Drug shortage leading to serendipitous adoption of high-value care practice

Gupta, Arjun; Rahman, Anita Abd; Alvarez, Kristin; Gard, John W; Johnson, David H.; Agrawal, Deepak

doi:10.1136/bmjqs-2017-007015

BMJ Qual Saf

2017

DOI: 10.1136/bmjqs-2017-007015

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Drug shortage leading to serendipitous adoption of high-value care practice

Arjun Gupta

Anita Abd Rahman

Kristin Alvarez

et al.

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Cited by 4 publications

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“…Another untoward effect of keeping patients NPO is excessive use of intravenous medications. In a retrospective study of use of intravenous proton pump inhibitors, the most common reason for inappropriate use was NPO status of the patient. This especially happens when the order placed is NPO rather than NPO except medications, costing hospitals thousands of dollars.…”

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confidence: 99%

Nil Per Os Before Procedures—Time to Reevaluate the Practice

Agrawal

2018

JAMA Intern Med

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low-value care, and we commend them on their research examining the clinical granularity of data that relies on diagnostic coding. Misclassifying a clinically appropriate service as lowvalue in our study 1 is an inherent limitation of using claims data. We would also note that misclassification can function in the other direction; that is, events excluded from the low-value category may be clinically inappropriate.We also agree that there are other important behavioral patient and clinician predictors of low-value care. Unfortunately, large-scale data sets that allow the statistical power to rigorously quantify predictors of low-value care do not contain the level of clinical information necessary to explore certain specific aspects of behavior. While our work cannot determine behavioral factors driving low-value care in detail, it suggests areas for targeting further analyses and interventions. 1 For example, research could examine at what point in clinical training low-value ordering habits begin, clinician characteristics associated with this, and the influences that reinforce this behavior.The work by Hahn and Gould pinpointing higher use of low-value breast cancer surveillance testing among clinicians who perceive that they had "nothing else to offer" highlights an especially pernicious habit. 2 When clinicians order testing that they know is unhelpful because they want to "do something," they miss the opportunity to communicate with and truly reassure a patient, and they ignore potential harms from downstream cascades of care. Beyond the cost implications of low-value care, these patient harms are the most concerning.Further research, including qualitative studies, should determine the modifiable clinician and patient behaviors that lead to low-value care. Unaddressed clinician behavioral factors can overwhelm the effectiveness of evidence-based clinical tools, even in countries where the financial and medico-legal incentives to order low-value care are less pronounced than in the United States. 3 At the same time, interventions to reduce low-value care that are designed with clinician behaviors in mind can be quite effective, 4 though few have been demonstrated at scale. We look forward to future work that will help inform large-scale interventions and steer the United States toward a more evidence-based and patient-centered care delivery system.

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confidence: 99%

Nil Per Os Before Procedures—Time to Reevaluate the Practice

Agrawal

2018

JAMA Intern Med

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“…Like Coronel et al, PPI infusion was recommended for suspected upper gastrointestinal bleeding before endoscopy. However, after successful endoscopic treatment of ulcers with high-risk features, the treatment was changed to oral or intravenous bolus (not infusion) . The endoscopist could request PPI infusion on a case by case basis.…”

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confidence: 99%

Expanding the Scope of High-Value Practice Beyond Guideline-Based Care

2018

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However, except in paragraph 2 of the Statistical Analysis section, Watkins and colleagues 1 describe the primary outcome as "abstinence from all alcohol or any opioids" (again our emphasis). Table 3 1 suggests that 80% or more of participants were abstinent from all opioids at follow-up while the proportion of patients with the primary outcome-reported abstinence from opioids or alcohol at 6 months-were 32.8% and 22.3% in the intervention and control arms, respectively. Because it seems impossible that a lower percentage of patients would be abstinent from opioids or alcohol than from opioids alone, it appears that the primary outcome assessed was consistent with that described in clinicaltrials.gov, 3 but this requires clarification from the authors.Second, the proportion of patients with AUDs (alone or in conjunction with OUDs) should be specified, and trial results should be stratified by condition. The SUMMIT intervention was not associated with increased use of medications for AUDs and OUDs overall. 1 Thus, the 6-session behavioral therapy may have been the efficacious component. Owing to differential efficacy of medications for AUDs and OUDs-specifically, medications are known to be more effective than behavioral therapies alone for OUDs but not AUDs-it is important to understand the condition-specific effects. Therefore, the prevalence of AUDs in the sample should be specified, and results should be presented in secondary analyses stratified by AUDs and OUDs as in a prior trial. 2 Clarification of the primary outcome and presentation of results separately for the overlapping samples of patients who met diagnostic criteria for AUDs and OUDs will enable readers to interpret the important results of the SUMMIT trial 1 and understand its implications for clinical practice and research.

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Supply Shortages: A Silver Lining

Gupta

Mang

Wei

et al. 2018

The American Journal of Medicine

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Drug shortage leading to serendipitous adoption of high-value care practice

Cited by 4 publications

References 10 publications

Nil Per Os Before Procedures—Time to Reevaluate the Practice

Nil Per Os Before Procedures—Time to Reevaluate the Practice

Expanding the Scope of High-Value Practice Beyond Guideline-Based Care

Supply Shortages: A Silver Lining

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