Trends in the Overuse of Ambulatory Health Care Services in the United States (original) (raw)
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Overuse of Health Care Services in the United States
Archives of Internal Medicine, 2012
Background: Overuse, the provision of health care services for which harms outweigh benefits, represents poor quality and contributes to high costs. A better understanding of overuse in US health care could inform efforts to reduce inappropriate care. We performed an extensive search for studies of overuse of therapeutic procedures, diagnostic tests, and medications in the United States and describe the state of the literature.
Urinary Tract Infections: Leading Initiatives in Selecting Empiric Outpatient Treatment (UTILISE)
The Canadian Journal of Hospital Pharmacy, 2014
Overuse of fluoroquinolone antibiotics is associated with outbreaks of methicillin-resistant Staphylococcus aureus and of Clostridium difficile-associated diarrhea and increasing resistance in gram-negative organisms. Over the past decade, resistance of Escherichia coli to ciprofloxacin has increased in the Regina Qu'Appelle Health Region. In August 2011, an exploratory audit of the Regina General Hospital (RGH) emergency department showed that 20% of new antibiotic orders were for fluoroquinolones, and 60% of these new fluoroquinolone orders were for ciprofloxacin. It was postulated that ciprofloxacin was predominantly prescribed for outpatients with urinary tract infection.
National Hospital Ambulatory Medical Care Survey: 2002 Outpatient Department Summary
2004
Objectives-This report describes ambulatory care visits to hospital outpatient departments (OPDs) in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics, as well as selected trends in OPD visits since 1992. Methods-The data presented in this report were collected from the 2002 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. Results-During 2002, an estimated 83.3 million visits were made to hospital OPDs in the United States, or about 29.4 visits per 100 persons. This 2002 rate represents a 31 percent increase since 1992, although rates have been stable since 1999. Females had higher OPD visit rates than males, and black or African American persons had higher OPD visit rates than white persons. The overwhelming majority of visits to hospital OPDs were made by established patients (82.8 percent); 23.8 percent of visits had six or more visits to the clinic within the past year. Private insurance was the most frequent expected payment source (37.3 percent), followed by Medicaid or State Children's Health Insurance Program (SCHIP) (27.3 percent). Since 1999, the percentage of children under 18 years of age relying on Medicaid/SCHIP increased by 23.4 percent. Preventive care visits comprised 18.0 percent of all OPD visits. Medicaid/SCHIP patients used OPDs for preventive care services more frequently than private pay patients. Diagnostic and screening services were ordered or provided at 88.3 percent of visits, therapeutic and preventive services were ordered or provided at 42.8 percent of visits, and medications were prescribed at 65.1 percent of visits. Most patients were given an appointment to return to the clinic (63.3 percent). The percentage of visits where any physician was seen decreased by 10.4 percent between 1992 and 2002, driven largely by a 50 percent decrease in visits to residents or interns. The percentage of visits in which either a physician assistant or nurse practitioner (midlevel providers) was seen increased by 47.0 percent between 1992 and 2002.
Antimicrobial Resistance & Infection Control
Background Although uncomplicated urinary tract infections (uUTIs; occurring in female patients without urological abnormalities or history of urological procedures or complicating comorbidities) are one of the most common community infections in the United States (US), limited data are available concerning associations between antibiotic resistance, suboptimal prescribing, and the economic burden of uUTI. We examined the prevalence of suboptimal antibiotic prescribing and antibiotic resistance and its effects on healthcare resource use and costs. Methods This retrospective cohort study utilized electronic health record data from a large Mid-Atlantic US integrated delivery network database, collected July 2016–March 2020. Female patients aged ≥ 12 years with a uUTI, who received ≥ 1 oral antibiotic treatment within ± 5 days of index uUTI diagnosis, and had ≥ 1 urine culture with antimicrobial susceptibility test, were eligible for inclusion in the study. The study examined the propo...
Ambulatory drug utilization review: opportunities for improved prescription drug use
A mbulatory prescription drug use and the risks associated with it are growing. Between 1983 and 1993, hospital inpatient days decreased by one-fifth and outpatient visits increased by three-quarters, 1 shifting medical care from more-to-less controlled environments for medication use. Of the more than 800 million office visits in 1998, 65% resulted in a drug being prescribed or given-75% or more for family practice and internal medicine specialties. 2 The risks of adverse drug events are substantial in the outpatient setting, with outpatient medication error deaths (7391 deaths in 1993) increasing faster than the number of prescriptions filled. These risks were greatest for African American males, then for white males, African American females, and white females. 1 In 1995, more than 2 million office visits were for medication-related morbidity, most commonly by women and by those aged 65 to 74 years. Medication errors occur for individuals when a mistake is made in prescribing, filling, and/or taking prescription drugs. Avoidable risk exposures and errors also occur at the healthcare delivery system level due to fragmented care and incomplete clinical information. Even in a hospital setting, adverse drug events are often the result of incomplete information when a prescription is being written 4 -a problem requiring an intervention at the level of the system in which medication use occurs. When ambulatory patients see multiple providers, change health plans, and have variable adherence to prescription medication regimens, exposure to the risk of adverse drug events increases substantially. A senior physician with extensive clinical and management experience recently asserted that "actual prescribing is not acceptable by any industry standard." 5 An observational study 6 of medication-related emergency department visits found that 70% were preventable. The accumulated evidence on avoidable GOAL To explain ambulatory prospective and retrospective drug utilization review (DUR), focusing on their potential to support improved prescription drug use.
National Ambulatory Medical Care Survey: 2003 Summary
2002
Objective—This report describes ambulatory care visits made to physician offices in the United States. Statistics are presented on selected characteristics of the physician's practice, the patient, and the visit. Selected trends in office visits from 1993 through 2003 are presented. Methods—The data presented in this report were collected from the 2003 National Ambulatory Medical Care Survey (NAMCS). NAMCS is part
Medical Care, 2013
Background: Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system.
BMC Infectious Diseases, 2016
Background: The Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidencebased guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG). Methods: A single center, prospective, observational study of patients with uncomplicated UTI presenting to an urban ED between September 2012 and February 2014 that examined ED physician adherence to ICPG when treating uncomplicated UTIs. Clinician-directed antibiotic treatment was compared to the ICPG using a standardized case definition for non-adherence. Binomial confidence intervals and student's t-tests were performed to evaluate differences in demographic characteristics and management between patients with pyelonephritis versus cystitis. Regression models were used to analyze the significance of various predictors to non-adherent treatment. Results: 103 cases met the inclusion and exclusion criteria, with 63.1 % receiving non-adherent treatment, most commonly use of a fluoroquinolone (FQ) in cases with cystitis (97.6 %). In cases with pyelonephritis, inappropriate antibiotic choice (39.1 %) and no initial IV antibiotic for pyelonephritis (39.1 %) where recommended were the most common characterizations of non-adherence. Overall, cases of cystitis were no more/less likely to receive nonadherent treatment than cases of pyelonephritis (OR 0.9, 95 % confidence interval 0.4-2.2, P = 0.90). In multivariable analysis, patients more likely to receive non-adherent treatment included those without a recent history of a UTI (OR 3.8, 95 % CI 1.3-11.4, P = 0.02) and cystitis cases with back or abdominal pain only (OR 11.4, 95 % CI 2.1-63.0, P = 0.01). Conclusions: Patients with cystitis with back or abdominal pain only were most likely to receive nonadherent treatment, potentially suggesting diagnostic inaccuracy. Physician education on evidence-based guidelines regarding the treatment of uncomplicated UTI will decrease broad-spectrum use and drug resistance in uropathogens.
To measure the rate of unnecessary antimicrobials (UAU), and the effect of the infectious disease consultation. A 17-week multicenter study, patients' records were reviewed for antimicrobials. A predefined UAU definition was developed. Excluded patients were those on prophylaxis and less than 1-year-old. The outcome is the UAU rate. Confounders were adjusted by Charlson index and APACHE 2 score. The analysis was by Χ 2 and Fischer's Exact Tests and multivariate analysis as appropriate. 662 records were reviewed: 169 qualified the necessary antimicrobial use (NAU) and 493 in the UAU categories. The rate of the UAU was 74.5%. The age means differed (53.85 years for the NAU versus 46.48 years for the UAU, P<0.001) without gender difference (P=0.285). The patients in the UAU category were represented more in UTI, SSTI, BSI, and no infection (P<0.05). The commonest UAU subcategory were non-infectious non-febrile conditions 36.71%, influenza-like illnesses, and viral syndromes 20.08%, combination therapy 17.6%. An infectious disease consultation was significantly associated with less UAU (P ≤ 0.004), and less mortality (P<0.05). In conclusion: UAU rate was high, and an infectious disease consultation significantly reduced the UAU rate and mortality.