Amylase and Lipase Co-ordering in the Workup of Pancreatic Disorders Is Unnecessary and Costly: An Institutional Lab Utilization Study

2019 ◽  
Vol 152 (Supplement_1) ◽  
pp. S25-S25
Author(s):  
Meghan Hupp ◽  
Nicholas Peterson ◽  
Sasha Buchner ◽  
Amy B Karger
Keyword(s):  
Acute Pancreatitis ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
The United States ◽  
Cohen’S Kappa ◽  
Cohen's Kappa ◽  
Meta Analyses ◽  
Lab Test ◽  
Evidence Based Guidelines

Abstract Background Acute pancreatitis is the most common gastrointestinal cause of hospitalization in the United States. Amylase and lipase are commonly ordered together in the workup of suspected pancreatitis at our institution (a large academic medical center), despite meta-analyses and evidence-based guidelines that recommend the use of lipase alone. Lipase has more diagnostic accuracy, rises earlier, and stays elevated longer than amylase. Co-ordering amylase has not been shown to increase sensitivity or specificity. This study aims to explore how well amylase and lipase correlate in our patient population, and which marker more accurately detects acute pancreatitis when the results are discrepant. Methods The laboratory information system was queried for co-orders of amylase and lipase during a 2-month period (November 1, 2016, to December 31, 2016). The overall agreement and Cohen’s kappa were calculated. Discrepant results were separated from concordant results. Clinical data were extracted from the electronic medical record, including the rationale for ordering and relevant diagnosis code. Results There were 962 instances of amylase and lipase co-orders in the 2-month period. Of these, 138 had high amylase and lipase, and 694 had normal amylase and lipase concentrations. The overall agreement was 86.5% and Cohen’s kappa was 0.596 (moderate agreement) (P < .0001). There were 88 cases in which the lipase was elevated and the amylase was normal. Of these, 12 were acute pancreatitis and 76 were not. There were 42 cases in which the amylase was elevated and the lipase was normal; only one case out of 42 was acute pancreatitis. Further investigation into this case revealed that the patient was approximately 7 months status-post pancreas transplant. During this admission, he was diagnosed with “graft pancreatitis” and, while amylase remained elevated above the reference range for longer than lipase after treatment, both enzymes were increased at diagnosis (lipase 831 U/L [73-393 U/L] and amylase 194 U/L [30-110 U/L]). These data show that, had only lipase been ordered, no cases of acute pancreatitis would have been missed. Conclusion Amylase has been shown to be an inferior marker of acute pancreatitis compared to lipase, and many guidelines recommend the use of lipase alone. However, these tests are commonly co-ordered at our institution; in a given 2-month period, there were 962 co-order events. Of these, there were no cases of pancreatitis that would have been missed by ordering lipase alone. Our laboratory charges $50 per amylase assay; therefore $48,100 was spent on unnecessary amylase orders during the 2 months of this study. Lab test overutilization has been identified as an important problem; if addressed and curtailed, labs and hospitals can increase efficiency and cost savings.

Development of an Abstraction Tool to Assess Palliative Care Components

2021 ◽  
pp. 104990912110617
Author(s):  
Meredith A. MacMartin ◽  
Amber E. Barnato
Keyword(s):  
Palliative Care ◽  
Qualitative Content Analysis ◽  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Physical Symptoms ◽  
Future Research ◽  
Clinical Documentation ◽  
Cohen’S Kappa ◽  
Cohen's Kappa

Background: Little is known regarding the fidelity of delivery of guideline-recommended components of palliative care in “real world” encounters. Objective: To develop a qualitative coding framework to identify components of clinical palliative care in clinical documentation across care settings. Design: Retrospective review of palliative care clinical documentation from medical providers, with directed qualitative content analysis to identify components of clinical care documented. Setting/Subjects: Purposively sampled deceased patients seen by palliative care at a US academic medical center between 7/1/2011–7/1/2018. Main Outcomes and Measures: The outcome of this work is a coding framework for use in future research. We assessed the robustness of the framework using Cohen’s kappa. Results: We reviewed sixty-two encounters from twenty-six patients. We identified 7 major themes in documentation: (1) addressing physical symptoms, (2) addressing psychological symptoms, (3) establishing illness understanding, (4) supporting decision making, (5) end-of-life planning, (6) understanding psychosocial context, and (7) care coordination. Interrater reliability varied widely between components, with Cohen’s kappa ranging from −.51 to 1. Conclusions: This pilot study provides a coding framework to measure documentation of clinical palliative care components. Several components could not be reliably identified using this framework, suggesting the need for additional measurement strategies.

scholarly journals Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians’ Training, Current Practices and Perceived Strategies to Improve Future Implementation

2021 ◽  
Vol 12 ◽  
pp. 215013272199688
Author(s):  
Ajeng J. Puspitasari ◽  
Dagoberto Heredia ◽  
Elise Weber ◽  
Hannah K Betcher ◽  
Brandon J. Coombes ◽  
...  
Keyword(s):  
Anxiety Disorder ◽  
Health Services ◽  
Behavioral Health ◽  
Psychiatric Symptoms ◽  
Medical Center ◽  
Academic Medical Center ◽  
Management Training ◽  
The United States ◽  
Behavioral Health Services ◽  
Perinatal Women

Background: This study aimed to explore clinicians’ perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation. Methods: This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States. Results: Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services. Conclusions: Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.

Evaluation of Cost-effectiveness and Clinical Value of Routine Histopathologic Examination of Septoplasty Specimens

2021 ◽  
pp. 019459982110129
Author(s):  
Randall S. Ruffner ◽  
Jessica W. Scordino
Keyword(s):  
Chart Review ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
Retrospective Chart Review ◽  
Clinical Value ◽  
Level Of Evidence ◽  
Significant Pathology ◽  
National Model ◽  
Routine Histopathologic Examination

Objectives During septoplasty, normal cartilage and bone are often sent for pathologic examination despite benign appearance. We explored pathology results following septoplasty from April 2016 to April 2018, examining clinical value and relevance, implications, and cost analysis. Study Design Retrospective chart review. Setting Single-institution academic medical center. Methods A retrospective chart review was compiled by using Current Procedural Terminology code 30520 for septoplasty for indication of nasal obstruction, deviated septum, and nasal deformity. Results A total of 236 consecutive cases were identified spanning a 2-year period. Septoplasty specimens were sent for pathology evaluation in 76 (31%). The decision to send a specimen for histopathology was largely physician dependent. No cases yielded unexpected or significant pathology that changed management. The average total charges for septoplasty were $10,200 at our institution, with 2.2% of procedural charges accounting for pathology preparation and review, averaging $225. Nationally, this results in an estimated charged cost of $58.5 million. The Centers for Medicare and Medicaid Services (CMS) reimbursement for septoplasty pathology charges was $46 in 2018, accounting for 1.3% of hospital-based reimbursements and 2.2% of ambulatory center reimbursements. With CMS as a national model for reimbursement, $11.8 million is spent yearly for septoplasty histopathology. Given that CMS reimbursement is significantly lower than private insurers, national total reimbursement is likely considerably higher. Conclusion Routine pathology review of routine septoplasty specimens is unnecessary, unremarkable, and wasteful. Correlation of the patient’s presentation and intraoperative findings should justify the need for pathology evaluation. This value-based approach can offer significant direct and indirect cost savings. Level of evidence 4.

scholarly journals Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center

2020 ◽  
Vol 41 (S1) ◽  
pp. s84-s84
Author(s):  
Lorinda Sheeler ◽  
Mary Kukla ◽  
Oluchi Abosi ◽  
Holly Meacham ◽  
Stephanie Holley ◽  
...  
Keyword(s):  
Screening Tool ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
The United States ◽  
World Health ◽  
Communication Campaign ◽  
Electronic Screening ◽  
Novel Coronavirus ◽  
The Impact

Background: In December of 2019, the World Health Organization reported a novel coronavirus (severe acute respiratory coronavirus virus 2 [SARS-CoV-2)]) causing severe respiratory illness originating in Wuhan, China. Since then, an increasing number of cases and the confirmation of human-to-human transmission has led to the need to develop a communication campaign at our institution. We describe the impact of the communication campaign on the number of calls received and describe patterns of calls during the early stages of our response to this emerging infection. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center with >200 outpatient clinics. In response to the coronavirus disease 2019 (COVID-19) outbreak, we launched a communications campaign on January 17, 2020. Initial communications included email updates to staff and a dedicated COVID-19 webpage with up-to-date information. Subsequently, we developed an electronic screening tool to guide a risk assessment during patient check in. The screening tool identifies travel to China in the past 14 days and the presence of symptoms defined as fever >37.7°C plus cough or difficulty breathing. The screening tool was activated on January 24, 2020. In addition, university staff contacted each student whose primary residence record included Hubei Province, China. Students were provided with medical contact information, signs and symptoms to monitor for, and a thermometer. Results: During the first 5 days of the campaign, 3 calls were related to COVID-19. The number of calls increased to 18 in the 5 days following the implementation of the electronic screening tool. Of the 21 calls received to date, 8 calls (38%) were generated due to the electronic travel screen, 4 calls (19%) were due to a positive coronavirus result in a multiplex respiratory panel, 4 calls (19%) were related to provider assessment only (without an electronic screening trigger), and 2 calls (10%) sought additional information following the viewing of the web-based communication campaign. Moreover, 3 calls (14%) were for people without travel history but with respiratory symptoms and contact with a person with recent travel to China. Among those reporting symptoms after travel to China, mean time since arrival to the United States was 2.7 days (range, 0–11 days). Conclusion: The COVID-19 outbreak is evolving, and providing up to date information is challenging. Implementing an electronic screening tool helped providers assess patients and direct questions to infection prevention professionals. Analyzing the types of calls received helped tailor messaging to frontline staff.Funding: NoneDisclosures: None

Evaluation of Patient Experience from Telemedicine Use for an Anesthesiology Pain Division: Time, Cost, and Patient Satisfaction Analysis (Preprint)

2021 ◽  
Author(s):  
Laleh Jalilian ◽  
Irene Wu ◽  
Jakun Ing ◽  
Xuezhi Dong ◽  
George Pan ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Pain Management ◽  
Travel Time ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
Travel Distance ◽  
Patient Cost ◽  
Academic Medical ◽  
Pain Patients

BACKGROUND An increasing number of patients require outpatient and interventional pain management. To help meet the rising demand for anesthesia pain subspecialty care in rural and metropolitan areas, healthcare providers have utilized telemedicine for pain management of both interventional and chronic pain patients. OBJECTIVE This study describes telemedicine implementation for pain management at an academic pain division in a large metropolitan area. The study estimates patient cost savings from telemedicine, before and after the California COVID-19 "Safer at Home" directive, and patient satisfaction with telemedicine for pain management care. METHODS This was a retrospective, observational case series study of telemedicine use in a pain division at an urban academic medical center. From August 2019 to June 2020, we evaluated 1,398 patients and conducted 2,948 video visits for remote pain management care. We utilize publicly available IRS Statistics of Income data to estimate hourly earnings by zip code in order to estimate patient cost savings. We estimate median travel time, travel distance, direct cost of travel, and time-based opportunity savings and report patient satisfaction scores. RESULTS Telemedicine patients avoided an estimated median roundtrip driving distance of 26 miles and a median travel time of 69 minutes during afternoon traffic conditions. Within sample, the median hourly earnings was $28/hr. Patients saved a median of $22 on gas and parking and a total of $52 per telemedicine visit based on estimated hourly earnings and travel time. Patients evaluated serially with telemedicine for medication management saved a median of $156 over three visits. 91% of patients surveyed (n = 313) were satisfied with their telemedicine experience. CONCLUSIONS Telemedicine use for pain management reduced travel distance, travel time, and travel and time-based opportunity costs for pain patients. We achieved the successful implementation of telemedicine across a pain division in an urban academic medical center with high patient satisfaction and patient cost savings.

scholarly journals An innovative resident-driven mortality case review curriculum to teach and drive system-based practice improvements in the United States

2018 ◽  
Vol 15 ◽  
pp. 31
Author(s):  
Nila S. Radhakrishnan ◽  
Margaret C. Lo ◽  
Rohit Bishnoi ◽  
Subhankar Samal ◽  
Robert Leverence ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Systems Of Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
The United States ◽  
Case Review ◽  
Failure To Rescue ◽  
Internal Medicine Residents ◽  
Mortality Case

Purpose: Traditionally, the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed. Although M&MCs can facilitate identification of opportunities for systemwide improvements, few studies have described their use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care. Methods: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017. The residents used case review worksheets to categorize and track causes of mortality, and then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. Results: The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases. Three possible management failure themes were identified, including failure to plan, failure to communicate, and failure to rescue, which accounted for 21.9%, 10.7 %, and 10.1% of cases, respectively. Following these reviews, quality improvement initiatives proposed by residents led to system-based changes. Conclusion: A resident-driven mortality review curriculum can lead to improvements in systems of care. This novel type of curriculum can be used to teach system-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

scholarly journals Evaluation of an Outpatient Pharmacist Consult Service at a Large Academic Medical Center

2021 ◽  
Vol 12 (2) ◽  
pp. 13
Author(s):  
Melanie Berry ◽  
Amy Gustafson ◽  
Maya Wai ◽  
Alex J. Luli
Keyword(s):  
Medical Record ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
Acceptance Rate ◽  
Demographic Information ◽  
Consult Service ◽  
Descriptive Data ◽  
Academic Medical ◽  
Patient Demographic Information

Objective: To evaluate a novel outpatient pharmacist consult service in a large academic medical center. Setting: Four outpatient pharmacies that are part of a large academic medical center Methods: An outpatient pharmacist consult order was created and embedded in the electronic medical record (EMR). Medical center providers utilized this consult order when identifying patients in need of specific services provided by outpatient pharmacists. Descriptive data about each individual consult was collected including number completed, type of service, and duration. Rate of accepted pharmacy recommendations and patient cost savings were also evaluated. A survey was administered at the completion of the study period to assess provider and pharmacist satisfaction with the service.  Patient demographic information was collected for those who had a documented completed consult. Results: A total of 193 consults were completed: 137 immunizations, 37 care affordability, 15 education, 3 polypharmacy and 1 OTC recommendation. 89% of completed consults took pharmacists 20 minutes or less to complete. Of completed care affordability consults (n=31), 55% of patients saved between $100 - $500 per medication fill. Of providers who completed a survey and utilized the service (n=12), 83.3% were extremely satisfied and 16.7% were satisfied with it. The provider acceptance rate of pharmacist’s recommendations was 74%. Conclusion: Implementation of an outpatient pharmacist consult service provided an alternative method for the utilization of pharmacist provided MTM services in outpatient pharmacies at a large academic medical center. The service was well received by both providers and pharmacists.

Evaluation of the dosing strategies of biologic agents and the theoretical impact of dose rounding

2016 ◽  
Vol 24 (1) ◽  
pp. 47-55
Author(s):  
Savannah Lindsey ◽  
Laura Beth Parsons ◽  
Lindsay Rosenbeck Figg ◽  
Jill Rhodes
Keyword(s):  
Monoclonal Antibody ◽  
Monoclonal Antibodies ◽  
Medical Center ◽  
Academic Medical Center ◽  
Wholesale Price ◽  
Cost Savings ◽  
Retrospective Chart Review ◽  
Potential Cost ◽  
Cost Avoidance ◽  
The Cost

Introduction Monoclonal antibodies possess unique pharmacokinetic properties that permit flexible dosing. Increased use and high costs of these medications have led to the development of cost-containing strategies. This study aims to quantify the cost savings and clinical impact associated with dose rounding monoclonal antibodies to the nearest vial size. Methods This study was a single-arm, retrospective chart review assessing all monoclonal antibody doses dispensed at an outpatient community infusion center associated with an academic medical center between August 2014 and August 2015. All monoclonal antibody doses were reviewed to determine the cost of drug wasted using two methods. The waste-cost analysis described the amount of drug disposed of due to the use of partial vials. The theoretical dose savings described potential cost avoidance based on rounding the ordered dose to the nearest vial size. The theoretical rounded dose was compared to the actual ordered dose to explore clinical implications. Results A total of 436 doses were included. Of these, 237 were not rounded to the nearest vial size and included in the analysis. The cost of waste associated with these doses was $108,013.64 using actual wholesale price. The potential cost avoidance associated with the theoretical dose calculation was $83,595.53. Rounding these doses to the nearest vial size resulted in a median 6.7% (range, 1.4–20%) deviation from ordered dose. Conclusions Rounding monoclonal antibodies to the nearest vial size could lead to significant cost and waste savings with minimal deviation from the actual ordered dose.

Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing

2019 ◽  
Vol 40 (6) ◽  
pp. 668-673 ◽  
Author(s):  
Jasmine R. Marcelin ◽  
Charlotte Brewer ◽  
Micah Beachy ◽  
Elizabeth Lyden ◽  
Tammy Winterboer ◽  
...  
Keyword(s):  
Best Practice ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
Poisson Model ◽  
Panel Testing ◽  
Period 2 ◽  
Gastrointestinal Pathogen ◽  
Pathogen Testing ◽  
The Impact

AbstractObjective:To evaluate the impact of a hard stop in the electronic health record (EHR) on inappropriate gastrointestinal pathogen panel testing (GIPP).Design:We used a quasi-experimental study to evaluate testing before and after the implementation of an EHR alert to stop inappropriate GIPP ordering.Setting:Midwest academic medical center.Participants:Hospitalized patients with diarrhea for which GIPP testing was ordered, between January 2016 through March 2017 (period 1) and April 2017 through June 2018 (period 2).Intervention:A hard stop in the EHR prevented clinicians from ordering a GIPP more than once per admission or in patients hospitalized for >72 hours.Results:During period 1, 1,587 GIPP tests were ordered over 212,212 patient days, at a rate of 7.48 per 1,000 patient days. In period 2, 1,165 GIPP tests were ordered over 222,343 patient days, at a rate of 5.24 per 1,000 patient days. The Poisson model estimated a 30% reduction in total GIPP ordering rates between the 2 periods (relative risk, 0.70; 95% confidence interval [CI], 0.63–0.78; P < .001). The rate of inappropriate tests ordered decreased from 21.5% to 4.9% between the 2 periods (P < .001). The total savings calculated factoring only GIPP orders that triggered the hard stop was ∼$67,000, with potential savings of $168,000 when factoring silent best-practice alert data.Conclusions:A simple hard stop alert in the EHR resulted in significant reduction of inappropriate GIPP testing, which was associated with significant cost savings. Clinicians can practice diagnostic stewardship by avoiding ordering this test more than once per admission or in patients hospitalized >72 hours.

scholarly journals Physicians as Advisors Not Leaders of Multidisciplinary Teams: A Qualitative Study of an Innovative Practice

2019 ◽  
Vol 1 (3) ◽  
Author(s):  
Eliezer Mendelev ◽  
Madhu Mazumdar ◽  
Laurie Keefer ◽  
Ksenia Gorbenko
Keyword(s):  
Medical Home ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
Leadership Role ◽  
Multidisciplinary Teams ◽  
Structured Interviews ◽  
Home Team ◽  
Team Meetings ◽  
Physician Role

Abstract Background and Aims As various models of team-based chronic disease management have proliferated, physicians have assumed the leadership role in most of them. However, physician time is costly, and regular attendance of team meetings adds another task to a long list of responsibilities. This is the first study to explore the role of physicians as advisors rather than leaders of a multidisciplinary team. Methods We conducted an exploratory qualitative research study of a subspecialty medical home located within a tertiary academic medical center that cares for highly complex pediatric and adult patients with inflammatory bowel diseases. The medical home team consists of a psychologist, dieticians, social workers, a clinical pharmacist, and nurses. No physicians regularly attend team meetings. We conducted semi-structured interviews with nonphysician team members (N = 11) and gastroenterologists (N = 6). Two authors coded interview transcripts in NVivo 11 for themes related to “physician role” using an inductive qualitative analysis approach. Results Nonphysician participant believed gastroenterologists did not need to attend weekly meetings. Having only nonphysician personnel in the room made them feel more empowered to openly express their views. Gastroenterologists expressed interest in attending one or more, but not all meetings, in order to better understand the process of the team and desired a more formal feedback loop for staying informed about their patients’ progress. Conclusions Our findings suggest that gastroenterologist participation may not require regular attendance of team meetings. Team meeting consisting of nonphysician providers would result in cost savings and may empower nonphysician providers.

Sign in / Sign up

Export Citation Format

Share Document