Background: Healthcare in the U.S. is increasingly delivered by large health systems that include one or more hospitals and associated outpatient practices. It is unclear what role health systems play in driving or preventing overutilization of healthcare services in the U.S. We sought to learn what characteristics allow certain health systems to avoid low-value care [...]

Background: Transient elevations of blood pressure are common in hospitalized older adults and may lead inpatient clinicians to intensify inpatient antihypertensive therapy and discharge patients on these intensified regimens. Intensification of outpatient regimens during hospitalization can easily become over-treatment once patients return home, increasing patients’ risk of adverse drug events including syncope and falls. Thus, [...]

Background: Medical short stay units (SSU) are increasing in prevalence and frequently care for patients with infections. Antibiotic misuse at discharge from acute hospitalization is common. SSUs, which have rapid patient turnover, could have increased risk for antibiotic misuse during care transitions. Thus, we aimed to characterize antibiotic misuse at discharge from SSUs. Methods: We [...]

Background: Low-value care in the form of overuse of inpatient diagnostic testing is an important driver of high healthcare costs. Financial incentives are known to impact physician behavior and may be a driver of inpatient diagnostic overuse. However, the association between hospital payer mix (which likely impacts the financial incentives for ordering diagnostic tests) and [...]

Background: Neutropenic Fever (NF) is a common complication for patients on myelosuppressive chemotherapy. Despite guidelines by the Infectious Diseases Society of America (IDSA), however, there is variability in physician compliance. There are limited prior studies assessing compliance in this realm and those studies do not fully assess drivers of poor compliance. Poor compliance can result in increased [...]

Background : As part of the Choosing Wisely campaign, the Society of Hospital Medicine recommends against performing “repetitive complete blood count [CBC] and chemistry testing in the face of clinical and lab stability.” This recommendation stems from a body of research that shows that frequent or excessive phlebotomy can have negative consequences, including iatrogenic anemia, increased [...]

Background: Studies have linked the use of anti-secretory agents to nosocomial complications including Clostridium difficile–induced pseudomembranous colitis and hospital acquired pneumonia. In the outpatient setting, the Federal Drug Administration has issued warnings regarding increased risk of hypomagnesemia as well as fractures of the hip, wrist, and spine with the use of proton pump inhibitors. Although [...]

Background: Laboratory testing is one of the highest volume medical activities in a health system. Despite their central role in driving clinical decision making, laboratory diagnostics are highly variable and expensive. The annual cost estimate in the U.S. for low value screening, testing, or procedures range from 17.2 billion to 27.9 billion dollars.1 Excessive laboratory [...]

Background: Repetitive morning laboratory orders are a well-known contributor to healthcare cost. Initial data collected in a related project on high-value care showed that 35% of our Internal Medicine residents identified “fear of attendings” as a reason to order morning labs on the inpatient Medicine service. This observation led us to design a project on [...]

Background: Healthcare costs are a challenge; for the greatest impact, high-value care education should begin early in residency training. Routine lab ordering for hospitalized patients is a well-known cause of high costs. This study utilized multiple interventions to decrease the number of BMPs, CMPs and CBCs ordered by residents on the inpatient medicine service. The [...]