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Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization

  • Author Footnotes
    1 Present address: Internal Medicine Department, Hospital Universitario Río Hortega (HURH), Calle Dulzaina, 2, 47012 Valladolid, Spain.
    Luis Corral-Gudino
    Correspondence
    Corresponding author at: Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain.
    Footnotes
    1 Present address: Internal Medicine Department, Hospital Universitario Río Hortega (HURH), Calle Dulzaina, 2, 47012 Valladolid, Spain.
    Affiliations
    Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain

    Internal Medicine Department, Hospital Universitario Río Hortega, Calle Dulzaina n°2, 47012 Valladolid, Spain
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  • Alicia Rivas-Lamazares
    Affiliations
    Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Ana González-Fernández
    Affiliations
    Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Miriam Rodríguez-María
    Affiliations
    Hospital Pharmacy Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Carmen Aguilera-Sanz
    Affiliations
    Haematology Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Ana Tierra-Rodríguez
    Affiliations
    Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Paula Runza-Buznego
    Affiliations
    Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Ester Hernández-Martín
    Affiliations
    Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Martín Ortega-Gil
    Affiliations
    Nurse Supervisor of Quality Improvement, Nurse Division, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
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  • Alberto Bahamonde-Carrasco
    Affiliations
    Internal Medicine Department, Hospital El Bierzo, GASBI (Gerencia de Asistencia Sanitaria del Bierzo), Calle Médicos sin Fronteras, 7, 24004 Ponferrada, Leon, Spain
    Search for articles by this author
  • Author Footnotes
    1 Present address: Internal Medicine Department, Hospital Universitario Río Hortega (HURH), Calle Dulzaina, 2, 47012 Valladolid, Spain.

      Highlights

      • Prophylaxis, bed rest or dietary restrictions are recommended daily for most inpatients.
      • In many cases, these supporting clinical practices are not necessary for patient management.
      • Physician should recognise the need to question these practices because they are not harmless.
      • The implementation of interventions to address low-value care is needed for all clinical practices.
      • Those interventions not aimed at the entire process from admission to discharge will fail.

      Abstract

      Introduction

      Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value.

      Methods

      We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices.

      Results

      BR or DR at admission were recommended in 37% (32–44) and 24% (19–30) of the patients respectively. In 81% (71–87) and 33% (21–45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92–98) had VL and 25% (19–32) UC. VL were not used in 10% (6–12), UC had no indications for insertion in 21% (11–35) and for maintenance in 31% (12–46) patients. Fifty-seven percent (49–64) of the patients were administered VTP and 69% (62–76) were prescribed SUP. Twenty-two percent (15–31) of patients with VTP and 52% (43–60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53–75) with BAF was prescribed in 38% (25–52) of them.
      An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results.

      Conclusion

      These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.

      Keywords

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