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Oct 18, 2019

Spend check

The story

Wasted time is a venerable and esteemed part of rounds, but are wasted dollars inevitable in healthcare? New research dives into the fluff.

The background

Every once in awhile you bring your own healthy lunch, and every so often prominent researchers team up to estimate how much money is thrown to the wolves within the US healthcare system. The tally is staggering: in 2012 a comprehensive review of US healthcare estimated that 34% of spending could be categorized as wasteful across 6 categories identified by the Institute of Medicine in 2010. Spending already comprises about 18% of US GDP and is projected to increase, even though the US consistently lags other countries in health outcomes.

The numbers

Waste accounts for 25% of US healthcare spending at a total cost of $760 - $930 billion, says a review of 71 estimates across 54 studies. Clinical waste, including inappropriate admissions and hospital complications, lack of preventive care, and excessive end-of-life care, accounted for just over a third of the total, while outright fraud and abuse totaled up to $80 billion. At $250 billion, administrative waste tied to needlessly complex billing procedures was the overall largest contributor. The authors say waste reduction methods could shave $190 - $280 billion if implemented broadly.
JAMA

The takeaway

The estimated waste figure is higher than the costs of Medicaid and Medicare combined and offers plenty of room for improvement. The issue should continue to generate widespread attention with so many dollars on the line.

Say it on rounds

When your patient dumps 5 different inhalers on your desk

You may want to clean that up, if only for the med rec. Asthma remains uncontrolled in up to 40% of patients on inhaled corticosteroids (ICS) and long-acting β2 agonists (LABA). Two RCTs compared use of a single-inhaler triple therapy with LABA, ICS, and a long-acting muscarinic agent (LAMA) with ICS/LABA alone for asthma patients with ≥ 1 exacerbation in the past year. At 26 weeks, both trials found improvements in pre-dose FEV1, and pooled data showed a 23% reduction in clinically relevant severe exacerbations.
Lancet

When you forgo research to spend elective in bed

May the decision bring you peace. A Swedish National Registry survey found that among transgender individuals, gender affirming surgery reduced use of mental health treatment and utilization over a 10-year follow up period. Each year after surgery was associated with an 8% reduction in use of services like mood and anxiety treatments and hospitalizations after suicide attempts. Despite the decrease, mental health utilization continued to exceed that of the general population. 
Am J Psych

When the intern's first 3 A-line approaches are ... off target

She'll improve, but clinical risk assessments for upper GI bleeds remain below expectations. Researchers used artificial intelligence to identify chart features like meds, vitals, and comorbidities that predicted risk of transfusion or death among 2,000 patients who presented with signs of upper GI bleeding. Upon external validation testing, the model (available here) outperformed clinical risk estimators like the Glasgow-Blatchford Bleeding Score, and can be used to help identify patients that can be safely discharged to outpatient management.
Gastroenterology

Brush up

Zika: after the pandemic

Zika was a perfect epidemiological storm: a new strain of the mosquito-borne virus migrated from Asia and rapidly infected a wholly susceptible population in the Americas, first with French Polynesia in 2013- 2014 and later with Brazil and neighboring countries. A dramatic increase in cases of microcephaly among afflicted newborns led the WHO to declare the virus a public health emergency in 2016. After 6,000 Zika-focused scientific publications were released in the past 3 years, you can be sure the field has a better handle on viral transmission and clinical risk.

What's the evidence

For risk of fetal harm following symptomatic maternal Zika infection? While 50 - 80% of Zika cases are asymptomatic, a 2016 prospective study of 117 live births following symptomatic gestational Zika infection in Brazil found abnormal clinical or brain imaging findings in 42% of exposed fetuses. As in other Zika studies, risk was greatest when infection occurred in the first trimester.

What your single friends are talking about

'Don't ever settle' rings a bell. But that doesn't apply to the land of corporate responsibility for the opiate crisis, where drug distributors are working on a $50 billion settlement package to avoid a slew of lawsuits.

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