Journal of evaluation in clinical practice
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The health care landscape is changing: it has become the largest part of the economy and changes in public management systems will greatly affect how we practice medicine in the future. Medical education will be more important than ever to ensure patients get the best care with empathy. However, new public management systems implemented without thorough analysis might challenge medical education. An increasing number of public health care institutions provide services based on competitive market rules and express their goals in financial terms and have set financial gains as their main goal, which contradicts the fundamental nature of medical ethics and practice. ⋯ Patients and teaching values are not reducible to financial terms only and the acknowledgement of non-financial values is fundamental to achieve quality in health care and education. The most essential step could be selecting managers who will implement public management principles while taking into account both business requirements and medical ethics.
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Review
Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework.
Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework. ⋯ Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework. This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation. From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.
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Inappropriate antibiotic prescribing is still a major concern that can lead to devastating outcomes including antibiotic resistance. This study aimed to simulate the antibiotic prescribing behaviour by providers for acute respiratory tract infections (ARTIs) and to evaluate the impact of patient expectation, provider's perception of patient's expectation to receive a prescription, and patient's risk for bacterial infection, on the decision to prescribe. ⋯ Given the high number of unnecessary prescriptions for ARTI, we found that policies are needed to influence provider's prescribing behaviour through patient's expectation and provider's perception regarding those expectations. Our simulation framework can further be used by policymakers to design and evaluate interventions that may modify the interaction between health providers and patients to optimize antibiotic prescriptions among ARTI patients for different regions and age groups.
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The true effect of laminar airflow (LAF) systems on postoperative infection is disputed, partly due to uncertainty regarding the validity of ventilation data in register studies. The aim of this study was to validate the information on operating room (OR) ventilation reported by the orthopaedic surgeons to the Norwegian Arthroplasty Register (NAR) after primary total hip arthroplasty (THA). ⋯ Surgeons were not fully aware of what kind of ventilation system they operated in. This study indicates that conclusions based on ventilation data reported on THA in the NAR should not be interpreted without considering the inaccuracy of the data.
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Breast cancer is the most common cancer in women worldwide. Most current guidelines recommend using multigene profiling assays to aid the decision on the addition of chemotherapy to adjuvant hormone therapy for women who present with early-stage, hormone receptor-positive, HER2-negative disease. One of these assays is the Oncotype DX, which predicts the disease recurrence risk and adjuvant chemotherapy benefits. ⋯ A series of sensitivity analysis was conducted to assess the robustness of the study findings. The Magee equations were associated with a total cost savings of C$100 per patient (95% CI, -C$3068 to C$5022) compared with standard of care. The difference in costs was highly sensitive to the extent that the Magee scores could reduce the frequency of adjuvant chemotherapy and Oncotype DX requests.