Dartmouth Institute Research Roundup 5.16
Beginning this May, we’ll be featuring a monthly roundup of some of our most recent research, work that is used to evaluate and to help improve way people experience health care. This month’s roundup includes research on ER visits for “non-urgent” conditions, physician knowledge of the FDA-approval process, the possible overuse of CT scans in the ER, patient recording of clinical encounters, and more patient-centered approach to statistical modeling.
Is there a role for urgent care centers in treating patients when they can’t get in to see their doctor?
An upcoming study by Dartmouth Institute alumni Gregory Corwin MPH’15, Devin Parker MS ’14 and associate professor Jeremiah Brown, MS'03, PhD'06, is the first to report on where Medicare patients go to seek treatment for “non-urgent” ailments such as upper respiratory infections, back pain, or arthritis. While considered to be conditions that do not require emergency care, it is estimated that nearly one-third of emergency department visits overall are for non-urgent conditions, which can result in costly care for patients.
Looking at Medicare data from FY 2012, Corwin, Parker and Brown found that the majority of non-urgent visits (83%) took place at physician offices. When unable to visit the doctor’s office, they found that patients visited urgent care centers at a rate of five-fold greater than visiting the ER (14% compared to 3%). In the paper to be published in the The American Journal of Medicine, the authors also looked at regional variation, finding that areas with a higher utilization of urgent care centers corresponded to lower utilization of emergency departments. Overall, the authors state their findings are important in understanding how alternative sites like urgent care centers can be better integrated within the primary care system to more cost effectively provide quality care in a timely manner.
The study is available at http://www.amjmed.com/article/S0002-9343%2816%2930341-2/fulltext
Physicians May Lack Understanding of FDA-Approval Process for New Drugs
A new study co-authored by Dartmouth Institute Researchers Lisa Schwartz and Steve Woloshin reveals a significant number of physicians may lack understanding of what is required for a new drug to gain FDA-approval or receive breakthrough status. In fact, most physicians tend to overestimate evidence requirements associated with both “FDA-approval” and the “breakthrough” designation.
As part of the study, which was recently published in JAMA, a random sample of internists and specialists (in endocrinology, hematology and infectious diseases) were asked three questions about FDA approval and five questions about breakthrough therapies. The questions were designed to test the physicians’ understanding of the terms. Almost three-quarters (73%) of respondents incorrectly believed approval required comparable effectiveness to other approved drugs, while 70% incorrectly believed approval required both a statistically significant and clinically important effect. When it came to the “breakthrough” questions, just over half (52%) of the respondents incorrectly believed that strong evidence, such as randomized clinical trials, is needed to earn breakthrough designation.
The study’s authors concluded that the “misconceptions identified may lead physicians to overprescribe newly approved drugs particularly breakthrough therapies and to inadequately communicate how well these drugs work to patients who will use them.”
The study is available at http://jama.jamanetwork.com/article.aspx?articleid=2512772
A patient-centered approach to statistical modeling yields better information on treatment outcomes for people with colorectal cancer
Recent work by Dartmouth researchers is aimed at getting better information on treatment outcomes for patients with colorectal cancer and their doctors. Currently, randomized clinical trials are considered the most effective measure of treatment outcomes, or the relative success of a particular treatment. In randomized trials, the most common method used to estimate treatment effects is something known as intention-to-treat (ITT). The ITT is preferred in such analysis because it is considered to be a non-biased estimator, which is defined as the contrast between the potential outcome if treated versus if not treated. However, Todd Mackenzie from Dartmouth’s Geisel School of Medicine and The Dartmouth Institute’s James O’Malley, along with Magnus Loberg from the University of Oslo in Norway, have developed a novel approach to measuring treatment effect which takes into account adherence and ultimately leads to better information for patients. “The approach we developed gives a better estimate for the subpopulation of interest – in this case the subpopulation this is actually going to comply to screening directives in the randomized trial,” O’Malley said. “It’s a more patient-centered approach because it more reliably defines the effect of treatment, which is what patients need to know.”
The paper is available at http://obsstudies.org/journal.php?id=33.http://obsstudies.org/journal.php?id=33.
Escalating Use of CT Scans in the Emergency Department is a Growing Concern
An analysis of emergency department (ED) visits for complaints ranging from the common cold to more severe respiratory symptoms points to steady escalation in the use of CT scans, according to a study by Dartmouth Institute researchers Frank Drescher and Brenda Sirovich.
Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), the study found that overall use of CT scans for a range of respiratory complaints quadrupled between 2001 and 2010. The sample of 23,416 visits studied represents approximately 79 million ED visits in the U.S. A marked increase in CT scans was noted across all subgroups, including patients with the least to gain — those with minor complaints such as nasal congestion — and the most to lose —the young (18-39 years of age).
The study concluded that while CT scans are clearly essential in addressing acute or life-threatening respiratory conditions, the steep rise in CT use regardless of indication, urgency, or patient age, raises serious concerns related to radiation exposure, cost and a likely proliferation of incidental findings. Drescher and Sirovich also found that increasing CT use did not appear to change management (likelihood of hospital admission) or improve diagnostic certainty as an increasing proportion of patients were discharged without a diagnosis over the 10-year study period.
The full study is available at http://archinte.jamanetwork.com/article.aspx?articleid=2477125
Dutch Minister of Health recommends patients record clinical encounters, citing work of Dartmouth Institute researchers
The Dutch Ministry of Health recently recommended that patients record conversations with their doctors. Listening to the recorded conversation at home can help patients and their families organize their thoughts, discuss options and make important decisions, wrote Minister of Health, Welfare and Sport Edith Schippers in a letter to the Dutch parliament.
Dr. Glyn Elwyn and other Dartmouth Institute researchers have been at the forefront of research and advocacy around this controversial topic within the health care field —a fact noted by the Ministry and commonly reported in Dutch media. In a 2015 survey of U.K. residents, Elwyn and co-investigators Paul Barr and Stuart Grande, found that 69% of respondents indicated a desire to record doctor visits. In an op-ed in BMJ last year, Elwyn also pointed to the need for clinicians to adapt to a changed digital landscape, asserting that doctors not supporting patients who want to record their clinical encounters is “like putting our heads in the digital sand.”
Patients in most U.S. states have a right to record even without a doctor’s consent. Only 12 states, including New Hampshire, require permission from all parties for audio recordings, including conversations with a doctor.