hospital discharge (for MI) andmortality.
Evaluating The Appropriateness Of Digoxin
Digoxin blood tests are overused. Only 16%
Canas, F.,Tanasijevic, M.J., Ma’luf, N.,
tients were appropriate. The vast majority
of inappropriate tests (76%) were for earlyroutine monitoring, i.e., a test repeated less
than 10 days after a previous test for inpa-
review to determine the appropriateness of
tients, and less than 10 months for outpa-
tient digoxin levels at Brigham & Women’sHospital.
Understanding Physician Adherence With A
Pneumonia Practice Guideline: Effects Of
and was associated with patient age (>65),
Patient, System, And Physician Factors
gender (male), employment, multilobar dis-
ease, or comorbid conditions. PCP involve-
tributed to increased non-compliance.
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 In
Antimicrobials were overused in hospital-
Hospitalized Patients: Current Patterns Of
ized patients, either through prescription
where antibiotics are not necessary, or mis-
Antianaerobic Spectrum Of Activity
application of drugs where antibiotics are
necessary. Approximately 30% of the thera-
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 Care
dangerous and costly. Treatment of nosoco-
mial infections are estimated to cost nearly
$5 billion per year. While this article is more
This article reviews the literature pertaining
patients in an intensive care unit with noso-
antibiotic misuse in its development.
comial infections and shows the percentageincrease of antimicrobial resistant pathogenswhich have increased across the spectrumsince 1994-1998.
Inappropriate Use Of Emergency Medical
Inappropriate ambulance use is a significant
Services Transport: Comparison Of Provider
patient perspectives. Approximately 43% of
Richards, J.R., Ferrall, S.J.; 1999; Acad
diverting resources from true emergencies.
41-50 year olds, whites, men and people
This study prospectively surveyed patients
without medical insurance or Medi-Cal are
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, And
Factors Related To Nonurgent Visits
Liu, 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 Emergency
visits can lead to inefficient utilization of
than those with private health insurance.
While 58% of visits were considered non-
This study used a subset of 1994 National
insured patients. Males make up more than
(NHAMCS) data (age <16) to investigate
50% of the caseload in both urgent and non-
the overall rate of non-urgent visits was
58%, 51% for HMO, 56% for privatelyinsured, and 60% for government insuredpediatric patients.
Parental Use And Misuse Of Antibiotics: Are
Parents in both settings are misusing and
There Differences In Urban Vs. Suburban
overusing antibiotics. However, the misuse
in suburbia is different from urban misuse.
likely to have misused antibiotics for their
children. Parents in urban settings weremore likely to seek a prescription from
This was a prospective survey of parents of
children 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 Nonurgent
Patients are more likely to use the ED for
their usual source of care is not meeting
their needs. Most participants reported highlevels of satisfaction with their USC. Access
ine whether patient dissatisfaction with the
usual source of care (USC) and perceivedaccess difficulties to that USC were associ-ated with nonurgent emergency department(ED) use.
Repeat Patients To The Emergency Department
Cook, L.J. Knight, S. Junkins, E.P., Jr.
patients made up one third of patients, they
accumulated more than 60% of all ED visitsand ED charges.
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.
Ineffective Use Of Radiology: The Hidden Cost
The authors estimate that 10-30% of diag-
nostic radiologic procedures are unneces-
sary. They cite self-referral by doctors who
own equipment, fear of litigation and “wor-ried well” as causes. Based on various
This narrative review describes the extent
provides a brief description of the causes
per year of in the US. They further esti-
and the costs in terms of radiation-induced
defects 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%).
Long Term Use Of Acid Suppression Started
196 out of 324 (60%) of general medical in-
Inappropriately During Hospitalization
not have an appropriate indication for the
medication. 67 out of 196 (34%) were dis-
charged on the medication with an appro-priate indication. 84% were discharged on
This study is a retrospective chart review of
months, 80% of those available for follow-
inpatient teaching service to determine the
up (31 out of 39) were still on it inappropri-
ately. At 6 months, 50% of those available
for follow-up (fifteen out of twenty-six)
were still on it. Current costs of PPI are
medicine service; to characterize patients
hypothesis that use of PPI/H2RA continues
Diagnosis And Management Of Acute Bronchitis
improvement resulting from antibiotic ther-apy.
This is a general review of the diagnosisand treatment of acute bronchitis.
Vulnerable Populations At Risk Of Potentially
Avoidable Hospitalizations: The Case Of
Nursing Home Residents With Alzheimer’s
infection (UTI), and gastroenteritis, but
less of dementia status, suggesting animportant quality issue.
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 For
CT scans can prevent avoidable laparotomy
Evaluating Patients With Right Lower
in equivocal cases, but routine scanning in
cases with low likelihood of appendicitis
Safran, D.B., Pilati, D., Folz, E., Oller,
can, as shown in this report, lead to extend-
ed hospitalizations and unnecessary costs.
This is a series of 4 cases to illustrate thecontroversy surrounding the routine use ofcomputed tomography (CT) for suspectedappendicitis.
Overuse Of Parenteral Antibiotics For Wound
Antibiotic use in about one-fifth (18%) of
Care In An Urban Emergency Department
guidelines (although the authors themselves
describe their criteria as “arbitrary in theface of no accepted consensus among infec-
This study retrospectively reviewed records
tion disease experts”). Some wounds were
unnecessarily treated with Ceftriaxone and
(EDs) for wound care but were not admit-ted, and assessed discrepancy with currentrecommendations derived from the litera-ture.
An Evidence-Based Clinical Pathway For
Patients who were treated according to the
Bronchiolitis Safely Reduces Antibiotic Overuse
more antibiotics than those not treated on
the pathway (9% vs. 35%) and received nosystemic steroids (0% vs. 10%) significantly
This study reviewed the charts of 181 chil-
less often. The cost of hospitalization was
dren admitted to an academic hospital and
significantly less ($2,241 vs. $3,257), length
estimated the extent to which antibiotics
of stay was lower (2.09 vs. 2.55 days), and
there was no statistically significant increasein return for unplanned care within 72hours (3.3% vs. 2.7% NS).
been shown to increase mortality by 81% or24% (two different studies) and cause 3
times as much deterioration in renal func-
tion as placebo. Mild efficacy in decreasing
(recombinant human brain natriuretic pep-
capillary wedge pressure was shown in one
tide), a costly vasodilator used in congestive
should not have been approved, and notesthat it is being heavily marketed.
Residents adopted attending physicians’
Antibiotic Prescribing Practices In A Teaching
prescribing behavior over time. In this case,
Clinic: Comparison Of Resident And Staff
attending physicians’ behavior was more
likely to be wasteful. First- and second-year
residents were significantly more likely to
prescribe narrow spectrum antibiotics foracute sinusitis (56%) compared with attend-
This study employed a record review of all
patients in an academic practice presentingwith acute sinusitis to determine the rela-tionship between inappropriate antibioticprescribing and years of training.
Association Between Medication Supplies And
Healthcare Costs In Older Adults From An
over-supply of medications. Both over-and
chance of emergency room visits and hospi-
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 Women
With A Cytological Diagnosis Of Atypical
Squamous Cells Of Undetermined Significance
likely to undergo colposcopic biopsy for fol-
low-up of ASCUS. In a multivariate model,
odds 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-up
analyze determinants of the type of follow-
up received (colposcopic biopsy v. repeat
The Impact Of Drug Coverage On COX-2
coverage, gastrointestinal risk had no inde-
prescribed this class of medications. Drugusage was higher in Medicare beneficiaries
with coverage compared with no coverage.
Beneficiary Survey were used to assess the
COX-2 use was twice as high in those with
impact of drug coverage on COX-2 inhibitor
use among elderly people with osteoarthri-
tis, taking into account risk for adverse gas-
with the most generous coverage, patients
with increased gastrointestinal risk are nomore likely to be prescribed COX-2inhibitors.
Acetaminophen Overuse In The Ohio Medicaid
A relatively small, but significant, number
of patients were prescribed doses of aceta-
patients were prescribed an average dose of
acetaminophen greater than or equal to4g/day or greater than or equal to 3g/day
Medicaid claims data to examine potential
acetaminophen overuse in patients with andwithout risk factors for hepatotoxicity.
Preventable Hospitalization Among Elderly
7% of all hospitalizations in this cohort were
Medicare Beneficiaries With Type 2 Diabetes
Niefeld, 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 Potentially
13.4% of patient visits involved PIMs based
Inappropriate Prescribing Among Ambulatory
on the 2002 Beers criteria (and 4.2% visits
Older Patients In The Year 2001: Comparison
involved PIMs based on the Zhan criteria).
included: a visit occurring in a metropolitan
area, and a visit receiving higher number ofmedications during a single visit.
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.
Nonurgent Pediatric Emergency Department
Visits: Care-Seeking Behavior And Parental
for the ED visit was convenience (62.8% of
cases). 38.7% stated that they were educat-
emergencies by their insurance. ED refer-
rals for nonurgent complaints are requiredby the insurance carrier for 74.9%, but only
This study surveyed 251 parents of children
37.2% of the parents said referrals were nec-
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.
High rates of preventable hospitalizations
Hospitalizations: A Small Area Analysis In
were associated with low income and race.
Cable, 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 Preventable
Higher odds of preventable hospitalizations
Hospitalizations Among The Elderly
were 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. Factors
This study examined inpatient claims data
associated with lower odds included: having
attended college, or having only Medicare
having a hospitalization due to an ambulato-ry care-sensitive condition.
Pap Screening In A U.S. Health Plan
Of the enrolled women, 31% received a Pap
smear in 1998. The highest utilization rates
received a Pap smear in 1998. Ratesdeclined with increasing age: 26% of 65-69
screened during the follow-up period, 36%
received annual smears, 22% received bien-
Force guidelines for cervical cancer screen-
smears. This study, using administrativedata, found lower utilization rates than simi-lar studies using self-report.
Inappropriate Prescribing For Elderly
Potentially inappropriate medications were
prescribed at 4.45% of elderly outpatient
visits involving medications. Patients were
more likely to be given potentially inappro-priate medications if they had been
referred; had a number of medications pre-
National Hospital Ambulatory Medical Care
scribed; had a prescription for certain types
frequency of potentially inappropriate pre-
scribed by a provider from a nonmetropoli-
scribing for elderly outpatients; and (2) fac-
tors predicting inappropriate prescribing.
Nosocomial Infections In The ICU: The Growing
Studies have shown that patients infected
Importance Of Antibiotic Resistant Pathogens
with resistant strains of bacteria are more
likely than control patients to have previ-
ously received antimicrobials, and hospitalareas that have the highest prevalence of
This article reviews the literature concern-
resistance also have the highest rates of
ing nosocomial infections in intensive care
include hand washing and surveillance pro-tocols, isolation measures, and occupationalhealth services for employees.
Inappropriate Medication Prescribing In
9.9% of prescriptions were inappropriate.
39.7% of the residents had at least one inap-
propriate prescription. Inappropriate drugs
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 For
Arthroscopic lavage or debridement was no
more effective than a placebo procedure on
pain or function. At 1-and 2-year follow-up,
mean pain scale scores were not significant-
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.
Patterns And Correlates Of Local Therapy For
Only 14% of patients at lowest risk of recur-
Women With Ductal Carcinoma-In-Situ
with 22.8% and 52.6% of patients at inter-
mediate and highest risk. Between-site dif-
ferences in receipt of radiation after breast
conserving surgery (BCS) were consistentwith patient recall of surgeon discussions
Ductal 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 For
brand-name versions of the same agents.
The majority of the unrealized savings wereconcentrated in a small group of medica-
This study used 2000 state-level Medicaid
tions, including clozapine, alprazolam, and
generic drugs and calculate potential costsavings.
Support Of Evidence Based Guidelines For The
Despite evidence to the contrary, 65% felt
Annual Physical Examination: A Survey Of
that an annual exam was necessary, 55% dis-
lipid panel, glucose, and mammography.
This study used a mailed survey to assessthe attitudes of 783 primary care physiciansregarding annual physical exams.
Distributional Issues In The Analysis Of
ACS admissions are geographically concen-
trated and have increased to 12.2% of all
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 Noninvasive
Utilization rates for nuclear imaging were 2-
tomography (CT) rates 30% higher inunmanaged plans. Utilization Management
consisted of both review and facility cre-
imaging management systems and 2unmanaged plans in the same geographicarea.
Safety And Cost-Effectiveness Of Early
Discharge After Primary Angioplasty In Low-
domized to an accelerated hospital course
Risk Patients With Acute Myocardial Infarction.
PAMI-II Investigators. Primary Angioplasty In
approach reduced hospital costs by $2,000
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.
The Cost-Effective Use Of Nebulized Racemic
Epinephrine In The Treatment Of Croup
studies suggesting safe discharge to home ispossible.
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 May
26% of those that were told they had bron-
Improve Patient Satisfaction With Appropriate
chitis were dissatisfied with their treatment,
attainment, age, and gender did not affectsatisfaction rates.
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 Tests
Tests for which there is no documented evi-
During Routine Preventive Health Exams
dence were routinely ordered during annual
preventive health exams (43% of the time).
The frequency of ordering specific testsranged from 7% to 37% of visits for x-rays
2002 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.
Cervical Cancer Screening Among Women
smear in the prior 3 years did not change
over the course of the study. In both 1992(before the U.S. Preventive Services Task
Force recommendation) and 2002 (after the
immunization survey (NIS) data to estimate
the number of women with a history of hys-
undergone a recent Pap smear. The authors
estimate that 10 million women, or half of
all women who have undergone hysterecto-my, are receiving Pap smears unnecessarily.
Excessive Antibiotic Use For Acute Respiratory
In 1998, antibiotic prescriptions in excess of
expectations amounted to 55% of all antibi-
otics prescribed for acute respiratory infec-
tions. Associated costs of this unnecessaryprescription totaled approximately $726
National Ambulatory Medical Care Survey(NAMCS) to estimate primary care officevisits and antibiotic prescription rates foracute respiratory infections.
Trends In Antimicrobial Prescribing Rates For
Although the average annual rate of antibi-
otic prescription for children and adoles-
cents decreased from 838 per 1,000 in 1989
to 503 per 1,000 in 1999, the authors con-clude that it is important to continue efforts
to improve appropriate antimicrobial pre-
(NAMCS) data to assess antibiotic prescrib-ing rates for respiratory infections in chil-dren < age 15.
Desire For Antibiotics And Antibiotic
39% of adults seeking care for upper respi-
Prescribing For Adults With Upper Respiratory
ratory tract infections wanted antibiotics,
which is less than in previous studies.
Predictors of wanting antibiotics were prior
antibiotic use and current smoking.
Wanting antibiotics was an independent
This is a prospective cohort study in adults
predictor of antibiotic prescribing.
with 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 Prolonged
Hospitalizations On A General Medicine
occurred because of delays in needed serv-
delays were due to difficulty finding a bedin a skilled nursing facility. Medical service
residents 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 Acute
Empiric antibiotic use without testing for
Cystitis On Unnecessary Antibiotic Use
nitrites and pyuria increases antibiotic usage
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.
Antibiotic Use For Upper Respiratory Tract
Infections: How Well Do Pediatric Residents
increased with level of training, from 16%
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 Upper
Staff does not influence parental care seek-
Respiratory Tract Infections For Children In
Friedman, 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 Chemotherapy
chemotherapy to metastatic cancer patients
generously reimbursed, however, prescribed
more costly chemotherapy regimens tometastatic breast, colorectal, and lung can-
This study sought to determine if physician
reimbursement rates for chemotherapydrugs affected the frequency of usingchemotherapy in metastatic cancer patientsduring 1995 and 1998.
Trends In Antibiotic Prescribing For Adults In
From 1996 to 2002, the percentage of out-
patient visits resulting in an antibiotic pre-
reduction was completely attributable to a
decrease in antibiotic prescription for acute
respiratory infections (ARIs). However, thepercentage of broad-spectrum antibiotics
prescribed for ARIs increased from 41% to
(NAMCS) to estimate the impact of effortsto limit antibiotic prescribing in adults.
Measuring The Quality Of Care For Group A
There is substantial variability in GAS test-
Streptococcal Pharyngitis In 5 US Health Plans
ing rates between health plans. Overall, the
studied. Rates of antibiotic prescription alsovaried tremendously by health plan, ranging
This study used claims data from 5 health
plans 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 Negative
In urban settings, increased physician sup-
Relationship Between Physician Supply And
Hospitalization For Ambulatory Care Sensitive
potentially preventable hospitalizations. In
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.
Is Routine Postoperative Chest Radiography
Of the 150 patients undergoing nephrecto-
CXR, and 4 of these had a pneumothorax.
Only 1 of these 4 needed a chest tube.
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 Versus
There was no statistical difference between
Magnetic Resonance Imaging In The Diagnosis
MRI and clinical examination in diagnosing
Of Meniscal Tears And Anterior Cruciate
Kocabey, 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 To
Clear Cervical Spines In Blunt Trauma
deficits, a negative CT, and persistent cervi-
Patients With Normal Computed Tomographic
cal pain, none had evidence of fracture on
Schuster, 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.
Health Insurance, Neighborhood Income, And
Emergency Department Usage By Utah Children
uninsured children (65%) was for non-trau-
had approximately 50% greater ED utiliza-
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 Of
A total of 1,910 radiologic tests, including
646 bone scans, 637 chest radiographs, and
patients with a known TN status.
Radiologic tests were performed in 42% of
In this study, records of newly diagnosed
patients with carcinoma in situ, but none of
breast cancer patients were retrospectively
the 183 tests detected metastases. 828 radi-
ologic tests were performed in patients who
were classified as having stage I disease on
with newly diagnosed breast cancer and the
the basis of TN criteria. Only 3 of these
yield of such tests in these patients.
tests (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.
Analysis Of Medication Use Patterns: Apparent
Overuse Of Antibiotics And Underuse Of
Prescription Drugs For Asthma, Depression And
antibiotics are not indicated, 35.7% received
This study used claims data from 3California Managed Care Organizations(MCOs) to assess the appropriateness ofprescription medication use based uponguidelines for various conditions.
The Cost Of Antibiotics In Treating Upper
Respiratory Tract Infections In A Medicaid
emergency department episodes resulted in
an antibiotic prescription being filled. In
outpatient settings, secondary diagnoses of
either otitis media or acute sinusitisaccounted for less than 6% of the episodes
that resulted in an antibiotic prescription
claims in order to examine the use and cost
of the nonindicated antibiotics for upper
antibiotic was amoxicillin, although second-
respiratory tract infections (URIs).
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.
Prescribing Potentially Inappropriate
Psychotropic Medications To The Ambulatory
Mort, 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.
Resource Utilization Of Patients With
Patients with healthcare-related anxiety use
Hypochondriacal Health Anxiety And
dria or somatization have more outpatient
visits (approximately 9 vs. 6), more outpa-tient costs (approximately $1,300 vs. $950),
876 patients attending an academic primary
and greater likelihood of hospitalization
care 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 Resonance
The study concludes that MRI is overused,
Imaging As A Diagnostic Screening Tool In
Patients With Chronic Shoulder Pain
were no differences (in age, sex, insurance
injury) among patients who received a pre-evaluation MRI and those who did not. (2)
chronic shoulder pain to see if magnetic res-
between patients who did or did not have a
evaluated by a shoulder specialist improved
could 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.
Musculoskeletal Imaging In Physical Therapist
This paper suggests that physical therapists
This article reviews literature pertinent toevidence-based use of diagnostic imagingand overuse of imaging for musculoskeletalconditions.
Current Antibiotic Therapy For Isolated
The study found that quinolones were pre-
scribed more commonly than sulfa drugs for
mended guidelines. The former were pre-scribed for 44% of UTIs compared with
30% for the latter, and nitrofurantoin for
National Hospital Ambulatory Medical Care
18%. There were few significant predictors
antibiotic prescribing for women with isolat-
ed uncomplicated urinary tract infections
Northeast) did not reflect geographically
higher rates of sulfa-resistant organisms.
Unnecessary Cesarean Delivery In Louisiana:
An Analysis Of Birth Certificate Data
17 and 43, respectively, per 100 cesarean
L., Khan, M.M., Herrera, E.A., Yu, S.
deliveries. The primary Cesarean delivery
rate decreased and the repeat Cesareandelivery rate increased during the study.
This study used the Louisiana birth certifi-
But neither the absence nor the presence of
cate database to determine temporal trends
potential risk factors accounted for these
Cesarean deliveries and potentially unnec-essary Cesarean deliveries.
Geographic Variation In Preventable
Using hospital discharge data, 5 county and
Hospitalizations Of Older Women And Men:
Implications For Access To Primary Health
are studied. There is significant variation in
preventable hospitalization within counties.
Areas having significantly higher rates of
these hospitalizations tend to have higherrates for both women and men. Problems of
This study reviewed hospital discharge data
demonstrate how readily available data andsmall area analysis can be used to identifypotential problems of access to primary careservices for older women and men.
Estimating The Proportion Of Unnecessary
Using the authors’ methods, nearly 40% of
Cesarean Sections In Ohio Using Birth
abnormalities on the birth certificate to jus-
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 And
Visit Duration In Adults With Upper
with a shorter visit duration (0.7 minutes
Linder, 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? The
Influence Of Community Radiologists’ Medical
Malpractice Perceptions And Experience On
claims increased their rate of recommenda-
tion for breast biopsies, and 76% expressed
concern about the impact of malpractice onmammography practice. About one-third
This study surveyed radiologists who inter-
the 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.
How Are Age And Payors Related To Avoidable
community characteristics is needed forMedicaid and self-pay patients.
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 And
The Role Of The Emergency Department
less or sufficiently poor or disabled to quali-
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 Pediatric
The challenge for rational antibiotic use is
Respiratory Tract Infections: Clinical Challenges
to determine which patients can be treated
conservatively and which require antimicro-
bial intervention. Different antibiotics arediscussed. The pneumococcal vaccine intro-
This study reviews the literature pertinent
to the development of antibiotic resistance
on decreasing antimicrobial resistance.
among upper respiratory infection (URI)pathogens and discusses both the overuseof antibiotics and the inadequate dosing ofantibiotics.
Triage Services: A Profile Of High Utilization
Factors associated with high utilization of
include: patient perception of health status;
number of prescription medications; andsocial needs.
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 On
Primary And Repeat Cesarean Rates Among
rates were significantly lower for TRICARE
U.S. Department Of Defense Health Care
Beneficiaries In Military And Civilian
differences in repeat C-section rates were
found. Primary and repeat C-section rateswere lower in military hospitals than in
civilian hospitals.The study suggests that to
(DOD) hospital records for 365,648 single-
ton deliveries to assess the impact of enroll-
decrease morbidity and decrease costs) we
ment in TRICARE prime, the department’s
managed care plan, on C-section rates.
health care plans have different C-section
rates, but it is not clearly understood why.
Antibiotic Prescribing Rates In The US
Antibiotic prescribing for influenza is wide-
Ambulatory Care Setting For Patients
spread; 38% of visits where the diagnosis of
Diagnosed With Influenza, 1997-2001
influenza was made led to an antibiotic pre-
scription of which one-third were for broad
spectrum antibiotics. Inappropriate antibi-otics cost $18.5 million annually and may
Medical 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.
Regional Air Transport Of Burn Patients: A
In 92 out of 225 cases, overestimation or
underestimation of burn size by referring
physicians or performance of endotracheal
incubation suggested that telemedicineevaluation before transport might have sig-
225 cases of patients transported by air for
nificantly altered transport decisions or care.
burn injuries were reviewed to determine iftelemedicine could have been used to assistin evaluation and treatment of burnpatients.
Improving Quality Through Identifying
Inappropriate Care: The Use Of Guideline-
shows that “guideline-based utilization
Based Utilization Review Protocols In The
review protocols” can be used to identify
Washington State Workers’ Compensation System
inappropriate care, and improve quality.
When “guideline-based review criteria”
were used during a utilization review, denial
rates were 7.9%. When “proprietary reviewcriteria” were used, denial rates were 4.9%.
When “other criteria” were used, denial
requests through an analysis of the 100,005
utilization 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 Organizations
On Cost And Utilization Of Hysterectomies
vaginal hysterectomy, suggesting overuse of
these procedures in indemnity plan benefi-
This study used claims data to comparehysterectomy rates for beneficiaries ofemployer sponsored PPO and indemnityplans between 1988 and 1990.
Radiograph Use In Low Back Pain: A United
Based upon published guidelines, the study
States Emergency Department Database
17.8% received an unnecessary radiograph.
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 Bronchitis
66% of patients diagnosed with bronchitis
received an antibiotic. Increasing age, puru-
lent cough, abnormal exam, and comorbidi-
ties were associated with higher likelihoodof antibiotic use. Smoking, duration of
This study examined the medical records of
symptoms, gender, and race did not predict
160 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 Mild
To Moderate Pediatric Trauma: Are We
patients the number of patients who need-
more pediatric patients receiving scans ofmultiple body areas. The higher number of
examined 102 cases of pediatric trauma to
they did not identify more injuries, and did
determine if children with mild to moderate
not decrease morbidity, mortality, length of
tomography (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.
Overuse Of Acid-Suppressive Therapy In
At this hospital, acid-suppressant medica-
tions were inappropriately used among out-
found that among patients who entered thehospital already on acid-suppressant med-
A chart review of 226 patients admitted to
frequency of use and indications of acid-
suppressive mediations, and to determine if
their hospitalization, 75% of these cases
stress ulcer prophylaxis were also prescribed
medications were started during a hospital-
ization, 55% of low-risk patients were dis-charged with a prescription for these med-ications.
Patient Characteristics And Patterns Of Use For
Lumbar X-rays for low-back pain are over-
Lumbar Patient Characteristics And Patterns Of
used in patients who scored worse on sur-
Use For Lumbar Spine Radiographs: Results
veys of mental health. The study found that
and psychological factors. Higher rates of
repeat lumbar spine X-rays were associatedwith worse mental health, but they were
To identify patient characteristics that pre-
not associated with worse physical health.
dict different patterns in the use of lumbar
There was no association between patterns
of X-ray use and the following factors: age,
over 12 months of 401 patients who present
income, education, alcohol or drug use, or
to Veterans Administration clinics for low-
number of medical and mental conditions.
Healthcare Utilization And Referral Patterns In
The study found that urgent care and emer-
The Initial Management Of New-Onset,
Uncomplicated, Low Back Workers’
saw their primary care physician first.
Specialist care was provided more common-
by specialists. Referral to specialists wasmade sooner than expected: the median for
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 Of
There was significant regional variation. Of
Antipsychotic Use In Residential Treatment: A
the children taking antipsychotic medica-
tion, 42.9% had no history of or current psy-
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:
rationale for treatment, and an antibiotic
prescription were significantly associated
with patient satisfaction. Clinicians pre-
scribed an antibiotic for 36% of the stu-dents.
129 university students with upper respira-tory symptoms were evaluated to determineif receiving an antibiotic prescription influ-enced patients’ satisfaction with visits to aclinician.
Infantile Hypertrophic Pyloric Stenosis: Delays
In Diagnosis And Overutilization Of Imaging
associated with delay in diagnosis, and pos-
sibly with adverse health problems. Theauthors propose an algorithm to decrease
This study is a retrospective chart review of
this waste; if there is clinical suspicion of
pyloric stenosis, the first step is prompt
referral to a pediatric surgeon or an “experi-
unnecessary and redundant diagnostic stud-
ies were done and to propose an algorithm
for the management of patients with sus-pected IHPS.
Propensity Of HIV Patients To Seek Urgent And
Many patients reported that they would use
Emergent Care. HIV Cost And Services
of same-day primary care for several com-
Americans, the poor, and patients with psy-
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 Suspected
Tuberculosis In A New York City Hospital
accounted for 36% of the days of TB isola-
Anderson, J.E., O’Brien, T,. Popper, C.,
consumption occurred during the diagnostic
period before a definitive culture result was
This study analyzed 151 adult admissionsfor suspected Tuberculosis (TB) at oneNew York hospital, in order to compareresource use by diagnostic outcome.
Preventive Pharmacologic Therapy Among
In contrast to the recommendations of the
Asthmatics Five Years After Publication Of
national guidelines, about half of moderate
did not fill any anti-inflammatory agents
short-acting bronchodilators without AI-rep-
resenting overutilization of symptom reliefagents.
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?
The study concludes that the findings raise
Prostate Cancer Diagnosis And PSA Screening
the “possibility of indiscriminate PSA test-
Patterns For A Single Veterans Affairs Medical
ing or unnecessary repetition of testing.”
of prostate cancer per PSA test performed
1998. There was a significant increase inthe number of PSA tests performed
between 1997 (9,410 tests) and 1998 (23,684
Medical Center (VAMC) to estimate theappropriateness of Prostate-SpecificAntigen (PSA) testing.
Analysis Of Chronic Emergency Department Use
62% of the visits were nonurgent, and the
patients were more likely to have nonurgentvisits (70%). Looking at visits, a greater per-
determine the relationship between acuity
level of illness and type of insurance for
(61%), even though this group represented
found that the age group with the highest
times a year. It was hypothesized that unin-
frequency of visits was the 24-64 year old
patients, and that the peak visit period for
have more visits for nonurgent needs.
these patients was between 0800 and 1600and did not increase on weekends, leadingthe authors to conclude that these patientswere not first seeking care elsewhere.
Department Congestion And Hospital Crowding
no association with total hospital costs or
For Chest Pain Patients Awaiting Admission
revenues, or total hospital length of stay.
However, patients awaiting telemetry beds
prevented ER use for new patients, thereby
causing a loss of potential revenue.
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 Hospitalization
fewer preventable admissions, compared to
private fee-for-service. However, Medicaidmanaged care enrollment was not associated
with a reduction in preventable admissions,
compared to Medicaid fee-for-service.
examine the association between managedcare enrollment and preventable hospital-ization patterns of adult Medicaid enrolleesin 4 states.
Non-Emergent And Preventable ED Visits
Approximately 21% of outpatient ED visits
primary-care treatable and emergent butpreventable with good primary care, respec-
To estimate the proportion of non-emergent
were more likely to visit the ED for non-
Extended Use Of Indwelling Urinary Catheters
32% of hip fracture discharges to SNFs had
In Postoperative Hip Fracture Patients
urinary catheters. At 30 days after operation,
and of rehospitalization for urinary tractinfection. Western region and urban loca-
This study used data from Medicare admis-
tion were associated with a higher likeli-
sions to skilled nursing facilities (SNFs)
from acute care hospitals with a diagnosis of
hip fracture to estimate the probability andimpact of having an indwelling urinarycatheter.
Decreasing Overuse Of Therapies In The
Treatment Of Bronchiolitis By Incorporating
decreased, although 53.7% of patients still
received bronchodilators and 46.5% a chest
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:
detecting serious, treatable disease withoutundue cost or undesirable effects.
This review article discusses the issue ofwhether or not whole-body computedtomography scans are appropriate. Theauthor discusses evidence from the US andother developed countries.
Estimated Risks Of Radiation-Induced Fatal
age of 15 years, a rough estimate is that 500
of these individuals might ultimately diefrom cancer attributable to the CT radia-
This article discusses biologic responses to
ionizing radiation and estimates potentialcancer deaths attributable to current levelsof pediatric computed tomography (CT)use.
The Clinical And Economic Correlates Of
Misdiagnosed Appendicitis: Nationwide Analysis
estimated to be negative appendectomies.
were suspected had longer lengths of stay(5.8 vs. 3.6 days), higher total charge-admis-
This study used data from the 1997 health
sion ($18,780 vs. $10,584), higher case fatal-
ity rate (1.5% vs. 0.2%), and higher rate of
National Inpatient Sample to estimate the
infectious complications (2.6% vs. 1.8%).
frequency and cost of negative appendecto-my.
An Evaluation Of Statewide Strategies To
There is over- and misuse of antibiotics for
the 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-
This article tested the hypothesis that inter-
ventions will decrease antibiotic overuse in
treatment of upper respiratory infection(URI) in pediatric populations. There werethree intervention groups: patient educationonly, provider education only, and bothpatient and provider education.
Urban Emergency Department Utilization By
Adolescents on public assistance or without
insurance may frequently utilize an urban
majority of triage codes for ED visits werenonurgent (n=140; 93%).
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 Children
Antibiotic prescription rates declined 19%
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: The
Effect Of Having A Regular Doctor.
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.
Emergency Department Use By Family Practice
Calling ahead was not associated with more
Patients 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 Emergency
Physician (PCP) prior to arrival in the PED.
Comparing the reasons given by these
This was a prospective study of non-urgent
pattern and reasons for nonurgent use of the
pediatric emergency department during reg-
l9% 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.”
Resource Utilization And Its Management In
Splenic injury cases managed at pediatric
longer hospital stays and higher total costs
facilities, even when controlled for injurytype and severity.
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.
Indigent Men’s Use Of Emergency Departments
Factors including a lack of insurance, unem-
Over Primary Care Settings (Letter)
$20,000 a year) were associated with a high-
er rate of ED utilization. Lower incomepatients visited the ED 2.5 times the fre-
study that surveyed 2 Bronx hospitals toexamine the factors leading to emergencydepartment (ED) overuse by men.
Emergency Department Management Of Acute
Careful selection of antimicrobial agents is
essential to maximize benefit and prevent
This study reviews common respiratoryinfections and considers the overuse ofantibiotics.
Practical Considerations When Treating
By avoiding inappropriate use of antimicro-
Children With Antimicrobials In The Outpatient
bials, we can avoid antiobitic resistance.
with therapeutic regimens and improveparental satisfaction
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 Department
Is Medically Nonurgent: Provider Ideologies
appropriateness of medically nonurgent ED
use were identified and found to be linked
to particular communication strategies that
providers employed with ED users: restric-
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.
Reducing Antibiotic Use In Children: A
Educational efforts targeting physicians and
parents can contribute to the declining rate
of antibiotic misuse and overuse in children
S.F., Metlay, J.P., Soumerai, S.B., Rifas-
between the ages of 3 months and 6 years.
antibiotic prescribing by 16% in children
aged 3-36 months, and 12% in children 36-72 months compared to a control group of
regarding antibiotics for upper respiratory
antibiotics per-patient per-year for ages 3-36
infection (URI) in 12 pediatric practices in
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%).
The Beginning Of The End Of The Antibiotic
Antibiotic overuse is one factor in the emer-
Era? Part I. The Problem: Abuse Of The
gence of significant antibiotic resistance.
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 Inebriates
These programs reduce health care use for
most patients; however serious medical ill-
ness and injury in a small number ofpatients contributed heavily to resource uti-
services 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.
Corticosteroids appear to be either overused
or over-prescribed in each of the conditions
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 And
“Angiography, percutaneous transluminal
Revascularization for Acute Coronary
coronary angioplasty (PTCA), and coronary
rather than on the basis of ischemia, do notimprove outcomes. All four studies show
that routine angiography and revasculariza-
tion do not reduce the incidence of nonfatal
reinfarction or death as compared with the
published in the same issue. The study is
the fourth large randomized clinical trial
approach. Physicians who work in hospitals
(RCT) looking at aggressive versus conser-
with catheterization facilities are more like-
ly to recommend coronary angiography than
those without easy access to such a facility.”
Preventing The Spread Of Antimicrobial
Patient pressure and suboptimal diagnosis
Resistance Among Bacterial Respiratory
and treatment contribute to antibiotic over-
Pathogens In Industrialized Countries: The Case
use. Curricula for doctors have been devel-
of respiratory infections. Patient educationmaterials and strategies to improve doctor-
This article reviews the literature and dis-
cusses the joint Centers for Disease Control
(AAP)/American Academy of FamilyPhysicians (AAFP) program to promoterational antibiotic use.
The Annual Physical: Are Physicians And
Although there is no evidence for the utility
of the annual physical, this editorial sug-
gests that it may persist because it provides
a forum to build and nurture the physician-patient relationship.
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 Antibiotics
This article supports the use of prophylactic
antibiotics for specific cardiac, colorectal,gynecologic, ophthalmologic, orthopedic, or
urologic procedures when given as a single
between microbial resistance and the over-
A Simple, Focused, Computerized Query To
A focused query of data derived from a clin-
Detect Overutilization Of Laboratory Tests
ical data repository can detect and docu-
ment overutilization of a common laborato-
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.
Resource Utilization And Outcome In Gravely
23% of patients in the cohort survived to
Ill Intensive Care Unit Patients With Predicted
hospital discharge; all but one were moder-
In-Hospital Mortality Rates Of 95% Or Higher
ately or severely disabled. 10% were alive at
By APACHE III Scores: The Relationship With
1 year. Resource utilization was extensive,
but costs were not calculated. Survival was
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 Prescription
Antibiotics were available in all stores in the
Hispanic neighborhood, but in none of the
stores in non-Hispanic neighborhoods.
This article describes a survey of the avail-ability of non-prescription antibiotics in 101independent stores in Manhattan, NewYork.
Combating Antimicrobial Resistance:
It appears that these interventions are suc-
Intervention Programs To Promote Appropriate
cessfully reducing the inappropriate use of
Emmer, 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.
Cost-Utility Analysis Of Screening Intervals For
Patients in the high-risk group cost an addi-
Diabetic Retinopathy In Patients With Type 2
tional $40,530 per quality-adjusted life year
(QALY) gained, while those in the low-risk
group cost an additional $211,570 per QALY
gained. Retinal screening annually vs. everyother year for patients with type 2 diabetes
This study performed a Markov cost-effec-
screening every other year vs. every third
National Health and Nutrition Examination
Survey 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 Respiratory
Tract Infections In The Primary Care Setting
Jacobs, M.R., Pelton, S., Sethi, S.; 2001;
nonbacterial infections, choosing an antibi-
otic based on the likelihood of infectionwith resistant pathogens, and providing cov-
This paper reviews the literature and the
erage against the predominant pathogens.
results 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 Transportation
transportation unnecessarily. Of the unnec-
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.
Antimigraine Therapy Clinical Features,
headaches. According to the study, treat-
ments for medication-overuse headachesshould include replacement of analgesics
This study is an examination of the litera-
ture on medication-overuse headaches (also
medications and the use of alternative treat-
describe a number of theories on cause anda number of suggestions for treatment.
Transformed Migraine And Medication Overuse
In A Tertiary Headache Centre—Clinical
their illness. The study found that the fre-
Characteristics And Treatment Outcomes
overuse (“detox”), and 17% in those who
were not. The duration of headache painwas reduced by 61% (detox) vs. 15% (no
To compare the outcomes for patients with
medication-overuse headaches (transformedmigraines) who were able to stop overusinganalgesics to those who were not.
Use Of Antihypertensive Drug Therapy In Older
A significant minority of patients (16%) had
Persons In An Academic Nursing Home
uncontrolled hypertension. Among patients
betes, coronary artery disease, and/or heartfailure, a specific recommended class of
This study analyzed the charts of all resi-
drugs (e.g., ACE inhibitors for diabetics)
the time, depending on condition and drug
and appropriate treatment of hypertension
Prevalence Of Subacute Patients In Acute Care:
Over one-third of hospitalized patients had
Results Of A Study Of VA Hospitals
length of stay of 12.7 days; of which 6.8
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 Hysterectomy
what as physicians reevaluate LAVH, adoptnew techniques such as arterial emboliza-
This article is a review about the topic of
tion and myolysis, and rediscover old tech-
“laparoscopically assisted vaginal hysterec-
niques such as uterine morcellation at vagi-
history, challenges, and future of this tech-nique.
Pediatric Emergency Room Visits For
and 522.5 for periapical abscess (47%).
Medicaid recipients used the ER at an
This study reviewed 149 visits to an emer-
gency room (ER) of a children’s hospital
which had a diagnosis of dental caries, peri-
insurance. Almost one-half of the accounts
apical abscess or facial cellulitis. The pur-
changed status during the billing process,
pose was to determine “the incidence and
with the majority being entered as private-
predisposing, enabling, and need factors of
outpatients” and to analyze the hospital
debt or charity after the registration records
were processed and collection was attempt-ed. Most patients were treated empiricallyby the ER physicians according to their pre-senting signs/symptoms.
Propoxyphene Use By Community-Dwelling And
The results show that propoxyphene use by
Institionalized Elderly Medicare Beneficiaries
but is much higher in the institutionalized
prescribing for older adults with pain couldbe improved, especially for vulnerable long-
first 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 The
Most patients had insurance (80%) and 78%
Population Of Individuals Who Seek Health
had 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
This study employed a retrospective record
(4.5% of diagnoses). It was also noted that
most visits were NOT related to alcohol or
gency department (ED) visits at 89 EDs in
Variation In Psychotropic Drug Use In Nursing
drug use are less likely to be hospital-based,
are less likely to have special care units, but
are more likely to have Alzheimer’s special-care units.
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.
Overcrowding In The Nation’s Emergency
Departments: Complex Causes And Disturbing
and acuity of patients using EDs; overall
increases in populations; unintended effects
of managed care; scarcity of inpatient beds;
increasing intensity of ED interventions toavoid hospitalization; delays in providing
This study reviews the literature regarding
ancillary services; nursing, clerical, and
physician shortages; shortages of on-call
(EDs) and describes root causes and conse-
specialty 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.
1998 ARRS Executive Council Award.
Radiology In The Emergency Department:
stable from 1991 to 1997, averaging 60,000
Technique For Quantitative Description Of Use
and 52,000 per year, respectively. Bone radi-
radiographs, 10.4%. The percentages ofradiographs interpreted as normal were
75.9% 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.
increased 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.
Care In The Emergency Department: How
43% of the articles had explicit definitions
tions varied widely in content and focus,
including emergency department, hospital,or external (non-hospital) factors.
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 The
The study reports three findings: 1) the ED
United States: An Emerging Threat To Patient
is a vital part of the safety net, 2) over-
main cause is inadequate inpatient capacity.
This is a systematic review that describeshow emergency department (ED) over-crowding threatens patient safety and pub-lic health.
Frequent Overcrowding In U.S. Emergency
91% of ED directors reported overcrowding
as a problem. Common definitions of over-
following: patients in hallways, all ED bedsoccupied, full waiting rooms longer than 6
hours a day, and acutely ill patients who
to assess the frequency, determinants, and
wait longer than 60 minutes to see a physi-
Ethnic Differences In Past Hysterectomy For
The highest rates of hysterectomy occurred
in the disadvantaged African American and
explained by known risk factors. Therefore,
overuse of hysterectomy in these disadvan-
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 Emergency
Department Headache “Repeater”
1004 visits. 54 patients accounted for 502
visits. Retrospectively, the ED charges forthis group of patients in the previous 12
months was $183,760, 41/52 used narcotics,
center chart reviews to analyze the healthcare utilization of patients who use EDsrepeatedly for recurrent headaches.
The Health Economics Of Asthma And Rhinitis.
In 1998, asthma in the U.S. cost 12.7 billion
dollars annually (for direct and indirect
costs). In 1994, allergic rhinitis cost $1.2
billion. Most of the costs were due to directmedical expenditures (especially medica-
This paper is a narrative review that looked
at 128 articles about asthma and allergicrhinitis in order to estimate the amount ofdirect and indirect costs of these 2 diseasesin the U.S.
Helicopter Transport Of Pediatric Trauma
Out of 175 patients transported by helicop-
Patients In An Urban Emergency Medical
Services System: A Critical Analysis
taken directly to the operating room (OR),33% were discharged home from the ED.
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 Tract
The underlying cause of catheter-associated
UTIs is biofilm formation by pathogens on
the urinary catheter. Research is ongoing
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 Prescribing
27% of all Medicare beneficiaries in nursing
guidelines were no more likely to achieve
stability or improved behavioral symptoms
than were those taking antipsychotics out-side the guidelines.
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.
Economic Evaluation Of Four Treatments For
The adjusted outpatient costs (not includ-
Low Back Pain: Results From A Randomized
ing pharmaceuticals) for the 4 modalities for
only, $560 for chiropractic care only, $579
for chiropractic care with physical modali-
ties, and $760 for medical care and physicaltherapy.
This study examined 18-month costs for 4treatments for low-back pain.
Medical Care- Is More Always Better?
High-intensity practice patterns are associ-
ated with lower quality of care and worseoutcomes than more conservative practice
This editorial discusses the effect of the
Veterans Adminstration’s reform of itshealth care system on patients with chronicdisease.
CT results in low level radiation exposure.
The cumulative effect of repeated examscan lead to significant exposure which could
This letter to the editor discusses theoreti-
predispose to a variety of malignancies.
cal risks and benefits of computed tomogra-phy (CT) scans in terms of the trade-offbetween low-level radiation exposure andincreased diagnostic certainty
Rivista Scientifica fondata nel 1945 da Gaetano Del Vecchio già diretta da Gaetano e Vittorio Del Vecchio Sed prior est sanitas quam sit curatio morbi APPENDICE Versione semplificata della cartella clinica utilizzata nel progetto di ricerca Intervento integrato di accoglienza, trattamento, orientamento ed indirizzo per tossicodipendenti e soggetti a rischio Periodico bimestr
Report available online: http://toxics.usgs.gov/pubs/OFR-02-94/index.html Water-Quality Data for Pharmaceuticals, Hormones, and Other Organic Wastewater Contaminants in U.S. Streams, 1999- 2000 By KIMBERLEE K. BARNES, DANA W. KOLPIN, MICHAEL T. MEYER, E. MICHAEL THURMAN, EDWARD T. FURLONG, STEVEN D. ZAUGG, AND LARRY B. BARBER U.S. Department of the Interior Gale A. Norton, Se