How much diagnostic safety can we afford, and how should we decide? A health economics perspective.
How much diagnostic safety can we afford, and how should we decide? A health economics perspective.
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DOI：
10.1136/bmjqs-2012-001616
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发表时间：
2013-10
影响因子：
5.4
通讯作者：
Meltzer DO
中科院分区：
文献类型：
--
作者：
Newman-Toker DE;McDonald KM;Meltzer DO
控制目前超过2.7万亿美元的医疗保健成本是一项经济要务。1-3诊断检测的费用可能占所有医疗保健费用的10%以上，而且随着时间的推移，这一比例正在迅速上升，4先进的诊断成像居于领先地位，诊断实验室检测紧随其后。用于“个性化医疗”的分子诊断测试可能会导致不成比例的增长。67一些诊断检测被误用或过度使用，仅诊断成像造成的浪费估计就超过250亿美元。8与此同时，诊断错误频繁发生，往往导致死亡或残疾，9最近的估计表明，美国每年有100多万人因诊断错误而受到伤害。对于那些受到伤害的人来说，直接的成本来自于未能治疗真实的病情，对错误诊断的人进行不适当的检测和治疗，以及任何医疗法律费用或付款。11间接费用还来自防御性医疗、医疗责任保费增加以及下游影响。每年仅“防御性医疗”一项的费用——大多是为了防止医疗事故诉讼而进行的不必要的诊断测试——就至少达到450亿至600亿美元，甚至可能达到数千亿美元。鉴于这些事实，公众意识运动（例如，“明智地选择”）寻求促进医生和患者之间就提高诊断安全性和效率的潜在方法进行对话。17然而，要确定诊断测试是否被过度使用或使用不足，以及“更多”的诊断何时并非“更好”的诊断，仍然具有挑战性。在本文中，我们利用一个案例研究示例（方框1）来探索诊断测试特性、适当使用、实际使用、诊断安全性和成本效益之间复杂的相互关系。我们围绕这个问题展开讨论，“我们能负担多少诊断安全性？”评估经济分析的作用，并建议未来研究的领域，这些领域与提高诊断价值和安全性的公共卫生必要性有关。
Controlling the costs of healthcare, which now exceed US $2.7 trillion, is an economic imperative. 1–3 Costs of diagnostic testing probably account for more than 10% of all healthcare costs, and that fraction is rising rapidly over time, 4 with advanced diagnostic imaging leading the way and diagnostic laboratory testing a close second. 5 Molecular diagnostic testing for ‘personalised medicine’may fuel disproportionate rises. 6 7 Some diagnostic tests are misused or overused, with waste from diagnostic imaging alone estimated at more than US $25 billion. 8 At the same time, diagnostic errors are frequent and often result in death or disability, 9 with recent estimates suggesting more than a million a year harmed by diagnostic error in the USA. 10 For those harmed, direct costs accrue from failure to treat the true condition, inappropriate testing and treatments for the incorrectly diagnosed one, and any medicolegal costs or payments. 11 Indirect costs also arise from defensive medicine, increased medical liability premiums, and downstream effects. 11 The annual costs of ‘defensive medicine’ alone—mostly unnecessary diagnostic tests obtained to guard against malpractice law suits—are at least US $45–60 billion12 13 and perhaps hundreds of billions. 14–16 Given these facts, public awareness campaigns (eg,‘Choosing Wisely’) have sought to foster dialogue between doctors and patients about potential ways to improve the safety and efficiency of diagnosis. 17 Nevertheless, it remains challenging to determine whether diagnostic tests are being overused or underused and when ‘more’diagnosis is not ‘better’diagnosis. In this article, we leverage a case study example (box 1) to explore complex inter-relationships between diagnostic test characteristics, appropriate use, actual use, diagnostic safety and cost effectiveness. We frame our discussion around the question,‘How much diagnostic safety can we afford?’to assess the role of economic analysis and suggest areas for future research related to the public health imperative of better value and safety in diagnosis.
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影响因子：
3.6
作者：
Bernstein, J
通讯作者：
Bernstein, J
影响因子：
120.7
作者：
BERWICK, DM;COLTIN, KL
通讯作者：
COLTIN, KL
影响因子：
5
作者：
CUMMINS, RO
通讯作者：
CUMMINS, RO
医学诊断错误的发生率。
影响因子：
5.4
作者：
Graber ML
通讯作者：
Graber ML
影响因子：
--
作者：
FEINSTEIN, AR
通讯作者：
FEINSTEIN, AR