Person: Tanasijevic, Milenko
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Tanasijevic
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Milenko
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Tanasijevic, Milenko
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Publication Evaluating the Appropriateness of Digoxin Level Monitoring(American Medical Association (AMA), 1999-02-22) Cañas, Fina; Ma'luf, Nell; Bates, David; Tanasijevic, MilenkoBackground Digoxin level determinations can be useful clinically in patients receiving digoxin therapy but are sometimes misused. Methods Explicit appropriateness criteria were adapted from previously published criteria and revised using local expert opinion. They were then used to evaluate the appropriateness of random samples of inpatient and outpatient serum digoxin levels. Overall agreement between reviewers regarding appropriateness was good (κ=0.65). Patients in the study included 162 inpatients in whom 224 digoxin levels were measured and 117 outpatients in whom 130 digoxin levels were measured during a 6-month period. The main outcome measure was the proportion of digoxin levels with an appropriate indication. Results Among inpatient levels, only 16% (95% confidence intervals [CI], 11%-20%) were appropriate. Of the 189 digoxin levels considered inappropriate, only 26 (14%) had a result of 2.3 nmol/L or more (≥1.8 ng/mL). None of these levels resulted in an important change in therapy, and no patient had a toxic reaction to the therapy. Among inappropriate levels, daily routine monitoring accounted for 78%. Of the 130 outpatient levels, 52% (95% CI, 44%-61%) were appropriate. Of 62 inappropriate levels, only 4 (6%) had a result of 2.3 nmol/L or more (≥1.8 ng/mL). One result led to a change in therapy, but none of the patients were believed to experience a toxic reaction. Among the inappropriate levels, 87% of patients underwent early routine monitoring before a steady state was achieved. Conclusions A high proportion of digoxin levels were inappropriate, particularly among inpatients. In both groups, the primary reason tests were judged inappropriate was early routine monitoring. Few inappropriate tests resulted in important data. Interventions to improve the use of digoxin levels could potentially save substantial resources without missing important clinical results. MANY FACTORS contribute to the rising costs of health care. These rising costs have led to attempts to rethink the ways services are provided and identify services that could be omitted, while maintaining high-quality care. While diagnostic tests are relatively inexpensive individually, they are costly in the aggregate and contribute significantly to the rising expenses of the health care system.1-3 At our institution, digoxin level monitoring accounts for 21% of all therapeutic drug concentration measurements. Digoxin level determinations can be clinically useful in patients receiving digoxin therapy for a variety of reasons, including evaluating compliance and verifying toxicity of the therapy.4-6 While many studies have evaluated the use of digoxin therapeutic drug–monitoring services and sampling for drug monitoring of digoxin, few have evaluated the proportion of digoxin level determinations with appropriate indications.7-10 Since we wanted to measure the appropriateness of serum digoxin levels in our institution, with the aim of developing interventions to improve it, we undertook a study with the following goals: (1) to develop explicit criteria that define appropriate indications for measuring digoxin levels in both inpatients and outpatients; (2) to use these criteria to evaluate the proportion of digoxin determinations with an inappropriate indication; (3) to describe the indications for ordering determinations of drug levels; and (4) to determine how often levels with an inappropriate indication generated clinically important results.Publication Does the Computerized Display of Charges Affect Inpatient Ancillary Test Utilization?(American Medical Association (AMA), 1997-11-24) Bates, David; Kuperman, Gilad J.; Jha, Ashish; Teich, Jonathan; Orav, Endel; Ma'luf, Nell; Onderdonk, Andrew; Pugatch, Robert; Wybenga, Donald; Winkelman, James; Brennan, Troyen; Komaroff, Anthony; Tanasijevic, MilenkoBackground: The computerized display of charges for ancillary tests in outpatients has been found to affect physician-ordering behavior, but this issue has not been studied in inpatients. Objective: To assess whether the computerized display of charges for clinical laboratory or radiological tests affected physician-ordering behavior. Patients and methods: Two prospective controlled trials, randomized by patient, were performed. Each trial included all medical and surgical inpatients at 1 large teaching hospital during 4 and 7 months: 3536 intervention and 3554 control inpatients in the group with clinical laboratory tests, and 8728 intervention and 8653 control inpatients in the group with radiological tests. The intervention consisted of the computerized display of charges for tests at the time of ordering. Main outcome measures: The number of clinical laboratory and radiological tests ordered per admission and the charges for these tests. Results: For the clinical laboratory tests, during a 4-month study period, patients in the intervention group had 4.5% fewer tests ordered, and the total charges for these tests were 4.2% lower, although neither difference was statistically significant. Compared with historical controls from the same 4-month period a year before, the charges for the tests per admission had decreased 13.3%, but the decrease was temporally correlated with a restriction of future ordering of tests, and not with the introduction of the display of charges. For the radiological tests, during a 7-month period, the intervention group had almost identical numbers of tests ordered and charges for these tests. Conclusions: The computerized display of charges had no statistically significant effect on the number of clinical laboratory tests or radiological procedures ordered or performed, although small trends were present for clinical laboratory tests. More intensive interventions may be needed to affect physician test utilization.