[Medical overuse, defensive medicine and new reform of professional mistake].

Reflecting on the inappropriateness (medical overuse) and on defensive medicine, the Authors wonder whether the new Italian reform of professional guilt, desired at all institutional levels, will actually contain the high economic costs produced by these large and widespread phenomena. After having characterized the medical overuse and the defensive medicine indicating the common traits and main differences, the reflection is conducted by exploring the many scientific evidence that does not document any causal link between the decriminalization of professional conduct and the containment of the costs produced by the prescriptive inappropriateness. They conclude by stating that, for their containment, a third reform of professional liability will not be helpful. Instead, it must focus on other issues, mainly addressing the excessive reliance on judicial recourse. It should provide for mandatory out-of-court conciliatory mechanisms and clarifying the protective umbrella of the doctor's non-criminality.

Prevalence, contemporary trends and associated factors of potentially inappropriate prescription of edoxaban in real-world clinical practice: A subanalysis of the SUNSHINE registry.

AIM: As the direct oral anticoagulant most recently approved in China, data pertaining to clinical edoxaban use are still scarce. This study investigated the prevalence of and contemporary trends in edoxaban prescription among Chinese patients as well as factors associated with its inappropriate use in a multicentre registry of patients treated in real-world clinical practice. METHODS: This real-world, prospective, multicentre and non-interventional study included 1005 inpatients treated with edoxaban. According to National Medical Products Administration and European Heart Rhythm Association guidelines, edoxaban therapy was determined to be appropriate or inappropriate in each case. RESULTS: The median patient age was 70.0 years (interquartile range 61.0-78.0 years) and 46.3% were women. Overall, 456 (45.4%) patients received inappropriate edoxaban therapy, and common issues included an inappropriately low dosage (183, 18.2%) or wrong drug selection (109, 10.8%), high dosage (73, 7.3%), unreasonable off-label use (49, 4.9%), contraindicated medication combinations (27, 2.7%) and incorrect administration timing (16, 1.6%). Several factors, such as age ≥75 years (odds ratio [OR] = 1.921, 95% confidence interval [CI] 1.355-2.723, P < 0.001), weight >60 kg (OR = 2.657, 95%CI 1.970-3.583, P < 0.001), severe renal insufficiency (OR = 1.988, 95% CI 1.043-3.790, P = 0.037), current anaemia (OR = 1.556, 95% CI 1.151-2.102, P = 0.004) and history of bleeding (OR = 2.931, 95% CI 1.605-5.351, P < 0.001) were associated with an increased risk of inappropriate edoxaban therapy, whereas factors associated with cardiovascular specialties, such as admission to a cardiovascular department (OR = 0.637, 95% CI 0.464-0.873, P = 0.005), dronedarone use (OR = 0.065, 95% CI 0.026-0.165, P < 0.001) and amiodarone use (OR = 0.365, 95% CI 0.209-0.637, P < 0.001) decreased this risk. CONCLUSION: In this real-world study, 45.4% of patients received an inappropriate treatment with edoxaban. Multiple clinical characteristics can help identify patients who should receive edoxaban. Further development and implantation of educational activities and management strategies are needed to ensure the correct use of edoxaban.

Are Tumor Marker Tests Applied Appropriately in Clinical Practice? A Healthcare Claims Data Analysis.

Tumor markers (TM) are crucial in the monitoring of cancer treatment. However, inappropriate requests for screening reasons have a high risk of false positive and negative findings, which can lead to patient anxiety and unnecessary follow-up examinations. We aimed to assess the appropriateness of TM testing in outpatient practice in Switzerland. We conducted a retrospective cohort study based on healthcare claims data. Patients who had received at least one out of seven TM tests (CEA, CA19-9, CA125, CA15-3, CA72-4, Calcitonin, or NSE) between 2018 and 2021 were analyzed. Appropriate determinations were defined as a request with a corresponding cancer-related diagnosis or intervention. Appropriateness of TM determination by patient characteristics and prescriber specialty was estimated by using multivariate analyses. A total of 51,395 TM determinations in 36,537 patients were included. An amount of 41.6% of all TM were determined appropriately. General practitioners most often determined TM (44.3%) and had the lowest number of appropriate requests (27.8%). A strong predictor for appropriate determinations were requests by medical oncologists. A remarkable proportion of TM testing was performed inappropriately, particularly in the primary care setting. Our results suggest that a considerable proportion of the population is at risk for various harms associated with misinterpretations of TM test results.

Potentially Inappropriate Medication Dispensing in Outpatients: Comparison of Different Measurement Approaches.

Purpose of the Research: This paper aims at comparing different approaches to measure potentially inappropriate medication (PIM) with routinely collected data on prescriptions, patient age institutionalization status (ie in nursing home or in the community). A secondary objective is to measure the rate and prevalence of PIM dispensing and to identify problematic practices in Switzerland. Material and Methods: The studied population includes about 90,000 insured over 17 years old from a Swiss health maintenance organization in 2019 and 2020. We computed and compared the number of PIM per patient for Beers criteria, Priscus list, Laroche, NORGEP and Prescrire approaches. We also created a composite indicator that accounts for the specificities of the Swiss context (adaptation to the Swiss drugs' market, recommendations in force related to sleeping pills, anxiolytics and NSAIDs). We also stratified the analysis per physician, including initiation and cessation of PIM prescription. Results: Our comparison revealed similarities between the approaches, but also that each of them had specific gaps that provides further motivation for the development of a composite approach. PIM rate was particularly high for sleeping pills, anxiolytics, NSAIDs, even when analyses were limited to chronic use. Drugs with anticholinergic effect were also frequently prescribed. Based on our composite indicator, 27% of insured over 64 years old received at least one PIM in 2020, and 8% received more than one. Our analyses also reveal that for sleeping pills and anxiolytics, half of the volume (or prevalence?) occurs in the <65 population. We observed strong variations between physicians and a significant proportion of new users among patients with PIM. Conclusion: Our results show that PIMs prescribing is very frequent in Switzerland and is driven mostly by a few drug categories. There is important physician variation in PIM prescribing that warrants the development of intervention targeted at high PIM-prescribers.

Humor research in management: Humor as Social Information (HASI).

Humor research is flourishing in Management. Diverse theories have been adopted and diverse factors have been used in research. Nonetheless, these disconnected efforts pose challenges to the development of a coherent body of knowledge on humor in organizational life. I propose the Humor-as-Social-Information (HASI) framework regarding the social effects of humor, and use it to guide my review on recent humor research in Management. Humor evokes affective and inferential processes leading to perceivers' cognitions and behaviors, and these processes are moderated by two sets of factors, including (1) information-processing motivation/ability and (2) humor inappropriateness. The proposed HASI framework highlights how humor exerts social influence within organizations, and paves new avenues for future research that will help further develop "humor science."

Effect of traumatic brain injury on mild behavioral impairment domains prior to all-cause dementia diagnosis and throughout disease progression.

Introduction: Traumatic brain injury (TBI) may alter dementia progression, although co-occurring neuropsychiatric symptoms (NPS) have received less attention. Originally designed to evaluate behavioral disruption prior to dementia diagnosis, the mild behavioral impairment (MBI) construct relates NPS to underlying neural circuit disruptions, with probable relevance across the progression of neurodegenerative disease. Therefore, the MBI construct may represent a valuable tool to identify and evaluate related NPS both preceding diagnosis of all-cause dementia throughout the progression of disease, representing an important area of inquiry regarding TBI and dementia. This investigation sought to evaluate the effect of TBI on NPS related by the MBI construct in participants progressing from normal cognitive status to all-cause dementia. Methods: Using National Alzheimer's Coordinating Center data, individuals progressing from normal cognition to all-cause dementia (clinician diagnosed) over 7.6 ± 3.0 years were studied to estimate prevalence of MBI domains in 124 participants with prior TBI history (57 with loss of consciousness [LOC] <5 minutes, 22 with LOC >5 min, 45 unknown severity) compared to 822 without. MBI domain prevalence was evaluated (1) prior to dementia onset (including only time points preceding time at dementia diagnosis, as per MBI's original definition) and (2) throughout dementia progression (evaluating all available time points, including both before and after dementia diagnosis). Results: More severe TBI (LOC >5 minutes) was associated with the social inappropriateness MBI domain (adjusted odds ratio = 4.034; P = 0.024) prior to dementia onset, and the abnormal perception/thought content domain looking across dementia progression (adjusted hazard ratio [HRadj] = 3.703; P = 0.005). TBI (all severities) was associated with the decreased motivation domain looking throughout dementia progression (HRadj. = 1.546; P = 0.014). Discussion: TBI history is associated with particular MBI profiles prior to onset and throughout progression of dementia. Understanding TBI's impact on inter-related NPS may help elucidate underlying neuropathology with implications for surveillance, detection, and treatment of behavioral concerns in aging TBI survivors. Highlights: The mild behavioral impairment (MBI) construct links related neuropsychiatric symptoms (NPS) by probable underlying neural network dysfunction.Traumatic brain injury (TBI) with loss of consciousness (LOC) > 5 minutes was associated with pre-dementia social inappropriateness.TBI was associated with decreased motivation looking across dementia progression.TBI with LOC > 5 minutes was associated with abnormal perception/thought content.The MBI construct may be useful for examining related NPS across dementia progression.

Predictors of inappropriate antimicrobial prescription: Eight-year point prevalence surveys experience in a third level hospital in Spain.

Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. We aimed to describe the Point Prevalence Surveys (PPS) methodology implemented in our hospital as an efficient tool to guide ASP strategies. Annually repeated PPS were conducted from 2012 to 2019 at a 750-bed university hospital in South Spain. Key quality indicators and inappropriateness of antimicrobial treatment, defined strictly according to local guidelines, were described. Variables associated with inappropriate treatment were identified by bi/multivariable analysis. A total of 1,600 patients were included. We found that 49% of the prescriptions were inappropriate due to unnecessary treatment (14%), not first line drug recommended (14%), inadequate drug according to microbiological results (9%), unsuitable doses (8%), route (3%) or duration (7%). Samples collection presented a significant protective effect together with sepsis presentation at onset and intensive care unit admission. However, age, receiving an empirical treatment and an unknown or urinary source of the infections treated were independent risk factors for inappropriateness. Site and severity of infection were documented in medical charts by prescribers (75 and 61% respectively). PPS may allow identifying the main risk factors for inappropriateness. This simple methodology may be useful for ASP to select modifiable factors to be prioritized for targeted interventions.

Uncover the Offensive Side of Disparagement Humor: An fMRI Study.

Disparagement humor is a kind of humor that denigrates, belittles an individual or a social group. In the aim to unveil the offensive side of these kinds of jokes, we have run an event-related fMRI study asking 30 healthy volunteers to judge the level of fun of a series of verbal stimuli that ended with a sentence that was socially inappropriate but funny (disparagement joke -DJ), socially inappropriate but not funny (SI) or neutral (N). Behavioral results showed disparagement jokes are perceived as funny and at the same time offensive. However, the level of offense in DJ is lower than that registered in SI stimuli. Functional data showed that DJ activated the insula, the SMA, the precuneus, the ACC, the dorsal striatum (the caudate nucleus), and the thalamus. These activations suggest that in DJ a feeling of mirth (and/or a desire to laugh) derived from the joke (e.g., SMA and precuneus) and the perception of the jokes' social inappropriateness (e.g., ACC and insula) coexist. Furthermore, DJ and SI share a common network related to mentalizing and to the processing of negative feelings, namely the medial prefrontal cortex, the putamen and the right thalamus.

Patrolling the boundaries of social domains: Neural activations to violations of expectations for romantic and work relationships.

According to the social domains hypothesis, we reduce the information-processing demands of complex social cues by classifying them into a limited number of domains, each with distinct sets of expectations. This requires rapid identification of violations of the boundaries between social domains. We hypothesized that these violations are likely to be associated with neural activation of the salience system. Using fMRI we compared responses of 20 adults to expected and unexpected everyday social scenarios in personal and work interactions. The vignettes exemplified different kinds of scenarios presented in the work setting, i.e., task-focused scenarios which are expected at work and scenarios with a personal focus, which are unexpected at work. The key contrast between task and personal focussed scenarios presented in the work setting was associated with fronto-insular activation. Perceived inappropriateness of the unexpected scenarios, and shorter response time to judgment of inappropriateness were also associated with fronto-insular activation, after controlling for unpleasantness. This study indicates specific neural responses to violations of expectations in different social situations. Our findings suggest that the fronto-insular region is implicated in rapid detection of behaviors that cross the boundaries of social domains, which are hypothesized to be necessary for efficient social information processing.

Analysis of Inadequacies in Hospital Care through Medical Liability Litigation.

Over the past two decades, health litigation has followed an exponentially incremental trend. As insurance companies tend to limit their interest because of the high risk of loss, health facilities increasingly need to internalize dispute management. This study was conducted through a retrospective analysis of existing files concerning the civil litigation of the Sant'Andrea Hospital in Rome. All claims from 1 June 2010 to 30 June 2019 were included. Paid claims were further classified according to the areas of health care inappropriateness found. Authors indexed 567 different claims along the study period, with an average number of 59 per year (range 38-77). The total litigation involved 47 different units; more than 40% concerned 5 high-incidence wards or services. Concerning the course of disputes, 91 cases were liquidated before a judicial procedure was instituted, while 177 cases landed in a civil court. Globally, 131 different claims hesitated in compensation, for a total of 16 million 625 thousand euros, 41% of which was related to the internal medicine area. Dealing with the inappropriateness analysis, clinical performance alone involved 76 cases, for a total of 10 million 320 thousand euros, while organization defects involved 20 disputes equivalent to 1 million 788 thousand euros. The aim of this study was to enhance the clinical risk management at our facility through a litigation analysis.

Prevalence and determinants of inappropriate admission and hospitalization in Iran: A systematic review and meta-analysis.

Background: A huge portion of health expenditure is attributed to hospital services. Thus, it is important to use the resources appropriately. Many studies have measured inappropriate admissions and hospitalizations. The aim of this study was to review them systematically and determine the pooled quantity as well as the reasons behind such admissions and hospitalizations. Methods: PubMed, Scopus, Web of Science, Google scholar, and internal databases such as Sid, Magiran, and Barkat were searched in January 2018. Moreover, the grey literature was also performed. All studies which had assessed the appropriateness and inappropriateness of services were included. Newcastle-Ottawa scale was used for quality appraisal. I2 test, subgroup analysis, metaregression, and sensitivity analysis were performed. STATA was used for analysis. There was neither time limitation nor language limitation. The registration number in PROSPERO is CRD42019123401. Results: Of 1576 studies, 15 met the inclusion criteria. The number of medical files ranged from 198 to 1815. Most of the studies (14) were performed in teaching hospitals. AEP was the most frequent tool for assessing inappropriateness of the services. The pooled inappropriate admission and hospitalization were 11% (95% CI= 8% - 14%)) and 13 % (95% CI= 10%-16%)), respectively. The most important determinants for inappropriate hospitalizations were attributed to physicians. Conclusion: A huge portion of health care services is inappropriate. Thus, it is highly recommended to monitor physicians more than before, as the more they are monitored, the less inappropriate the delivered services will be.

The Impact of Non-normative Displays of Emotion in the Workplace: How Inappropriateness Shapes the Interpersonal Outcomes of Emotional Displays.

When it comes to evaluating emotions as either "good" or "bad," everyday beliefs regarding emotions rely mostly on their hedonic features-does the emotion feel good to the person experiencing the emotion? However, emotions are not only felt inwardly; they are also displayed outwardly, and others' responses to an emotional display can produce asymmetric outcomes (i.e., even emotions that feel good to the displayer can lead to negative outcomes for the displayer and others). Focusing on organizational settings, this manuscript reviews the literature on the outcomes of emotional expressions and argues that the evidence points to perceived (in)appropriateness of emotional displays as key to their consequences: emotional displays that are deemed inappropriate generate disadvantageous outcomes for the displayer, and at times also the organization. Drawing on relevant theoretical models [Emotions as Social Information (EASI) theory, the Dual Threshold Model of Anger, and Asymmetrical Outcomes of Emotions], the paper highlights three broad and interrelated reasons why emotion displays could be deemed unfitting and inappropriate: (1) characteristics of the displayer (e.g., status, gender); (2) characteristics of the display (e.g., intensity, mode); and (3) characteristics of the context (e.g., national or organizational culture, topic of interaction). The review focuses on three different emotions-anger, sadness, and happiness-which differ in their valence based on how they feel to the displayer, but can yield different interpersonal outcomes. In conclusion, the paper argues that inappropriateness must be judged separately from whether an emotional display is civil (i.e., polite and courteous) or uncivil (i.e., rude, discourteous, and offensive). Testable propositions are presented, as well as suggested future research directions.

Comparing the Prevalence of Polypharmacy and Potential Drug-Drug Interactions in Nursing Homes and in the Community Dwelling Elderly of Emilia Romagna Region.

Backround: We aimed at assessing the prevalence of polypharmacy and potential drug-drug interactions (DDIs) with clinical relevance in elderly patient on Emilia Romagna area. Both outpatients and residents in nursing homes were assessed, with only partially overlapping strategies. Methods: We defined a list of 190 pairs of potentially interacting drugs, based on literature appraisal and availability of therapeutic alternatives. January-June 2018 data on drug use in patients over 65 years-old were collected from nine Local Health Authorities of Emilia Romagna: data on community-dwelling subjects were extracted from archives of reimbursed prescriptions, while drug use in a sample of nursing homes was recorded from clinical charts in one index day within the same semester. The frequency of polypharmacy (at least five or at least 10 concurrent drugs) and of each DDI was calculated. Results: In line with different rates of polypharmacy (80% vs 16%), the risk of exposure to at least one interaction was 53.7% in nursing homes and 26.4% in outpatients. Among DDIs, in nursing homes antidepressants-anxiolytics (11.9%) ranked first, followed by antidepressants-aspirin (7.4%). In outpatients, ACE-inhibitors-non-steroidal anti-inflammatory drugs (NSAIDs) reached 7.2% followed by the calcium channel blockers-α-blockers (2.4%). Discussion: Polypharmacy and risk of DDIs appeared very different in the two settings, due to both technical and clinical reasons. In order to reduce use of benzodiazepines, NSAIDs, antidepressants and relevant DDIs, 1) defining alternative options for pain relief in elderly outpatients, and 2) implementing non-pharmacological management of insomnia and anxiety in nursing homes should be prioritized.

Inappropriateness of RNAlater to preserve Caenorhabditis elegans for RNA extraction.

Caenorhabditis elegans is a well-established laboratory animal model and has been widely used in biological research. However, it is still a challenge to obtain a good amount of quality RNA from a limited number of C. elegans for gene expression studies. To address this issue, the present study has compared different conditions to preserve C. elegans for RNA extraction after the failure of an initial effort to use RNAlater-preserved worms for RNA extraction. The effects of different concentrations of proteinase K, different worm life stages, and different worm numbers on RNA extraction were also investigated. The best results were achieved under the following conditions: 1) adult worms that were either freshly prepared or quickly frozen in liquid nitrogen followed by storage at -80 °C; 2) disruption of C. elegans with proteinase K (1 mg/mL) in a lysis buffer (65 °C for 10 min) prior to extraction with Trizol agent. This method can provide a stable, rapid, and effective means to extract RNA from C. elegans with variable worm numbers from 20 to 200. •RNAlater was inappropriate for preserving C. elegans for effective RNA extraction.•Proteinase K was verified for lysing a limited number of C. elegans for RNA extraction.

Managing inappropriate utilization of laboratory resources.

Background The inappropriate use of laboratory resources, due to excessive number of tests not really necessary for patient care or by failure to order the appropriate diagnostic test, may lead to wrong, missed or delayed diagnosis, thus potentially jeopardizing patient safety. It is estimated that 5-95% of tests are currently used inappropriately, depending on the appropriateness criteria, thus significantly contributing to the potential of generating medical errors, the third leading cause of death in the US. Content In this review, we discuss the reasons as well as the medical and financial consequences of inappropriate utilization of laboratory tests. We then provide demand management (DM) tools as a means for overcoming this issue and also discuss their benefits, challenges, limitations and requirements for successful implementation. Summary and outlook When based on current evidence, adapted to local conditions and developed in close collaboration with clinicians, DM is a reasonable strategy for progressing toward better management of over- and underuse of laboratory resources.

Are laboratory tests always needed? Frequency and causes of laboratory overuse in a hospital setting.

BACKGROUND: Inappropriate utilization of laboratory resources is an increasing concern especially in high-throughput facilities. Until now, no reliable information has been published addressing to which extent laboratory results are actually used for clinical decision-making. Therefore, we aimed to close this gap using a novel retrospective approach including a survey of clinicians and nurses. METHODS: We retrospectively evaluated the number of re-orders for potassium (K), lactate dehydrogenase (LD), aspartate-aminotransferase (AST), activated partial thromboplastin-time (APTT) and prothrombin-time/INR (PT/INR), after the initial order had to be cancelled due to preanalytical non-conformities. We analyzed subgroups regarding time to re-order, ward and sample priority (urgent vs. routine). Subsequently, we surveyed clinicians and nurses, asking for their estimate of the amount of failed re-orders as well as for possible reasons. RESULTS: From initially cancelled tests, only ~20% of K, LD, AST and ~30% of APTT and PT/INR tests were re-ordered within 24 h. 70% of the investigated clinical chemistry and 60% of coagulation tests were re-ordered one week after cancellation or not at all. Survey participants quite accurately estimated these numbers. Routine laboratory panels, short stay of out-patients, obsolete test results and avoiding additional phlebotomies were the main reasons for not re-ordering cancelled tests. CONCLUSIONS: Overall, 60-70% of test results in the investigated assays ordered in a high throughput laboratory are potentially inappropriate or of doubtful clinically importance. Although clinicians and nurses are aware of this situation, it is the duty of laboratory specialists to overcome overutilization in close collaboration with all involved healthcare workers.

Do public hospitals respond to changes in DRG price regulation? The case of birth deliveries in the Italian NHS.

We study how changes in Diagnosis-Related Group price regulation affect hospital behaviour in quasi-markets with exclusive provision by public hospitals. Exploiting a quasi-natural experiment, we use a difference-in-differences approach to test whether public hospitals respond to an exogenous change in Diagnosis-Related Group tariffs by increasing C-section rates and/or by upcoding. Controlling for a detailed set of mother characteristics, we find that price changes did not affect the probability of a C-section. We do however find evidence of upcoding: Conditional on the birth delivery method (either a C-section or a vaginal delivery), public hospitals experiencing the largest price change exhibit a higher probability of treating patients coded as complicated. This finding suggests that even public hospitals may be sensitive to market incentives.

Timing of appropriate empirical antimicrobial administration and outcome of adults with community-onset bacteremia.

BACKGROUND: Early administration of appropriate antimicrobials has been correlated with a better prognosis in patients with bacteremia, but the optimum timing of early antibiotic administration as one of the resuscitation strategies for severe bacterial infections remains unclear. METHODS: In a retrospective cohort study, adults with community-onset bacteremia at the emergency department (ED) were analyzed. Effects of different cutoffs of time to appropriate antibiotic (TtAa) administration after arrival at the ED on 28-day mortality were examined, after adjustment for independent predictors of mortality identified by multivariate regression analysis. RESULTS: Among 2349 patients, the mean (interquartile range) TtAa was 2.0 (<1 to 12) hours. All selected cutoffs of TtAa, ranging from 1 to 96 hours, were significantly associated with 28-day mortality (adjusted odds ratio (AOR), 0.54-0.65, all P < 0.001), after adjustment of the following prognostic factors: fatal comorbidities (McCabe classification), critical illness (Pitt bacteremia score (PBS) ≥4) on arrival at the ED, polymicrobial bacteremia, extended-spectrum beta-lactamase-producer bacteremia, underlying malignancies or liver cirrhosis, and bacteremia caused by pneumonia or urinary tract infections. The adverse impact of TtAa on 28-day mortality was most evident at the cutoff of 48 hours, as the lowest AOR was identified (0.54, P < 0.001). In subgroup analyses, the most evident TtAa cutoff (i.e., the lowest AOR) remained at 48 hours in mildly ill (PBS = 0; AOR 0.47; P = 0.04) and moderately ill (PBS = 1-3; AOR 0.55; P = 0.02) patients, but shifted to 1 hour in critically ill patients (PBS ≥4; AOR 0.56; P < 0.001). CONCLUSIONS: The time from triage to administration of appropriate antimicrobials is one of the primary determinants of mortality. The optimum timing of appropriate antimicrobial administration is the first 48 hours after non-critically ill patients arrive at the ED. As bacteremia severity increases, effective antimicrobial therapy should be empirically prescribed within 1 hour after critically ill patients arrive at the ED.