2,565 research outputs found

    Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping review

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    OBJECTIVE: Overdiagnosis and overuse of healthcare services harm individuals, take resources that could be used to address underuse, and threaten the sustainability of health systems. These problems are attracting increasing attention in low-income and middle-income countries (LMICs). Unaware of any review of relevant evidence, we conducted a scoping review of the evidence around overdiagnosis and overuse of diagnostic and screening tests in LMICs. DESIGN: Scoping review. METHODS: We searched PubMed, Embase, PsycINFO, Global Index Medicus for relevant studies published until 24 May 2021, with no restrictions on date or language. We categorised included studies by major focus (overdiagnosis, overuse of tests, or both) and main themes (presence or estimates of extent; drivers; consequences and solutions). RESULTS: We identified 2763 unique records and included 162 articles reporting on 154 studies across 55 countries, involving over 2.8 million participants and/or requests for tests. Almost half the studies focused on overdiagnosis (70; 45.5%), one-third on overuse of tests (61; 39.6%) and one-fifth on both (23; 14.9%). Common overdiagnosed conditions included malaria (61; 39.6%) and thyroid cancer (25; 16.2%), estimated to be >70% in China. Overused tests included imaging (n=25 studies) such as CT and MRI; laboratory investigations (n=18) such as serological tests and tumour markers; and procedures (n=14) such as colonoscopy. Drivers included fear of conflict with patients and expanding disease definitions. Common consequences included unnecessary treatments such as antimalarials, and wasted resources, with costs of malaria overdiagnosis estimated at US$86 million in Sudan in 1 year alone. Only 9% of studies discussed solutions, which included addressing inappropriately lowered diagnostic thresholds and reforming test-ordering processes. CONCLUSIONS: Overdiagnosis and overuse of tests are widespread in LMICs and generate significant harm and waste. Better understanding of the problems and robust evaluation of solutions is needed, informed by a new global alliance of researchers and policy-makers

    Why Not the Best? Results From the National Scorecard on U.S. Health System Performance, 2011

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    Assesses the U.S. healthcare system's average performance in 2007-09 as measured by forty-two indicators of health outcomes, quality, access, efficiency, and equity compared with the 2006 and 2008 scorecards and with domestic and international benchmarks

    Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer)

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    Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of return to training' and return to play' in football. We agreed on return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D

    ITALIAN CONSENSUS STATEMENT (2020) ON RETURN TO PLAY AFTER LOWER LIMB MUSCLE INJURY IN FOOTBALL (SOCCER)

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    Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision- making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of \u2018return to training\u2019 and \u2018return to play\u2019 in football. We agreed on \u2018return to training\u2019 and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D

    Volume III (2014)

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    From Data to Decision: An Implementation Model for the Use of Evidence-based Medicine, Data Analytics, and Education in Transfusion Medicine Practice

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    Healthcare in the United States is underperforming despite record increases in spending. The causes are as myriad and complex as the suggested solutions. It is increasingly important to carefully assess the appropriateness and cost-effectiveness of treatments especially the most resource-consuming clinical interventions. Healthcare reimbursement models are evolving from fee-for-service to outcome-based payment. The Patient Protection and Affordable Care Act has added new incentives to address some of the cost, quality, and access issues related to healthcare, making the use of healthcare data and evidence-based decision-making essential strategies. However, despite the great promise of these strategies, the transition to data-driven, evidence-based medical practice is complex and faces many challenges. This study aims to bridge the gaps that exist between data, knowledge, and practice in a healthcare setting through the use of a comprehensive framework to address the administrative, cultural, clinical, and technical issues that make the implementation and sustainability of an evidence-based program and utilization of healthcare data so challenging. The study focuses on promoting evidence-based medical practice by leveraging a performance management system, targeted education, and data analytics to improve outcomes and control costs. The framework was implemented and validated in transfusion medicine practice. Transfusion is one of the top ten coded hospital procedures in the United States. Unfortunately, the costs of transfusion are underestimated and the benefits to patients are overestimated. The particular aim of this study was to reduce practice inconsistencies in red blood cell transfusion among hospitalists in a large urban hospital using evidence-based guidelines, a performance management system, recurrent reporting of practice-specific information, focused education, and data analytics in a continuous feedback mechanism to drive appropriate decision-making prior to the decision to transfuse and prior to issuing the blood component. The research in this dissertation provides the foundation for implementation of an integrated framework that proved to be effective in encouraging evidence-based best practices among hospitalists to improve quality and lower costs of care. What follows is a discussion of the essential components of the framework, the results that were achieved and observations relative to next steps a learning healthcare organization would consider

    12th World Congress on Controversies in Neurology

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    Warszawa, 22–25 marca 2018 rok

    High-Deductible Health Plans: New Twists on Old Challenges from Tort and Contract

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    In just a few decades American health care financing has, in a sense, come full circle. After being largely patient-financed in the early twentieth century, generous insurance coverage in mid-century largely permitted providers to do as they wished and charge what they pleased-an Artesian Well of Money that left patients and physicians well-insulated from the costs of care. That system\u27s inevitable explosion of costs spurred urgent efforts to contain health care expenditures, as payors sought to control or at least influence medical decisions. In many ways this managed care was clinically vexatious and economically disappointing. Its medically intrusive tactics have now largely though not entirely faded, and-back to the future-the current trend is to place economic responsibility back in patients\u27 hands via Consumer-Defined Health Plans ( CDHPs ) that couple catastrophic insurance coverage with large deductibles. Across this trajectory of financial changes, the focus of health care litigation has evolved right alongside. When physicians largely controlled both care and costs, medical malpractice occupied center stage. Then, as managed care entities exerted greater financial and clinical control, they too became litigation targets, sometimes via direct corporate liability for their own financial and medical decisions, and sometimes under ostensible agency for alleged missteps of physicians with whom they associated. And now, as patients regain financial responsibility, the focus will shift yet again. This Article explores that shift. After further surveying history and the current transition to CDHPs, I will examine three kinds of litigation that are especially likely to arise where patients pay for their own care. Torts questions will arise: when physicians do not disclose the projected costs of care, is this a breach of informed consent? Further issues may arise from the fact that, although physicians have a confidential relationship with patients, their financial interests can create significant conflicts of interest. Where physicians\u27 medical recommendations are too cozy with their own financial interests, can this be a breach of fiduciary duty? Finally, contract questions will emerge around price tags. Where prices are not agreed on in advance, they must generally be reasonable. And yet price structures in health care are often too incomprehensible to discern what reasonableness might mean. When patients complain providers\u27 charges are too high, jurors may be asked to address important questions of health care pricing. Many of these potential litigation issues are not inherently novel. But they may arise with surprising force and frequency. When large numbers of middle income people begin paying directly for substantial procedures out of pocket, they will likely begin scrutinizing more closely the ecomonic as well as medical wisdom of their health care. This Article explores some of the directions that scrutiny may take

    The effects of a typical training run on overuse running-related injury risk factors in recreational runners

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    Running has increased in popularity over recent decades to become one of the five most popular recreational activities worldwide. With this rise in popularity, there has however been a concomitant increase in rate of running related overuse injuries with epidemiology studies reporting 7.7 injuries every 1000 hours of running. Patellofemoral pain and iliotibial band syndrome are the most common RROI accounting up to 17% and 8%, respectively. Runners experiencing either injury share common gait signatures of excessive hip adduction. Running induced fatigue has been shown to reduce strength in numerous muscle groups important for initiating and regulating gait, notably increased hip adduction. These fatigue induced changes to gait have been examined during prolonged or continuous runs, often to exhaustion. Runners however do not typically perform runs to exhaustion during their regular training, rather they perform high intensity interval training or medium intensity continuous running. The level of fatigue induced by these typical training sessions, or its impact on gait is unknown. The aim of this thesis was to examine the effect of fatigue on risk factors associated with development of running related injuries during typical training runs. Acceptable to excellent relative and absolute reliability for risk factors were reported. The absolute reliability enabled an alternative statistical approach to be alongside traditional, group level, P values. This alternative statistical approach used minimum detectable change to detect ‘real changes’ in risk factors post-run. Following two typical running sessions, fatigue induced a changes in running related overuse injury risk factors were found. There was a significant (P < 0.05) reduction in muscle strength (12%) following high intensity interval training session and medium intensity continuous run (10.6%) in both the hip and knee musculature. Force reduction was accompanied by increased maximum hip adduction angle and range of motion (P < 0.05). Fatigue increased coordination variability significantly (P < 0.05) in nearly all variables for hip and knee couplings. Individual assessment showed that the high intensity interval training run induced gait changes in more runners, a finding not observable in group assessment. The fatigue induced changes following training runs could potentially increase the risk of RROI development. This risk however, can only be considered detrimental if still present immediately prior to the next training session. Recovery of strength, kinematic and coordination variability at 24-h following a high intensity interval run was then examined. To fully assess recovery kinetics, evoked electrical stimulation was used to examine the extent of central (voluntary activation) and peripheral (knee extension maximum voluntary contractions and quadriceps twitch potentiation) fatigue immediately post and 24-h after high intensity interval training session. The results not only corroborated those in the previous findings of the thesis, but showed decrements in both central and peripheral drive. Collectively, immediately post, runners exhibited a reduction in hip musculature strength (8.1%),voluntary activation (6.8%), both remaining significantly (P < 0.05) impaired at 24-h. The changes were also accompanied by increased maximum angle and RoM for hip adduction immediately post training run and at 24-hr post. Coordination variability was again increased with fatigue and remained increased at 24-h in those who remained fatigued. The most noteworthy finding was that while collectively there were signs of lack of recovery, on an individual level most runners had recovered within 24-h, while only a few did not and still exhibit impaired gait. Only four runners were identified to be at risk of injury development following fatigue induced changes to risk factors and impaired neuromuscular function following a typical training run. This thesis demonstrated that fatigue induced during a typical training session causes changes to gait. For a minority of runners these changes are still evident 24-h after training placing them at an increased risk of running related overuse injury development
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