Common Diagnostic Test Panels for Clinical Evaluation of New Primary Care Outpatients in Japan: A Cost-Effectiveness Evaluation

Abstract Background: The Japan Society of Clinical Pathology (JSCP) has developed a guideline for common diagnostic test utilization in new primary care outpatients. To determine the scientific and economic validity of the JSCP panel testing system, we analyzed cost-effectiveness parameters of test panels advocated. Methods: The “Essential Laboratory Tests” panel (2) [ELT(2) panel], a package of common diagnostic tests added to the ELT(1) baseline health-status screening panel, was applied to 540 new outpatients who visited the Comprehensive Medicine Clinics in an academic medical center during 1991 to 1997. A “useful result” (UR) of testing was defined as a finding that contributed to a change in a physician’s diagnosis- or decision-making, relating to a “tentative initial diagnosis” (TID) obtained from history and physical examination alone. Results: Clinical usefulness was demonstrated in 259 patients with ELT(2), in whom 398 URs were generated. Clinical effectiveness (UR/TID) ranged from 1.65 (hematological) to 0.088 (neurological disease), with a cost disparity from ¥1251 (∼$10) to ¥23 037 (∼$200) per UR. A total of 1137 tests generated URs. We further assessed the clinical effectiveness and economic efficiency (cost/UR) of ELT(1) and restructured panels. Use of the ELT(1) alone generated 244 URs in 167 patients. The poor efficiency of the ELT(1) panel was markedly improved with the addition of certain ELT(2)-specific tests in liver/pancreatobiliary, metabolic/endocrine, and cardiovascular disease groups. Conclusions: A wide disparity in the utility of ELT panels in different patient groups does not support the JSCP recommendation of their routine use for new outpatients. Selective test combinations should be used in selected patient groups.

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Specialised orthotic care to improve functioning in adults with neuromuscular disorders: protocol of a prospective randomised open-label blinded end-point study

BMJ Open ◽

10.1136/bmjopen-2020-039683 ◽

2020 ◽

Vol 10 (11) ◽

pp. e039683

Author(s):

Elza van Duijnhoven ◽

Fieke Sophia Koopman ◽

Jana Antonius Maria Tuijtelaars ◽

Viola Altmann ◽

Rimke Lagrand ◽

...

Keyword(s):

Cost Effectiveness ◽

Goal Attainment ◽

Walking Speed ◽

Fear Of Falling ◽

Medical Center ◽

Neuromuscular Disorders ◽

Academic Medical Center ◽

Clinical Effectiveness ◽

Open Label ◽

End Point

IntroductionPeople suffering from leg muscle weakness caused by neuromuscular disorders (NMDs) are often provided with leg orthoses to reduce walking problems such as increased walking effort, diminished walking speed, reduced balance and falls. However, evidence for the effectiveness of leg orthoses to improve walking in this patient group is limited and there is an absence of standardised practice in orthotic prescription. In 2012 a Dutch multidisciplinary guideline was developed aimed to standardise the orthotic treatment process in NMD. Although application of the guideline in expert centres (specialised orthotic care) seems beneficial regarding clinical effectiveness, larger studies are necessary to confirm results and investigate cost-effectiveness. Therefore, this study aims to examine the effectiveness and cost-effectiveness of specialised orthotic care compared with usual orthotic care in adults with slowly progressive NMD.Methods and analysisA prospective randomised open-label blinded end-point study will be performed, in which 70 adults with slowly progressive NMD are randomly assigned to specialised orthotic care (intervention) or usual orthotic care (control). Outcome measures are assessed at baseline and at 3 and 6 months follow-up. The primary endpoints are gross walking energy cost (J/kg/m) assessed during a 6 min walk test and achievement of personal goals, measured with the Goal Attainment Scale. Secondary endpoints include walking speed, gait biomechanics, stability, physical functioning, falls and fear of falling, perceived fatigue and satisfaction. For the economic evaluation, societal costs and health-related quality of life will be assessed using cost questionnaires and the 5-Level version of EuroQol 5 Dimension, retrospectively.Ethics and disseminationThe study is registered in the Dutch trial register (NL 7511) and the protocol has been approved by the Medical Ethics Committee of the Academic Medical Center in Amsterdam. Results will be presented at national and international scientific conferences and disseminated through peer-reviewed journals and media aimed at a broad audience including patients.

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Yield and Cost of Individual Common Diagnostic Tests in New Primary Care Outpatients in Japan

Clinical Chemistry ◽

10.1093/clinchem/48.1.42 ◽

2002 ◽

Vol 48 (1) ◽

pp. 42-54 ◽

Cited By ~ 11

Author(s):

Yuzuru Takemura ◽

Haku Ishida ◽

Yuji Inoue ◽

J Robert Beck

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Diagnostic Tests ◽

Diagnostic Testing ◽

Cost Savings ◽

Clinical Pathology ◽

Panel Testing ◽

Occult Disease ◽

Definition Of ◽

The Cost

Abstract Background:Appropriate diagnostic testing involves considerations of cost-effectiveness. We examined the cost-effectiveness of individual tests in a panel of tests defined by the Japan Society of Clinical Pathology. Methods: We studied 540 new, symptomatic primary care outpatients with a set of 30 common diagnostic tests [the Essential Laboratory Tests (2); ELT(2) panel] for clinical evaluation and identification of occult disease. A useful result (UR) of testing was defined as a finding that contributed to a change in a physician’s diagnosis or decision-making relating to a “tentative initial diagnosis” obtained from history and physical examination alone. Results: The ELT(2) panel testing yielded 398 URs and uncovered 261 occult diseases among 540 patients. In total, 1592 tests contributed to either UR-generation or discovery of occult disease. The cost per effective test (cost required per test that contributed to either definition of effectiveness) ranged from ¥108 (∼US$0.92) for total cholesterol to ¥6200 (∼$52.50) for chest x-ray. Contribution rates and the cost per effective test varied among disease categories. We restructured panel components considering the effectiveness of each test. Subsets of the ELT(2) would have improved cost-effectiveness and achieved cost savings in five of eight disease categories. Conclusions: Assembly of tests based on cost-effectiveness can improve clinical efficiency and decrease total cost of panel testing for selected patient groups.

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Clinical utility and cost‐effectiveness analysis of chromosome testing concomitant with chromosomal microarray of patients with constitutional disorders in a U.S. academic medical center

Journal of Genetic Counseling ◽

10.1002/jgc4.1496 ◽

2021 ◽

Author(s):

Meng Su ◽

Stephanie Page ◽

Mary Haag ◽

Karen Swisshelm ◽

Deborrah Hennerich ◽

...

Keyword(s):

Cost Effectiveness ◽

Clinical Utility ◽

Medical Center ◽

Academic Medical Center ◽

Cost Effectiveness Analysis ◽

Chromosomal Microarray ◽

Effectiveness Analysis ◽

Academic Medical

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Primary Care Population Management for COVID-19 Patients

10.21203/rs.3.rs-29530/v1 ◽

2020 ◽

Author(s):

MD Deborah Blazey-Martin ◽

FNP Elizabeth Barnhart ◽

Joseph Gillis ◽

Gabriela Andujar Vazquez

Keyword(s):

Primary Care ◽

Nurse Practitioners ◽

Medical Center ◽

Academic Medical Center ◽

Physician Assistants ◽

Population Management ◽

Severe Illness ◽

Management Approach ◽

Primary Care Population ◽

At Home

Abstract BACKGROUND: Most patients infected with SARS-CoV-2 have mild to moderate symptoms manageable at home; however up to 20% develop severe illness requiring additional support. Primary care practices performing population management can use these tools to remotely assess and manage COVID-19 patients and identify those needing additional medical support before becoming critically ill.AIM: We developed an innovative population management approach for managing COVID-19 patients remotely.SETTING: Development, implementation, and evaluation took place in April 2020 within a large urban academic medical center primary care practice.PARTICIPANTS: Our panel consists of 40,000 patients. By April 27, 2020, 305 had tested positive for SARS-CoV-2 by RT-qPCR. Outreach was performed by teams of doctors, nurse practitioners, physician assistants, and nurses.PROGRAM DESCRIPTION: Our innovation includes an algorithm, an EMR component, and a twice daily population report for managing COVID-19 patients remotely.PROGRAM EVALUATION: Of the 305 patients with COVID-19 in our practice at time of submission, 196 had returned to baseline; 54 were admitted to hospitals, six of these died, and 40 were discharged.DISCUSSION: Our population management strategy helped us optimize at-home care for our COVID-19 patients and enabled us to identify those who require inpatient medical care in a timely fashion.

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Hardwiring diagnostic stewardship using electronic ordering restrictions for gastrointestinal pathogen testing

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.78 ◽

2019 ◽

Vol 40 (6) ◽

pp. 668-673 ◽

Cited By ~ 2

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.

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Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center

Annals of Internal Medicine ◽

10.7326/m20-1814 ◽

2020 ◽

Vol 173 (7) ◽

pp. 527-535

Author(s):

Malathi Srinivasan ◽

Steven Asch ◽

Stacie Vilendrer ◽

Samuel Crandall Thomas ◽

Rika Bajra ◽

...

Keyword(s):

Primary Care ◽

Medical Center ◽

Academic Medical Center ◽

Qualitative Assessment ◽

System Transformation ◽

Academic Medical

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Depression Screening and Measurement-Based Care in Primary Care

Journal of Primary Care & Community Health ◽

10.1177/2150132720931261 ◽

2020 ◽

Vol 11 ◽

pp. 215013272093126

Author(s):

Kimberly A. Siniscalchi ◽

Marion E. Broome ◽

Jason Fish ◽

Joseph Ventimiglia ◽

Julie Thompson ◽

...

Keyword(s):

Primary Care ◽

Task Force ◽

Medical Center ◽

Academic Medical Center ◽

Unmet Need ◽

The United States ◽

Depression Screening ◽

Improvement Project ◽

Measurement Based Care

The health issue addressed is the unmet need to universally screen and treat depression, which is one of the most common mental health disorders among adults in the United States. The US Preventive Services Task Force recommends screening adults for depression in primary care and using evidence-based protocols. This quality improvement project implemented VitalSign6, a measurement-based care program, to improve depression screening and treatment of adults in primary care at an academic medical center. A pre-post design was used to determine effectiveness of changes in screening, outcomes, and satisfaction. Of 1200 unique adult patients, 95.4% received initial screening. Providers diagnosed and administered measurement-based care to 236 patients. After 14 weeks, 27.5% returned for at least 1 follow-up. Results showed a statistically significant decrease in self-reported depression scores from baseline to follow-up. VitalSign6 was effective in improving identification and management of depression in primary care.

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Family Medicine Patients Have Shorter Length of Stay When Cared for on a Family Medicine Inpatient Service

Journal of Primary Care & Community Health ◽

10.1177/2150132719840517 ◽

2019 ◽

Vol 10 ◽

pp. 215013271984051 ◽

Cited By ~ 1

Author(s):

Gregory M. Garrison ◽

Rachel L. Keuseman ◽

Christopher L. Boswell ◽

Jennifer L. Horn ◽

Nathaniel T. Nielsen ◽

...

Keyword(s):

Primary Care ◽

Family Medicine ◽

Length Of Stay ◽

Medical Center ◽

Academic Medical Center ◽

General Medicine ◽

Inpatient Service ◽

Academic Medical ◽

The Family ◽

Hospital To Home

Introduction: Hospitalists have been shown to have shorter lengths of stays than physicians with concurrent outpatient practices. However, hospitalists at academic medical centers may be less aware of local resources that can support the hospital to home transition for local primary care patients. We hypothesized that local family medicine patients admitted to a family medicine inpatient service have shorter length of stay than those admitted to general hospitalist services which also care for tertiary patients at an academic medical center. Methods: A retrospective cohort study was conducted at an academic medical center with a department of family medicine providing primary care to over 80 000 local patients. A total of 3100 consecutive family medicine patients admitted to either the family medicine inpatient service or a general medicine inpatient service over 3 years were studied. The primary outcome was length of stay, which was adjusted using multivariate linear regression for demographics, prior utilization, diagnosis, and disease severity. Results: Adjusted length of stay was 33% longer (95% CI 24%-44%) for local family medicine patients admitted to general medicine inpatient services as compared with the family medicine inpatient service. Readmission rates within 30 days were not different (19% vs 16%, P = .14). Conclusions: Local primary care patients were safely discharged from the hospital sooner on the family medicine inpatient service than on general medicine inpatient services. This is likely because the family physicians staffing their inpatient service are more familiar with outpatient resources that can be effectively marshaled to help local patients with the transition from hospital to home.

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