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O'Reilly-Jacob M, Perloff J, Buerhaus P. Low-Value Back Imaging in the Care of Medicare Beneficiaries: A Comparison of Nurse Practitioners and Physician Assistants. Med Care Res Rev 2019; 78:197-207. [PMID: 31549583 DOI: 10.1177/1077558719877796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Little is known about practice pattern differences between nurse practitioners (NPs) and physician assistants (PAs). We compared the rates of low-value back images ordered by NPs and PAs. For this comparison, we used 2012-2013 Medicare Part B claims for all beneficiaries in 18 hospital referral regions and a measure of low-value back imaging from the Choosing Wisely recommendations. Models included a random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician type, the emergency department setting, and region. NPs (N = 234) order low-value back images significantly less than PAs (N = 204) (NPs 25.5% vs. PAs 39.2%, p < .0001). Controlling for relevant factors, NPs are 10.0 percentage points (p < .0001) less likely to order a low-value back image than PAs. NPs and PAs have distinct patterns of low-value back imaging, which is likely a reflection of their different practice settings.
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Xu S, Hom J, Balasubramanian S, Schroeder LF, Najafi N, Roy S, Chen JH. Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests. JAMA Netw Open 2019; 2:e1910967. [PMID: 31509205 PMCID: PMC6739729 DOI: 10.1001/jamanetworkopen.2019.10967] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Laboratory testing is an important target for high-value care initiatives, constituting the highest volume of medical procedures. Prior studies have found that up to half of all inpatient laboratory tests may be medically unnecessary, but a systematic method to identify these unnecessary tests in individual cases is lacking. OBJECTIVE To systematically identify low-yield inpatient laboratory testing through personalized predictions. DESIGN, SETTING, AND PARTICIPANTS In this retrospective diagnostic study with multivariable prediction models, 116 637 inpatients treated at Stanford University Hospital from January 1, 2008, to December 31, 2017, a total of 60 929 inpatients treated at University of Michigan from January 1, 2015, to December 31, 2018, and 13 940 inpatients treated at the University of California, San Francisco from January 1 to December 31, 2018, were assessed. MAIN OUTCOMES AND MEASURES Diagnostic accuracy measures, including sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUROC), of machine learning models when predicting whether inpatient laboratory tests yield a normal result as defined by local laboratory reference ranges. RESULTS In the recent data sets (July 1, 2014, to June 30, 2017) from Stanford University Hospital (including 22 664 female inpatients with a mean [SD] age of 58.8 [19.0] years and 22 016 male inpatients with a mean [SD] age of 59.0 [18.1] years), among the top 20 highest-volume tests, 792 397 were repeats of orders within 24 hours, including tests that are physiologically unlikely to yield new information that quickly (eg, white blood cell differential, glycated hemoglobin, and serum albumin level). The best-performing machine learning models predicted normal results with an AUROC of 0.90 or greater for 12 stand-alone laboratory tests (eg, sodium AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 98%; specificity, 35%; PPV, 66%; NPV, 93%; lactate dehydrogenase AUROC, 0.93 [95% CI, 0.93-0.94]; sensitivity, 96%; specificity, 65%; PPV, 71%; NPV, 95%; and troponin I AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 88%; specificity, 79%; PPV, 67%; NPV, 93%) and 10 common laboratory test components (eg, hemoglobin AUROC, 0.94 [95% CI, 0.92-0.95]; sensitivity, 99%; specificity, 17%; PPV, 90%; NPV, 81%; creatinine AUROC, 0.96 [95% CI, 0.96-0.97]; sensitivity, 93%; specificity, 83%; PPV, 79%; NPV, 94%; and urea nitrogen AUROC, 0.95 [95% CI, 0.94, 0.96]; sensitivity, 87%; specificity, 89%; PPV, 77%; NPV 94%). CONCLUSIONS AND RELEVANCE The findings suggest that low-yield diagnostic testing is common and can be systematically identified through data-driven methods and patient context-aware predictions. Implementing machine learning models appear to be able to quantify the level of uncertainty and expected information gained from diagnostic tests explicitly, with the potential to encourage useful testing and discourage low-value testing that incurs direct costs and indirect harms.
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Affiliation(s)
- Song Xu
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Jason Hom
- Division of Hospital Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Santhosh Balasubramanian
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Lee F. Schroeder
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor
| | - Nader Najafi
- Department of Medicine, University of California, San Francisco
| | - Shivaal Roy
- Department of Computer Science, Stanford University, Stanford, California
| | - Jonathan H. Chen
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
- Division of Hospital Medicine, Department of Medicine, Stanford University, Stanford, California
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Ganguli I, Lupo C, Mainor AJ, Raymond S, Wang Q, Orav EJ, Chang CH, Morden NE, Rosenthal MB, Colla CH, Sequist TD. Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Intern Med 2019; 179:1211-1219. [PMID: 31158270 PMCID: PMC6547245 DOI: 10.1001/jamainternmed.2019.1739] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care. OBJECTIVE To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019. EXPOSURES Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG. MAIN OUTCOMES AND MEASURES Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade. RESULTS Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade. CONCLUSIONS AND RELEVANCE Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
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Affiliation(s)
- Ishani Ganguli
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Partners HealthCare, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alexander J Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephanie Raymond
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Chiang-Hua Chang
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Meredith B Rosenthal
- Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Thomas D Sequist
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Partners HealthCare, Boston, Massachusetts
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Arab-Zozani M, Janati A, Zakaria Pezeshki M, Khodayari-Zarnaq R. Policy package for preventing overuse and underuse of health care services in the Iranian health care system: A study protocol. Med J Islam Repub Iran 2019; 33:86. [PMID: 31696080 PMCID: PMC6825377 DOI: 10.34171/mjiri.33.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Indexed: 01/20/2023] Open
Abstract
Background: Overuse and underuse of health care services are progressively recognized in all health systems around the world. There is evidence of overuse and underuse of health care services in Iran. In this study, it was aimed to summarize the evidence of overuse and underuse of health care services in the Iranian health care system. Methods: This study will be conducted in 5 steps using a sequential explanatory multimethod design, literature review, systematic review, qualitative interview, expert panel, and policy Delphi method. This study was approved by Tabriz University of Medical Sciences (ethical confirmation number: IR.TBZMED.REC.1396.908). Conclusion: There is a strong evidence of worldwide overuse and underuse of health care services. Designing context-based prevention strategies by conducting comprehensive and systematic studies will improve the appropriate use of routine services and help patients, physicians, and providers make evidence-based decisions.
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Affiliation(s)
- Morteza Arab-Zozani
- Iranian Center of Excellence in Health Management, Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Social Determinants of Health Research Center, Faculty of Health, Birjand University of Medical Sciences, Birjand, Iran
| | - Ali Janati
- Iranian Center of Excellence in Health Management, Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Zakaria Pezeshki
- Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rahim Khodayari-Zarnaq
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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Maughan BC, Rabin E, Cantrill SV. A Broader View of Quality: Choosing Wisely Recommendations From Other Specialties With High Relevance to Emergency Care. Ann Emerg Med 2019; 72:246-253. [PMID: 30144861 DOI: 10.1016/j.annemergmed.2018.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/21/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE The American College of Emergency Physicians (ACEP) joined the Choosing Wisely campaign in 2013 and has contributed 10 recommendations to reduce low-value care. Recommendations from other specialties may also identify opportunities to improve quality and patient safety in emergency care. The Choosing Wisely work group of the ACEP Quality and Patient Safety Committee seeks to identify and characterize the Choosing Wisely recommendations from other professional societies with the highest relevance to emergency care. METHODS In June 2016, all Choosing Wisely recommendations from other specialties were obtained from the American Board of Internal Medicine Foundation. Using a modified Delphi method, the 10 group members rated recommendations for relevance on a validated 7-point scale. Recommendations identified as highly relevant (median score=7) were rated on 3 additional characteristics: cost savings (1=large, 5=none), risk-benefit profile (1=benefit >risk, 5=risk >benefit), and actionability by emergency physicians (1=complete, 5=none). Results are presented as overall means (eg, mean of subcategory means) and subcategory means with SDs. RESULTS Initial review of 412 recommendations identified 49 items as highly relevant to emergency care. Eleven were redundant with ACEP recommendations, leaving 38 items from 25 professional societies. Overall means for items ranged from 1.57 to 3.1. Recommendations' scores averaged 3.2 (SD 0.6) for cost savings, 1.9 (SD 0.4) for risk-benefit, and 1.6 (SD 0.5) for actionability. The most common conditions in these recommendations were infectious diseases (14 items; 37%), head injury (4 items; 11%), and primary headache disorders (4 items; 11%). The most frequently addressed interventions were imaging studies (11 items; 29%) and antibiotics (9 items; 24%). CONCLUSION Thirty-eight Choosing Wisely recommendations from other specialties are highly relevant to emergency care. Imaging studies and antibiotic use are heavily represented among them.
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Affiliation(s)
- Brandon C Maughan
- Emergency Physicians Integrated Care, Salt Lake City, UT, and The Lewin Group, Falls Church, VA.
| | - Elaine Rabin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephen V Cantrill
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, Denver, CO
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106
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Jacobs ZG, Elnicki DM, Perera S, Weiner DK. An E-learning Module on Chronic Low Back Pain in Older Adults: Effect on Medical Resident Attitudes, Confidence, Knowledge, and Clinical Skills. PAIN MEDICINE 2019; 19:1112-1120. [PMID: 29315426 DOI: 10.1093/pm/pnx333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective To determine 1) the feasibility of implementing an e-learning module on chronic low back pain (CLBP) in an older adult into an existing internal medicine residency curriculum and 2) the impact of this module on resident attitudes, confidence, knowledge, and clinical skills relating to CLBP. Methods Participants were assigned to complete either the online module (N = 73) or the Yale Office-based curriculum on CLBP (N = 70). Attitudes, confidence, and knowledge were evaluated pre- and postintervention via survey. A retrospective blinded chart review of resident clinic encounters was conducted, wherein diagnosis codes and physical exam documentation were rated as basic or advanced. Results There was no improvement in overall knowledge scores in either group (60% average on both metrics). There were tendencies for greater improvements in the intervention group compared with controls for confidence in managing fibromyalgia (2.4 to 2.9 vs 2.5 to 2.5, P = 0.06) and leg length discrepancy (1.8 to 2.5 vs 1.5 to 1.9, P = 0.05). Those exposed to the online module also showed an increase in the percentage of physical exam documentation rated as advanced following the intervention (13% to 32%, P = 0.006), whereas the control group showed no change (14% to 12%, P = 0.68). Conclusions An online module on CLBP in the older adult was a feasible addition to an existing curriculum for internal medicine residents. The module positively and substantively impacted resident clinical behaviors, as evidenced by enhanced sophistication in physical exam documentation; it also was associated with improved confidence in certain aspects of chronic pain management.
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Affiliation(s)
| | | | | | - Debra K Weiner
- Division of Geriatric Medicine.,Department of Medicine.,Department of Psychiatry.,Department of Anesthesiology.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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107
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Wang P, Hutfless SM, Shin EJ, Hartman C, Disney S, Fain CC, Bull-Henry KP, Daniels DK, Abdi T, Singh VK, Kalloo AN, Makary MA. Same-Day vs Different-Day Elective Upper and Lower Endoscopic Procedures by Setting. JAMA Intern Med 2019; 179:953-963. [PMID: 31081872 PMCID: PMC6515815 DOI: 10.1001/jamainternmed.2018.8766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied. OBJECTIVES To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices. MAIN OUTCOMES AND MEASURES Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated. RESULTS A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD: aOR, 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR, 1.27; 95% CI, 1.23-1.32). Older age (85-94 years vs 65-74 years: aOR, 1.10; 95% CI, 1.08-1.11; 95 years or older vs 65-74 years: aOR, 1.14; 95% CI, 1.03-1.26), black and Hispanic race/ethnicity (black: aOR, 1.15; 95% CI, 1.12-1.17; Hispanic: aOR, 1.12; 95% CI, 1.10-1.14), and residing in the Northeast region (adjusted OR, 1.32; 95% CI, 1.28-1.36) were risk factors for undergoing different-day procedures. Micropolitan location (aOR, 0.94; 95% CI, 0.92-0.96) and rural location (aOR, 0.91; 95% CI, 0.89-0.93), more comorbidities (≥5: aOR, 0.75; 95% CI, 0.74-0.76), physician's fewer years in practice (aOR, 0.84; 95% CI, 0.81-0.87), physician's higher procedure volume (aOR, 0.65; 95% CI, 0.62-0.68), and physician's specialty of general surgery (aOR, 0.86; 95% CI, 0.80-0.91) were protective factors. CONCLUSIONS AND RELEVANCE Physician offices and ASCs had much higher different-day procedure rates compared with HOPDs. This disparity may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.
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Affiliation(s)
- Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan M Hutfless
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eun J Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christian Hartman
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah Disney
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Fain
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathy P Bull-Henry
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Tsion Abdi
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Schulman JM, Palchaudhuri S, Lau BD, O'Rourke P. Infusing High Value Care Education Directly into Patient Care on the Medicine Wards. MEDEDPUBLISH 2019; 8:136. [PMID: 38089387 PMCID: PMC10712453 DOI: 10.15694/mep.2019.000136.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
This article was migrated. The article was marked as recommended. Background: Multiple national initiatives have been implemented to promote cost-conscious care. Yet, there remains a deficiency of formal high value care (HVC) curricula among internal medicine residency programs.We aimedto develop a curriculum that teaches HVC material that can be utilized at the point of care and to assess the curriculum's impact on the participants' attitudes, knowledge, and practice patterns pertaining to HVC. Methods: We conducted our study on the inpatient internal medicine service over two-week rotations at Johns Hopkins Bayview Medical Center. Internal medicine residentsparticipated in two collaborative educational sessions that incorporated an introduction of important concepts in HVC, Bayesian thinking, clinical cases, and a review of a hospital bill of one of the patients under the team's care. Participants were also encouraged to reflect on their practice patterns and incorporate the HVC principles taught into their daily clinical work. We administered pre- and post-curriculum surveys to assess change in reported HVC-related practice behaviors, knowledge, and attitudes. Results: Forty-seven residents participated in the study. We included the twenty participants who completed both a pre- and post-curriculum survey in the data analysis. After participation in the curriculum, there was a significant increase in the use of pre-test probabilities in clinical decision making ( p=0.005). There was also a trend toward improvement in HVC knowledge and practice patterns after the rotation. Conclusion: We implemented a curriculum that may have improved high-value practice patterns through point-of-care education on the inpatient medicine wards.
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Badgery-Parker T, Feng Y, Pearson SA, Levesque JF, Dunn S, Elshaug AG. Exploring variation in low-value care: a multilevel modelling study. BMC Health Serv Res 2019; 19:345. [PMID: 31146744 PMCID: PMC6543591 DOI: 10.1186/s12913-019-4159-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 05/10/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Whether patients receive low-value hospital care (care that is not expected to provide a net benefit) may be influenced by unmeasured factors at the hospital they attend or the hospital's Local Health District (LHD), or the patients' areas of residence. Multilevel modelling presents a method to examine the effects of these different levels simultaneously and assess their relative importance to the outcome. Knowing which of these levels has the greatest contextual effects can help target further investigation or initiatives to reduce low-value care. METHODS We conducted multilevel logistic regression modelling for nine low-value hospital procedures. We fit a series of six models for each procedure. The baseline model included only episode-level variables with no multilevel structure. We then added each level (hospital, LHD, Statistical Local Area [SLA] of residence) separately and used the change in the c statistic from the baseline model as a measure of the contribution of the level to the outcome. We then examined the variance partition coefficients (VPCs) and median odds ratios for a model including all three levels. Finally, we added level-specific covariates to examine if they were associated with the outcome. RESULTS Analysis of the c statistics showed that hospital was more important than LHD or SLA in explaining whether patients receive low-value care. The greatest increases were 0.16 for endoscopy for dyspepsia, 0.13 for colonoscopy for constipation, and 0.14 for sentinel lymph node biopsy for early melanoma. SLA gave a small increase in c compared with the baseline model, but no increase over the model with hospital. The VPCs indicated that hospital accounted for most of the variation not explained by the episode-level variables, reaching 36.8% (95% CI, 31.9-39.0) for knee arthroscopy. ERCP (8.5%; 95% CI, 3.9-14.7) and EVAR (7.8%; 95% CI, 2.9-15.8) had the lowest residual variation at the hospital level. The variables at the hospital, LHD and SLA levels that were available for this study generally showed no significant effect. CONCLUSIONS Investigations into the causes of low-value care and initiatives to reduce low-value care might best be targeted at the hospital level, as the high variation at this level suggests the greatest potential to reduce low-value care.
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Affiliation(s)
- Tim Badgery-Parker
- Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, The University of Sydney, Level 2, Charles Perkins Centre D17, Sydney, NSW, 2006, Australia.
| | - Yingyu Feng
- Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, The University of Sydney, Level 2, Charles Perkins Centre D17, Sydney, NSW, 2006, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | | | - Susan Dunn
- NSW Ministry of Health, Sydney, Australia
| | - Adam G Elshaug
- Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, The University of Sydney, Level 2, Charles Perkins Centre D17, Sydney, NSW, 2006, Australia
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Aikens RC, Balasubramanian S, Chen JH. A Machine Learning Approach to Predicting the Stability of Inpatient Lab Test Results. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE PROCEEDINGS. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE 2019; 2019:515-523. [PMID: 31259006 PMCID: PMC6568078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A primary focus for reducing waste in healthcare expenditure is identifying and discouraging unnecessary repeat lab tests. A machine learning model which could reliably predict low information lab tests could provide personalized, real-time predictions to discourage over-testing. To this end, we apply six standard machine learning algorithms to six years (2008-2014) of inpatient data from a tertiary academic center, to predict when the next measurement of a lab test is likely to be the "same" as the previous one. Out of 13 common inpatient lab tests selected for this analysis, several are predictably stable in many cases. This points to potential areas where machine learning approaches may identify and prevent unneeded testing before it occurs, and a methodological framework for how these tasks can be accomplished.
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Affiliation(s)
- Rachael C Aikens
- Program in Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Santhosh Balasubramanian
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Jonathan H Chen
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
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Oakes AH, Chang HY, Segal JB. Systemic overuse of health care in a commercially insured US population, 2010-2015. BMC Health Serv Res 2019; 19:280. [PMID: 31046746 PMCID: PMC6498548 DOI: 10.1186/s12913-019-4079-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/09/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Overuse is a leading contributor to the high cost of health care in the United States. Overuse harms patients and is a definitive waste of resources. The Johns Hopkins Overuse Index (JHOI) is a normalized measure of systemic health care services overuse, generated from claims data, that has been used to describe overuse in Medicare beneficiaries and to understand drivers of overuse. We aimed to adapt the JHOI for application to a commercially insured US population, to examine geographic variation in systemic overuse in this population, and to analyze trends over time to inform whether systemic overuse is an enduring problem. METHODS We analyzed commercial insurance claims from 18 to 64 year old beneficiaries. We calculated a semiannual JHOI for each of the 375 Metropolitan Statistical Areas and 47 rural regions of the US. We generated maps to examine geographic variation and then analyzed each region's change in their JHOI quintile from January 2011 to June 2015. RESULTS The JHOI varied markedly across the US. Across the country, rural regions tended to have less systemic overuse than their MSA counterparts (p < 0.01). Regional systemic overuse is positively correlated from one time period to the next (p < 0.001). Between 2011 and 2015, 53.7% (N = 226) of regions remained in the same quintile of the JHOI. Eighty of these regions had a persistently high or persistently low JHOI throughout study duration. CONCLUSIONS The systemic overuse of health care resources is an enduring, regional problem. Areas identified as having a persistently high rate of systemic overuse merit further investigation to understand drivers and potential points of intervention.
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Affiliation(s)
- Allison H Oakes
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
- Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, MD, USA.
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
The preanesthesia evaluation is an opportunity to elucidate a patient's underlying medical disease, determine if the patient is optimized, treat modifiable conditions, screen for potentially unrecognized disorders, and present the clear picture of the patient's overall risk for perioperative complications. This article presents the preoperative assessment of pulmonary patients in 2 sections. First, the components of a thorough assessment of patients presenting for preanesthesia evaluation, which should occur for all patients, regardless of the presence of pulmonary pathology, are discussed. Then, the considerations unique to patients with pulmonary diseases commonly encountered are described.
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Affiliation(s)
- Angela Selzer
- Department of Anesthesiology, University of Colorado, 12401 East 17th Avenue, 7th floor, Aurora, CO 80045, USA
| | - Mona Sarkiss
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA.
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113
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Mafi JN, Godoy-Travieso P, Wei E, Anders M, Amaya R, Carrillo CA, Berry JL, Sarff L, Daskivich L, Vangala S, Ladapo J, Keeler E, Damberg CL, Sarkisian C. Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System. JAMA Intern Med 2019; 179:648-657. [PMID: 30907922 PMCID: PMC6503569 DOI: 10.1001/jamainternmed.2018.8358] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. OBJECTIVE To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. DESIGN, SETTING, AND PARTICIPANTS This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. INTERVENTIONS Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. MAIN OUTCOMES AND MEASURES Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. RESULTS Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. CONCLUSIONS AND RELEVANCE This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.
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Affiliation(s)
- John N Mafi
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles.,RAND Health, RAND Corporation
| | - Patricia Godoy-Travieso
- Department of Quality, Patient Safety and Risk Management, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Eric Wei
- Department of Quality, Patient Safety and Risk Management, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Malvin Anders
- Department of Ophthalmology, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Rodolfo Amaya
- Department of Anesthesiology, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Carmen A Carrillo
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles
| | - Jesse L Berry
- Department of Ophthalmology, Los Angeles County and University of Southern California Medical Center, Los Angeles.,University of Southern California Roski Eye Institute, Keck School of Medicine, Los Angeles
| | - Laura Sarff
- Department of Quality, Patient Safety and Risk Management, Los Angeles County and University of Southern California Medical Center, Los Angeles
| | - Lauren Daskivich
- Ophthalmology and Eye Health Programs, Los Angeles County Department of Health Services, Los Angeles, California
| | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
| | - Joseph Ladapo
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
| | | | | | - Catherine Sarkisian
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles.,Geriatric Research Education and Clinical Center, Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, California
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Badgery-Parker T, Pearson SA, Dunn S, Elshaug AG. Measuring Hospital-Acquired Complications Associated With Low-Value Care. JAMA Intern Med 2019; 179:499-505. [PMID: 30801628 PMCID: PMC6450303 DOI: 10.1001/jamainternmed.2018.7464] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Studies of low-value care have focused on the prevalence of low-value care interventions but have rarely quantified downstream consequences of these interventions for patients or the health care system. OBJECTIVE To measure immediate in-hospital harm associated with 7 low-value procedures. DESIGN, SETTING, AND PARTICIPANTS A cohort study with a descriptive analysis using hospital admission data from 225 public hospitals in New South Wales, Australia, was conducted from July 1, 2014, to June 30, 2017. All 9330 episodes involving 1 of 7 low-value procedures were evaluated, including endoscopy for dyspepsia in people younger than 55 years (3689 episodes); knee arthroscopy for osteoarthritis or meniscal tears (3963 episodes); colonoscopy for constipation in people younger than 50 years (665 episodes); endovascular repair of abdominal aortic aneurysm in asymptomatic, high-risk patients (508 episodes); carotid endarterectomy in asymptomatic, high-risk patients (273 episodes); renal artery angioplasty (176 episodes); and spinal fusion for uncomplicated low back pain (56 episodes). Sixteen hospital-acquired complications (HACs) were used as a measure of harm associated with low-value care. MAIN OUTCOMES AND MEASURES For each low-value procedure, the percentage associated with any HAC and the difference in mean length of stay for patients receiving low-value care with and without HACs were calculated. RESULTS Across the 225 hospitals and 9330 episodes of low-value care, rates of HACs were low for low-value endoscopy (4 [0.1%] episodes; 95% CI, 0.02%-0.2%), knee arthroscopy (18 [0.5%] episodes; 95% CI, 0.2%-0.7%), and colonoscopy (2 [0.3%] episodes; 95% CI, 0.0%-0.9%) but higher for low-value spinal fusion (4 [7.1%] episodes; 95% CI, 2.2%-11.5%), endovascular repair of abdominal aortic aneurysm (76 [15.0%] episodes; 95% CI, 11.1%-19.7%), carotid endarterectomy (21 [7.7%] episodes; 95% CI, 5.2%-10.1%), and renal artery angioplasty (15 [8.5%] episodes; 95% CI, 5.8%-11.5%). For most procedures, the most common HAC was health care-associated infection, which accounted for 83 (26.3%) (95% CI, 21.8%-31.5%) of all HACs observed. The highest rate of health care-associated infection was 8.4% (95% CI, 5.2%-11.4%) for renal artery angioplasty. For all 7 low-value procedures, median length of stay for patients with an HAC was 2 times or more the median length of stay for patients without a complication. For example, median length of stay was 1 (interquartile range [IQR], 1-1) day for knee arthroscopy with no HACs but increased to 10.5 (IQR, 1.0-21.3) days for patients with an HAC. CONCLUSIONS AND RELEVANCE These findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate. Although only some immediate consequences of just 7 low-value services were examined, harm related to all low-value procedures was noted, including high rates of harm for certain higher-risk procedures. The full burden of low-value care for patients and the health system is yet to be quantified.
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Affiliation(s)
- Tim Badgery-Parker
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia.,Capital Markets Cooperative Research Centre, Health Market Quality Program, Sydney, Australia
| | - Sallie-Anne Pearson
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia.,Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Susan Dunn
- Activity Based Management, New South Wales Ministry of Health, Sydney, Australia
| | - Adam G Elshaug
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia
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Maintaining automated measurement of Choosing Wisely adherence across the ICD 9 to 10 transition. J Biomed Inform 2019; 93:103142. [PMID: 30853653 DOI: 10.1016/j.jbi.2019.103142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND It remains unclear how to incorporate terminology changes, such as the International Classification of Disease (ICD) transition from ICD-9 to ICD-10, into established automated healthcare quality metrics. OBJECTIVE To evaluate whether general equivalence mapping (GEM) can apply ICD-9 based metrics to ICD-10 patient data. To develop and validate novel ICD-10 reference codesets. DESIGN Retrospective analysis for eleven Choosing Wisely (CW) metrics was performed using three scripted algorithms on an institutional clinical data warehouse. ICD-10 data were compared against published ICD-9 based metric definitions using two equivalence mapping algorithms. A third algorithm implemented novel reference ICD-10 codes matching the original ICD-9 codes' intent for comparison with patient ICD-10 data. PARTICIPANTS All adult patients seen at Vanderbilt University Medical Center, April - September 2016. MAIN MEASURES The prevalence of eleven CW services during the six-month period. KEY RESULTS The three algorithms found similar prevalence of avoidable CW services, with an unweighted-mean of 8.4% (range: 0.16-65%), or approximately 20,000 CW services out of 240,000 potential cases in 515,406 unique patients. The algorithms' median sensitivity was 0.80 (interquartile range: 0.75-0.95), median specificity was 0.88 (IQR: 0.77-0.94), and median Rand accuracy was 0.84 (IQR: 0.79-0.89). The attributed waste of these eleven services for the period ranged from $871,049 to $951,829 between methods. Accuracy assessment demonstrated that the GEM-based methods suffered recall losses for metrics requiring multistep mapping due to incompleteness, while novel ICD-10 metric definitions avoided these challenges. CONCLUSIONS Comprehensive mapping enables use of legacy metrics across ICD generations, but requires computational complexity that can be avoided with novel ICD-10 based metric definitions. Variation in the dollars attributed to waste due to ICD mapping introduces ambiguity that may affect quality-based reimbursement.
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Chalmers K, Pearson SA, Badgery-Parker T, Brett J, Scott IA, Elshaug AG. Measuring 21 low-value hospital procedures: claims analysis of Australian private health insurance data (2010-2014). BMJ Open 2019; 9:e024142. [PMID: 30842110 PMCID: PMC6429894 DOI: 10.1136/bmjopen-2018-024142] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To examine the prevalence, costs and trends (2010-2014) for 21 low-value inpatient procedures in a privately insured Australian patient cohort. DESIGN We developed indicators for 21 low-value procedures from evidence-based lists such as Choosing Wisely, and applied them to a claims data set of hospital admissions. We used narrow and broad indicators where multiple low-value procedure definitions exist. SETTING AND PARTICIPANTS A cohort of 376 354 patients who claimed for an inpatient service from any of 13 insurance funds in calendar years 2010-2014; approximately 7% of the privately insured Australian population. MAIN OUTCOME MEASURES Counts and proportions of low-value procedures in 2014, and relative change between 2010 and 2014. We also report both the Medicare (Australian government) and the private insurance financial contributions to these low-value admissions. RESULTS Of the 14 662 patients with admissions for at least 1 of the 21 procedures in 2014, 20.8%-32.0% were low-value using the narrow and broad indicators, respectively. Of the 21 procedures, admissions for knee arthroscopy were highest in both the volume and the proportion that were low-value (1607-2956; 44.4%-81.7%).Seven low-value procedures decreased in use between 2010 and 2014, while admissions for low-value percutaneous coronary interventions and inpatient intravitreal injections increased (51% and 8%, respectively).For this sample, we estimated 2014 Medicare contributions for admissions with low-value procedures to be between $A1.8 and $A2.9 million, and total charges between $A12.4 and $A22.7 million. CONCLUSIONS The Australian federal government is currently reviewing low-value healthcare covered by Medicare and private health insurers. Estimates from this study can provide crucial baseline data and inform design and assessment of policy strategies within the Australian private healthcare sector aimed at curtailing the high volume and/or proportions of low-value procedures.
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Affiliation(s)
- Kelsey Chalmers
- Menzies Centre for Health Policy, University of Sydney School of Public Health, Sydney, New South Wales, Australia
- Health Market Quality Program, Capital Markets CRC Ltd, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, University of New South Wales, UNSW, New South Wales, Australia
| | - Tim Badgery-Parker
- Menzies Centre for Health Policy, University of Sydney School of Public Health, Sydney, New South Wales, Australia
- Health Market Quality Program, Capital Markets CRC Ltd, Sydney, New South Wales, Australia
| | - Jonathan Brett
- Medicines Policy Research Unit, University of New South Wales, UNSW, New South Wales, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Queensland, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, University of Sydney School of Public Health, Sydney, New South Wales, Australia
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Venkatraman G. Variation in Care Delivery and Diagnostic Modalities Among the Medicare Population. JAMA Otolaryngol Head Neck Surg 2019; 145:263-264. [PMID: 30703195 DOI: 10.1001/jamaoto.2018.3998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Giri Venkatraman
- Section of Otolaryngology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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Trumbo SP, Iams WT, Limper HM, Goggins K, Gibson J, Oliver L, Leverenz DL, Samuels LR, Brady DW, Kripalani S. Deimplementation of Routine Chest X-rays in Adult Intensive Care Units. J Hosp Med 2019; 14:83-89. [PMID: 30785415 PMCID: PMC8102033 DOI: 10.12788/jhm.3129] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. SETTING The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.
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Affiliation(s)
- Silas P Trumbo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wade T Iams
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heather M Limper
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn Goggins
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jayme Gibson
- Cardiovascular Intensive Care Unit, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Lauren Oliver
- Cardiovascular Intensive Care Unit, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - David L Leverenz
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lauren R Samuels
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Donald W Brady
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Whittington MD, Ho PM, Helfrich CD. Recommendations for the Use of Audit and Feedback to De-Implement Low-Value Care. Am J Med Qual 2019; 34:409-411. [PMID: 30654620 DOI: 10.1177/1062860618824153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Melanie D Whittington
- 1 VA Eastern Colorado Health Care System, Aurora, CO.,2 University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- 1 VA Eastern Colorado Health Care System, Aurora, CO.,2 University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Christian D Helfrich
- 3 VA Puget Sound Health Care System, Seattle, WA.,4 University of Washington, Seattle, WA
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Schwartz AL, Jena AB, Zaslavsky AM, McWilliams JM. Analysis of Physician Variation in Provision of Low-Value Services. JAMA Intern Med 2019; 179:16-25. [PMID: 30508010 PMCID: PMC6583417 DOI: 10.1001/jamainternmed.2018.5086] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Facing new financial incentives to reduce unnecessary spending, health care organizations may attempt to reduce wasteful care by influencing physician practices or selecting more cost-effective physicians. However, physicians' role in determining the use of low-value services has not been well described. OBJECTIVES To quantify variation in provision of low-value health care services among primary care physicians and to estimate the proportion of variation attributable to physician characteristics that may be used to predict performance. DESIGN, SETTING, AND PARTICIPANTS This retrospective analysis included national Medicare fee-for-service claims of 3 159 834 beneficiaries served by 41 773 generalist physicians from January 1, 2008, through December 31, 2013 (data were analyzed in 2016 through 2018). Multilevel modeling was used to estimate the extent of variation in service use across physicians within their region and provider organization, adjusted for patient clinical and sociodemographic characteristics and sampling variation. The proportion of variation attributable to physician characteristics that may be used to predict performance (age, sex, academic degree, professorship, publication record, trial investigation, grant receipt, pharmaceutical or device manufacturer payment, and panel size) was estimated via additional regression analysis. MAIN OUTCOMES AND MEASURES Annual count per beneficiary of 17 primary care-associated services that provide minimal clinical benefit. RESULTS Among the 3 159 834 beneficiaries (58.3% women; mean [SD] age, 73.2 [11.0] years) served by 41 773 physicians (74.9% men; mean [SD] age, 48.0 [10.1] years), the mean annual rate of low-value services was 33.1 services per 100 beneficiaries. Considerable variation across physicians within the same region was found (SD, 8.8 [95% CI, 8.7-8.9]; 90th:10th percentile ratio, 2.03 [95% CI, 2.01-2.06]) and across physicians within the same organization (SD, 6.1 [95% CI, 6.0-6.2]; 90th:10th percentile ratio, 1.61 [95% CI, 1.60-1.63]). The corresponding rates at the 10th percentile of physicians within region and within organization respectively were 21.8 and 25.3 services per 100 beneficiaries. Observable physician characteristics accounted for only 4.4% of physician variation within region and 1.4% of physician variation within organization. CONCLUSIONS AND RELEVANCE Physician practices may substantially contribute to low-value service use, which is prevalent even among the least wasteful physicians. Because little variation is predicted by measured physician characteristics, direct measures of low-value care provision may aid organizational efforts to encourage high-value practices.
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Affiliation(s)
- Aaron L Schwartz
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Massachusetts General Hospital, Boston
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Brett J, Zoega H, Buckley NA, Daniels BJ, Elshaug AG, Pearson SA. Choosing wisely? Quantifying the extent of three low value psychotropic prescribing practices in Australia. BMC Health Serv Res 2018; 18:1009. [PMID: 30594192 PMCID: PMC6310957 DOI: 10.1186/s12913-018-3811-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 12/11/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The global Choosing Wisely campaign has identified the following psychotropic prescribing as low-value (harmful or wasteful): (1) benzodiazepine use in the elderly, (2) antipsychotic use in dementia and (3) prescribing two or more antipsychotics concurrently. We aimed to quantify the extent of these prescribing practices in the Australian population. METHODS We applied indicators to dispensing claims of a 10% random sample of Australian Pharmaceutical Benefits Scheme beneficiaries to quantify annual rates of each low-value practice from 2013 to 2016. We also assessed patient factors and direct medicine costs (extrapolated to the entire Australian population) associated with each practice in 2016. RESULTS We observed little change in the rates of the three practices between 2013 and 2016. In 2016, 15.3% of people aged ≥65 years were prescribed a benzodiazepine, 0.5% were prescribed antipsychotics in the context of dementia and 0.2% of people aged ≥18 years received two or more antipsychotics concurrently. The likelihood of elderly people receiving benzodiazepines or antipsychotics in the context of dementia increased with age and the likelihood of receiving all three practices increased with comorbidity burden. In 2016, direct medicine costs to the government of all three practices combined, extrapolated to national figures, were > $21 million AUD. CONCLUSIONS Our indicators suggest that the frequency of these three practices has not changed appreciably in recent years and that they incur significant costs. Worryingly, people with the greatest risk of harm from these prescribing practices are often the most likely to receive them.
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Affiliation(s)
- Jonathan Brett
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, 2052, Australia.
| | - Helga Zoega
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, 2052, Australia.,Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Benjamin J Daniels
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, The University of Sydney, Sydney, Australia
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, 2052, Australia.,Menzies Centre for Health Policy, The University of Sydney, Sydney, Australia
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Nili M, Shen C, Sambamoorthi U. Low-value care: antipsychotic medication use among community-dwelling medicare beneficiaries with Alzheimer's disease and related dementias and without severe mental illness. Aging Ment Health 2018; 24:504-510. [PMID: 30521375 PMCID: PMC6551311 DOI: 10.1080/13607863.2018.1544211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Antipsychotic medication use among elderly with Alzheimer's disease and related dementias (ADRD) and without severe mental illness is considered as low-value care. Our objective was to assess the factors associated with this inappropriate use of antipsychotic medications among community-dwelling Medicare beneficiaries with ADRD and without severe mental illness.Methods: This study used a retrospective cross-sectional design. Data for this study were derived from the nationally representative Medicare Current Beneficiary Survey (MCBS) and linked Medicare claims. Logistic regression models were used to examine factors associated with low-value care.Results: Overall 8.5% had low-value care. In the final adjusted logistic regression model, race other than Hispanic or Non-Hispanic White (AOR =0.54, 95% CI = [0.30,0.98]), individuals over 80 years of age (AOR =0.53, 95% CI = [0.36,0.76]), and obese individuals (AOR =0.55, 95% CI = [0.35,0.85]) had significantly lower odds of receiving low-value care. Those with depression (AOR =1.71, 95% CI = [1.21, 2.43]), who lived in the Midwest (AOR =1.7, 95% CI = [1.08,2.68]), and with a higher number of ADL limitations (AOR =1.28, 95% CI = [1.19,1.38]) had significantly higher odds of low-value care.Conclusions: There were subgroup differences in low-value care. Interventions may target these subgroups to reduce low-value care.
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Affiliation(s)
- Mona Nili
- Department of Pharmaceutical Systems and Policy, West Virginia University, Morgantown, WV, USA
| | - Chan Shen
- Departments of Health Services Research and Biostatistic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, West Virginia University, Morgantown, WV, USA
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Zhou M, Oakes AH, Bridges JFP, Padula WV, Segal JB. Regional Supply of Medical Resources and Systemic Overuse of Health Care Among Medicare Beneficiaries. J Gen Intern Med 2018; 33:2127-2131. [PMID: 30229364 PMCID: PMC6258607 DOI: 10.1007/s11606-018-4638-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/30/2018] [Accepted: 07/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Overuse of health care resources has been identified as the leading contributor to waste in the US health care system. OBJECTIVE To explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services. DESIGN Using Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas. KEY RESULTS Regions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P < 0.001). Regional characteristics associated with higher JHOI scores, indicating more systemic overuse, included number per 1000 residents of acute care hospital beds (P = 0.002) and of hospital-based anesthesiologists, pathologists, and radiologists (P = 0.02). CONCLUSIONS Regional variations in health care resources including the clinician workforce are associated with the intensity of systemic overuse of health care. The role of primary care doctors in reducing health care overuse deserves further attention.
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Affiliation(s)
- Mo Zhou
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.,Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, USA
| | - Allison H Oakes
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.,Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, USA
| | - John F P Bridges
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.,Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, USA
| | - William V Padula
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.,Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, USA
| | - Jodi B Segal
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA. .,Center for Health Services and Outcomes Research of the Bloomberg School of Public Health, Baltimore, USA. .,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Pugel S, Stallworth JL, Pugh LB, Terrell C, Bailey Z, Gramling T, Ward H. Choosing Wisely in Georgia: A Quality Improvement Initiative in 25 Adult Ambulatory Medicine Offices. Jt Comm J Qual Patient Saf 2018; 44:699-707. [DOI: 10.1016/j.jcjq.2018.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 10/27/2022]
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Bouck Z, Ferguson J, Ivers NM, Kerr EA, Shojania KG, Kim M, Cram P, Pendrith C, Mecredy GC, Glazier RH, Tepper J, Austin PC, Martin D, Levinson W, Bhatia RS. Physician Characteristics Associated With Ordering 4 Low-Value Screening Tests in Primary Care. JAMA Netw Open 2018; 1:e183506. [PMID: 30646242 PMCID: PMC6324437 DOI: 10.1001/jamanetworkopen.2018.3506] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently. OBJECTIVES To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians. EXPOSURES Physician sex, years since medical school graduation, and primary care model. MAIN OUTCOMES AND MEASURES This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2). RESULTS The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users. CONCLUSIONS AND RELEVANCE This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.
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Affiliation(s)
- Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Jacob Ferguson
- currently a student at Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Noah M. Ivers
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eve A. Kerr
- Center for Clinical Management, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Kaveh G. Shojania
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Min Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System and Health Network, Toronto, Ontario, Canada
| | - Ciara Pendrith
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Graham C. Mecredy
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Richard H. Glazier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joshua Tepper
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Ziemba YC, Lomsadze L, Jacobs Y, Chang TY, Haghi N. Using Heatmaps to Identify Opportunities for Optimization of Test Utilization and Care Delivery. J Pathol Inform 2018; 9:31. [PMID: 30294500 PMCID: PMC6166481 DOI: 10.4103/jpi.jpi_7_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 08/07/2018] [Indexed: 11/21/2022] Open
Abstract
Background: When a provider orders a test in a pattern that is substantially different than their peers, it may indicate confusion in the test name or inappropriate use of the test, which can be elucidated by initiating dialog between clinicians and the laboratory. However, the analysis of ordering patterns can be challenging. We propose a utilization index (UI) as a means to quantify utilization patterns for individual providers and demonstrate the use of heatmaps to identify opportunities for improvement. Materials and Methods: Laboratory test orders by all providers were extracted from the laboratory information system. Providers were grouped into cohorts based on the specialty and patient population. A UI was calculated for each provider's use of each test using the following formula: (UI = [provider volume of specific test/provider volume of all tests]/[cohort volume of specific test/cohort volume of all tests]). A heatmap was generated to compare each provider to their cohort. Results: This method identified several hot spots and was helpful in reducing confusion and overutilization. Conclusion: The UI is a useful measure of test ordering behavior, and heatmaps provide a clear visual illustration of the utilization indices. This information can be used to identify areas for improvement and initiate meaningful dialog with providers, which will ultimately bring improvement and reduction in costs. Our method is simple and uses resources that are widely available, making this method effective convenient for many other laboratories.
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Affiliation(s)
- Yonah C Ziemba
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Liya Lomsadze
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Yehuda Jacobs
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Tylis Y Chang
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
| | - Nina Haghi
- Department of Pathology and Laboratory Medicine, Northwell Health, Lake Success, NY, USA
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Rehman H, Ali F, Mangi MA. Choosing Wisely Campaign - Innovations in Cardiovascular Science and The United States Healthcare System. Cureus 2018; 10:e2931. [PMID: 30310762 PMCID: PMC6170190 DOI: 10.7759/cureus.2931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The United States (US) is the third most expensive health care system in the world, but despite that, the US ranked last in the top 50 countries of the world when it comes to the performance measures, such as healthcare efficiency, life expectancy, health care costs, and gross domestic product (GDP) percentage. The spending health care cost keeps increasing and most of the healthcare costs go to waste. Due to this reason, it is therefore extremely important to focus on improving the quality and to bring the costs in appropriate control. To avoid this issue, the Choosing Wisely Campaign (CWC) came into being in 2012. The CWC encourages discussions between providers and patients regarding the care based on the evidence base, free from harm, duplicative or redundant tests/procedures that the patient already received, and whether medications, tests, or procedures are really necessary. Although diagnostic tests or procedures are highly valued for decision-making, unnecessary testing creates harmful health services and an economic impact on the healthcare system. The CWC has spread widely throughout the world but has many challenges which are limiting the CWC in further adoption and spread in the US. To overcome challenges in implementing and spreading the CWC, the government, physicians, social media, and mass media play an important role.
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Affiliation(s)
- Hiba Rehman
- Internal Medicine, Hamdard University Hospital, Karachi, PAK
| | - Fahad Ali
- Cardiology, Lehigh Valley Hospital Network, Allentown, USA
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Haverkamp MH, Peiris D, Mainor AJ, Westert GP, Rosenthal MB, Sequist TD, Colla CH. ACOs with risk-bearing experience are likely taking steps to reduce low-value medical services. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:e216-e221. [PMID: 30020757 PMCID: PMC6594369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Accountable care organizations (ACOs) are groups of healthcare providers responsible for quality of care and spending for a defined patient population. The elimination of low-value medical services will improve quality and reduce costs and, therefore, ACOs should actively work to reduce the use of low-value services. We set out to identify ACO characteristics associated with implementation of strategies to reduce overuse. STUDY DESIGN Survey analysis. METHODS We used the National Survey of ACOs to determine the percentage of responding ACOs aware of the Choosing Wisely campaign and to what degree ACOs have taken steps to reduce the use of low-value services. We identified characteristics of ACOs associated with implementing low-value care-reducing strategies using 3 statistical models (stepwise and LASSO logistic regression and random forest). RESULTS Responding executives of 155 of 267 ACOs (58%) were aware of Choosing Wisely. Eighty-four of those 155 ACO leaders said that their ACOs also actively implemented strategies to reduce the use of low-value services, largely through educating physicians and stimulating shared decision making. All 3 models identified the presence of at least 1 commercial payer contract and prior joint experience pursuing risk-based payment contracts as the most important predictors of an ACO actively implementing strategies to reduce low-value care. CONCLUSIONS In the first year of implementation, just one-third of ACOs had taken steps to reduce the use of low-value medical services. Safety-net ACOs and those with little experience as a risk-bearing organization need more time and support from healthcare payers and the Choosing Wisely campaign to prioritize the reduction of overuse.
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Affiliation(s)
- Margje H Haverkamp
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Kresge Bldg, Rm 431, 677 Huntington Ave, Boston, MA 02115.
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Asuzu DT, Chao GF, Pei KY. Revised cardiac risk index poorly predicts cardiovascular complications after adhesiolysis for small bowel obstruction. Surgery 2018; 164:1198-1203. [PMID: 29945781 DOI: 10.1016/j.surg.2018.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/08/2018] [Accepted: 05/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The number of patients undergoing preoperative risk stratification in the United States is expected to increase as the population ages. A large percentage of patients undergo some form of preoperative testing, and society guidelines suggest that up to 50% of the testing in lower risk surgical subgroups is unnecessary. The Revised Cardiac Risk Index and the risk calculator of the American College of Surgeons National Surgical Quality Improvement Program are widely used tools as the first step of preoperative cardiac evaluation. The Revised Cardiac Risk Index was developed to fill a need for objective perioperative cardiac risk evaluation. Despite the ease of use of Revised Cardiac Risk Index, it is uncertain if the stratification is accurate for surgical patients because its accuracy in large surgical samples has not been tested. With the National Surgical Quality Improvement Program risk calculator having excellent accuracy in estimating cardiac complications (area under the receiver operating characteristic 0.895), a unique opportunity to test the predictive accuracy of postsurgical cardiac events became available. The purpose of this study is to determine the accuracy of the Revised Cardiac Risk Index for predicting cardiovascular complications after adhesiolysis for small bowel obstruction. METHODS From 2005 to 2015, 34,032 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for small bowel obstruction (International Classification of Diseases, 10th edition [ICD-10]) were analyzed using the National Surgical Quality Improvement Program dataset. Revised Cardiac Risk Index estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (area under the receiver operating characteristic) and model calibration (Hosmer-Lemeshow chi-squared statistics). RESULTS Although the Revised Cardiac Risk Index predicted cardiovascular complications with an odds ratio of 2.3 and a 95% confidence interval of 1.9 to 2.8 (P < .001) and the Hosmer-Lemeshow chi-square was significant (0.22, P = 0.64), the area under the receiver operating characteristic was poor (0.63, 95% confidence interval 0.59-0.67). CONCLUSION Despite its relative simplicity, the Revised Cardiac Risk Index performed poorly as a predictor of cardiovascular complications after adhesiolysis for small bowel obstruction. These findings question the utility of the Revised Cardiac Risk Index in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy.
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Affiliation(s)
- David T Asuzu
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Grace F Chao
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, CT.
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130
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Ellen ME, Wilson MG, Vélez M, Shach R, Lavis JN, Grimshaw JM, Moat KA. Addressing overuse of health services in health systems: a critical interpretive synthesis. Health Res Policy Syst 2018; 16:48. [PMID: 29907158 PMCID: PMC6003114 DOI: 10.1186/s12961-018-0325-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/08/2018] [Indexed: 01/08/2023] Open
Abstract
Background Health systems are increasingly focusing on the issue of ‘overuse’ of health services and how to address it. We developed a framework focused on (1) the rationale and context for health systems prioritising addressing overuse, (2) elements of a comprehensive process and approach to reduce overuse and (3) implementation considerations for addressing overuse. Methods We conducted a critical interpretive synthesis informed by a stakeholder-engagement process. The synthesis identified relevant empirical and non-empirical articles about system-level overuse. Two reviewers independently screened records, assessed for inclusion and conceptually mapped included articles. From these, we selected a purposive sample, created structured summaries of key findings and thematically synthesised the results. Results Our search identified 3545 references, from which we included 251. Most articles (76%; n = 192) were published within 5 years of conducting the review and addressed processes for addressing overuse (63%; n = 158) or political and health system context (60%; n = 151). Besides negative outcomes at the patient, system and global level, there were various contextual factors to addressing service overuse that seem to be key issue drivers. Processes for addressing overuse can be grouped into three elements comprising a comprehensive approach, including (1) approaches to identify overused health services, (2) stakeholder- or patient-led approaches and (3) government-led initiatives. Key implementation considerations include the need to develop ‘buy in’ from stakeholders and citizens. Conclusions Health systems want to ensure the use of high-value services to keep citizens healthy and avoid harm. Our synthesis can be used by policy-makers, stakeholders and researchers to understand how the issue has been prioritised, what approaches have been used to address it and implementation considerations. Systematic review registration PROSPERO CRD42014013204.
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Affiliation(s)
- Moriah E Ellen
- Department of Health Systems Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, 84105, Beer-Sheva, Israel.,Institute for Health Policy, Management and Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, ON, M5T 3M6, Canada.,McMaster Health Forum, McMaster University, 1280 Main St. West, MML-417, Hamilton, ON, L8S 4L6, Canada
| | - Michael G Wilson
- McMaster Health Forum, McMaster University, 1280 Main St. West, MML-417, Hamilton, ON, L8S 4L6, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada. .,Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.
| | - Marcela Vélez
- McMaster Health Forum, McMaster University, 1280 Main St. West, MML-417, Hamilton, ON, L8S 4L6, Canada.,Health Policy PhD Program, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.,Faculty of Medicine, University of Antioquia, Cra. 51d #62-29, Medellín, Antioquia, Colombia
| | - Ruth Shach
- Brown School of Social Work, Washington University in St Louis, 1 Brookings Dr, St Louis, MO, 63130, United States of America
| | - John N Lavis
- McMaster Health Forum, McMaster University, 1280 Main St. West, MML-417, Hamilton, ON, L8S 4L6, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.,Department of Political Science, McMaster University, Hamilton, Canada.,Department of Global Health and Population, Harvard School of Public Health, Cambridge, MA, United States of America
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Kaelan A Moat
- McMaster Health Forum, McMaster University, 1280 Main St. West, MML-417, Hamilton, ON, L8S 4L6, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
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Roy SK, Hom J, Mackey L, Shah N, Chen JH. Predicting Low Information Laboratory Diagnostic Tests. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE PROCEEDINGS. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE 2018; 2017:217-226. [PMID: 29888076 PMCID: PMC5961775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Escalating healthcare costs and inconsistent quality is exacerbated by clinical practice variability. Diagnostic testing is the highest volume medical activity, but human intuition is typically unreliable for quantitative inferences on diagnostic performance characteristics. Electronic medical records from a tertiary academic hospital (2008-2014) allow us to systematically predict laboratory pre-test probabilities of being normal under different conditions. We find that low yield laboratory tests are common (e.g., ~90% of blood cultures are normal). Clinical decision support could triage cases based on available data, such as consecutive use (e.g., lactate, potassium, and troponin are >90% normal given two previously normal results) or more complex patterns assimilated through common machine learning methods (nearly 100% precision for the top 1% of several example labs).
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Affiliation(s)
- Shivaal K Roy
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Jason Hom
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Neil Shah
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Jonathan H Chen
- Department of Medicine, Stanford University, Stanford, CA, USA
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Affiliation(s)
- Bo Abrahamsen
- Department of Medicine, Holbaek Hospital, Holbaek, Denmark.,Department of Clinical Research, OPEN, University of Southern Denmark, Odense, Denmark
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133
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Rockwell M, Kraak V, Hulver M, Epling J. Clinical Management of Low Vitamin D: A Scoping Review of Physicians' Practices. Nutrients 2018; 10:nu10040493. [PMID: 29659534 PMCID: PMC5946278 DOI: 10.3390/nu10040493] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/07/2018] [Accepted: 04/12/2018] [Indexed: 12/13/2022] Open
Abstract
The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies do not recommend population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. To assess patterns of physicians’ management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and the gray literature. Thirty-eight records met inclusion criteria and were summarized in an evidence table. Thirteen studies published between 2006 and 2015 across seven countries showed a consistent increase in vitamin D lab tests and related costs. Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term. Variability and controversy were pervasive in many aspects of vitamin D management, shining a light on physicians’ practices in the face of uncertainty. Future research is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations.
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Affiliation(s)
- Michelle Rockwell
- Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute & State University, Blacksburg, VA 24061, USA.
| | - Vivica Kraak
- Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute & State University, Blacksburg, VA 24061, USA.
| | - Matthew Hulver
- Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute & State University, Blacksburg, VA 24061, USA.
| | - John Epling
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA 24016, USA.
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Miller G, Rhyan C, Beaudin-Seiler B, Hughes-Cromwick P. A Framework for Measuring Low-Value Care. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:375-379. [PMID: 29680091 DOI: 10.1016/j.jval.2017.10.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/11/2017] [Accepted: 10/23/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND It has been estimated that more than 30% of health care spending in the United States is wasteful, and that low-value care, which drives up costs unnecessarily while increasing patient risk, is a significant component of wasteful spending. OBJECTIVES To address the need for an ability to measure the magnitude of low-value care nationwide, identify the clinical services that are the greatest contributors to waste, and track progress toward eliminating low-value use of these services. Such an ability could provide valuable input to the efforts of policymakers and health systems to improve efficiency. METHODS AND RESULTS We reviewed existing methods that could contribute to measuring low-value care and developed an integrated framework that combines multiple methods to comprehensively estimate and track the magnitude and principal sources of clinical waste. We also identified a process and needed research for implementing the framework. CONCLUSIONS A comprehensive methodology for measuring and tracking low-value care in the United States would provide an important contribution toward reducing waste. Implementation of the framework described in this article appears feasible, and the proposed research program will allow moving incrementally toward full implementation while providing a near-term capability for measuring low-value care that can be enhanced over time.
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Affiliation(s)
- George Miller
- Altarum Center for Value in Health Care, Arbor, MI, USA.
| | - Corwin Rhyan
- Altarum Center for Value in Health Care, Arbor, MI, USA
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Urine Culture on Admission Impacts Antibiotic Use and Length of Stay: A Retrospective Cohort Study. Infect Control Hosp Epidemiol 2018; 39:547-554. [DOI: 10.1017/ice.2018.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVETo examine the impact of urine culture testing on day 1 of admission on inpatient antibiotic use and hospital length of stay (LOS).DESIGNWe performed a retrospective cohort study using a national dataset from 2009 to 2014.SETTINGThe study used data from 230 hospitals in the United States.PARTICIPANTSAdmissions for adults 18 years and older were included in this study. Hospitalizations were matched with coarsened exact matching by facility, patient age, gender, Medicare severity-diagnosis related group (MS-DRG), and 3 measures of disease severity.METHODSA multilevel Poisson model and a multilevel linear regression model were used to determine the impact of an admission urine culture on inpatient antibiotic use and LOS.RESULTSMatching produced a cohort of 88,481 patients (n=41,070 with a culture on day 1, n=47,411 without a culture). A urine culture on admission led to an increase in days of inpatient antibiotic use (incidence rate ratio, 1.26; P<.001) and resulted in an additional 36,607 days of inpatient antibiotic treatment. Urine culture on admission resulted in a 2.1% increase in LOS (P=.004). The predicted difference in bed days of care between admissions with and without a urine culture resulted in 6,071 additional bed days of care. The impact of urine culture testing varied by admitting diagnosis.CONCLUSIONSPatients with a urine culture sent on day 1 of hospital admission receive more days of antibiotics and have a longer hospital stay than patients who do not have a urine culture. Targeted interventions may reduce the potential harms associated with low-yield urine cultures on day 1.Infect Control Hosp Epidemiol 2018;39:547–554
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Rosenthal MB, Colla CH, Morden NE, Sequist TD, Mainor AJ, Li Z, Nguyen KH. Overuse and insurance plan type in a privately insured population. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:140-146. [PMID: 29553277 PMCID: PMC5985657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES A substantial portion of healthcare spending is wasted on services that do not directly improve patient health and that cause harm in some cases. Features of health insurance coverage, including enrollment in high-deductible health plans (HDHPs) or health maintenance organizations (HMOs), may provide financial and nonfinancial mechanisms to potentially reduce overuse of low-value healthcare services. STUDY DESIGN Using 2009 to 2013 administrative data from 3 large commercial insurers, we examined patient characteristics and health insurance plan types associated with overuse of 6 healthcare services identified by the Choosing Wisely campaign. METHODS We explored associations between overuse and patient characteristics using multivariate logistic regression models, including patient age, gender, enrollment in an HMO, enrollment in an HDHP, an indicator of primary care fragmentation, and number of outpatient visits as explanatory variables. RESULTS Measurement of services highlighted as potential overuse by the Choosing Wisely recommendations revealed low to moderate prevalence, depending on the service. HMO coverage and enrollment in HDHPs were significantly associated with differences in prevalence of all 6 services, albeit differently in terms of the direction of the effects. Primary care fragmentation was significantly associated with higher rates of overuse. CONCLUSIONS Neither HDHPs nor HMO plans, with their closed networks and referral requirements, consistently reduced overuse, although HMO plans were never associated with higher rates of overuse. As policy makers seek levers for reducing low-value healthcare utilization, health insurance plan features may prove a valuable target, although the effect may be complicated by other factors.
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Affiliation(s)
- Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02215.
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Kleinpell RM, Farmer JC, Pastores SM. Reducing Unnecessary Testing in the Intensive Care Unit by Choosing Wisely. Acute Crit Care 2018; 33:1-6. [PMID: 31723853 PMCID: PMC6849007 DOI: 10.4266/acc.2018.00052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/08/2018] [Indexed: 11/30/2022] Open
Abstract
Overuse of laboratory and X-ray testing is common in the intensive care unit (ICU). This review highlights focused strategies for critical care clinicians as outlined by the Critical Care Societies Collaborative (CCSC) as part of the American Board of Internal Medicine Foundation’s Choosing Wisely® campaign. The campaign aims to promote the use of judicious testing and decrease unnecessary treatment measures in the ICU. The CCSC outlines five specific recommendations for reducing unnecessary testing in the ICU. First, reduce the use of daily or regular interval diagnostic testing. Second, do not transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dl. Third, do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of ICU stay. Fourth, do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Finally, do not continue life support for patients at high risk of death without offering patients and their families the alternative of comfort focused care. A number of strategies can be used to reduce unnecessary testing in the ICU, including educational campaigns, audit and feedback, and implementing prompts in the electronic ordering system to allow only acceptable indications when ordering routine testing. Greater awareness of the lack of outcome benefit and associated costs can prompt clinicians to be more mindful of ordering tests and procedures in order to reduce unnecessary testing in the ICU.
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Affiliation(s)
- Ruth M Kleinpell
- Vanderbilt University Medical Center and School of Nursing, Nashville, TN, USA.,Rush University Medical Center and College of Nursing, Chicago, IL, USA
| | | | - Stephen M Pastores
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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138
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Mafi JN, Parchman M. Low-value care: an intractable global problem with no quick fix. BMJ Qual Saf 2018; 27:333-336. [PMID: 29331955 DOI: 10.1136/bmjqs-2017-007477] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 12/16/2022]
Affiliation(s)
- John N Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,RAND Health, RAND Corporation, Santa Monica, California, USA
| | - Michael Parchman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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139
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Tamblyn R, Winslade N, Qian CJ, Moraga T, Huang A. What is in your wallet? A cluster randomized trial of the effects of showing comparative patient out-of-pocket costs on primary care prescribing for uncomplicated hypertension. Implement Sci 2018; 13:7. [PMID: 29321043 PMCID: PMC5763524 DOI: 10.1186/s13012-017-0701-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/18/2017] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Drug expenditures are responsible for an increasing proportion of health costs, accounting for $1.1 trillion in annual expenditure worldwide. As hundreds of billions of dollars are being spent each year on overtreatment with prescribed medications that are either unnecessary or are in excess of lowest cost-effective therapy, programs are needed that optimize fiscally appropriate use. We evaluated whether providing physicians with information on the patient out-of-pocket payment consequences of prescribing decisions that were in excess of lowest cost-effective therapy would alter prescribing decisions using the treatment of uncomplicated hypertension as an exemplar. METHODS A single-blind cluster randomized trial was conducted over a 60-month follow-up period in 76 primary care physicians in Quebec, Canada, and their patients with uncomplicated hypertension who were using the MOXXI integrated electronic health record for drug and health problem management. Physicians were randomized to an out-of-pocket expenditure module that provided alerts for comparative out-of-payment costs, thiazide diuretics as recommended first-line therapy, and tools to monitor blood pressure targets and medication compliance, or alternatively the basic MOXXI system. System software and prescription claims were used to analyze the impact of the intervention on treatment choice, adherence, and overall and out-of-pocket payment costs using generalized estimating equations. RESULTS Three thousand five-hundred ninety-two eligible patients with uncomplicated hypertension were enrolled, of whom 1261 (35.1%) were newly started (incident patient) on treatment during follow-up. There was a statistically significant increase in the prescription of diuretics in the newly treated intervention (26.6%) compared to control patients (19.8%) (RR 1.65, 95% CI 1.17 to 2.33). For patients already treated (prevalent patient), there was a statistically significant interaction between the intervention and patient age, with older patients being less likely to be switched to a diuretic. Among the incident patients, physicians with less than 15 years of experience were much more likely to prescribe a diuretic (OR 10.69; 95% CI 1.49 to 76.64) than physicians with 15 to 25 years (OR 0.67; 95%CI 0.25 to 1.78), or more than 25 years of experience (OR 1.80; 95% CI 1.23 to 2.65). There was no statistically significant effect of the intervention on adherence or out-of-pocket payment cost. CONCLUSIONS The provision of comparative information on patient out-of-pocket payments for treatment of uncomplicated hypertension had a statistically significant impact on increasing the initiation of diuretics in incident patients and switching to diuretics in younger prevalent patients. The impact of interventions to improve the cost-effectiveness of prescribing may be enhanced by also targeting patients with tools to participate in treatment decision-making and by providing physicians with comparative out-of-pocket information on all evidence-based alternatives that would enhance clinical decision-making. TRIAL REGISTRATION ISRCTN96253624.
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Affiliation(s)
- Robyn Tamblyn
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada.
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada.
- McGill University, Morrice House, 1140 Pine Ave West, Montreal, QC, H3A 1A3, Canada.
| | - Nancy Winslade
- Division of Geriatric Medicine, McGill University, Montreal, QC, Canada
| | - Christina J Qian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Teresa Moraga
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Allen Huang
- Division of Geriatric Medicine, University of Ottawa, Ottawa, ON, Canada
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140
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Norton WE, Kennedy AE, Chambers DA. Studying de-implementation in health: an analysis of funded research grants. Implement Sci 2017; 12:144. [PMID: 29202782 PMCID: PMC5715998 DOI: 10.1186/s13012-017-0655-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/18/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Studying de-implementation-defined herein as reducing or stopping the use of a health service or practice provided to patients by healthcare practitioners and systems-has gained traction in recent years. De-implementing ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices is important for mitigating patient harm, improving processes of care, and reducing healthcare costs. A better understanding of the state-of-the-science is needed to guide future objectives and funding initiatives. To this end, we characterized de-implementation research grants funded by the United States (US) National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ). METHODS We used systematic methods to search, identify, and describe de-implementation research grants funded across all 27 NIH Institutes and Centers (ICs) and AHRQ from fiscal year 2000 through 2017. Eleven key terms and three funding opportunity announcements were used to search for research grants in the NIH Query, View and Report (QVR) system. Two coders identified eligible grants based on inclusion/exclusion criteria. A codebook was developed, pilot tested, and revised before coding the full grant applications of the final sample. RESULTS A total of 1277 grants were identified through the QVR system; 542 remained after removing duplicates. After the multistep eligibility assessment and review process, 20 grant applications were coded. Many grants were funded by NIH (n = 15), with fewer funded by AHRQ, and a majority were funded between fiscal years 2015 and 2016 (n = 11). Grant proposals focused on de-implementing a range of health services and practices (e.g., medications, therapies, screening tests) across various health areas (e.g., cancer, cardiovascular disease) and delivery settings (e.g., hospitals, nursing homes, schools). Grants proposed to use a variety of study designs and research methods (e.g., experimental, observational, mixed methods) to accomplish study aims. CONCLUSIONS Based on the systematic portfolio analysis of NIH- and AHRQ-funded research grants over the past 17 years, relatively few have focused on studying the de-implementation of ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices provided to patients by healthcare practitioners and systems. Strategies for raising the profile and growing the field of research on de-implementation are discussed.
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Affiliation(s)
- Wynne E. Norton
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, 9609 Medical Center Drive, Bethesda, MD 20850 USA
| | - Amy E. Kennedy
- Center for Research Strategy, Office of the Director, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - David A. Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, 9609 Medical Center Drive, Bethesda, MD 20850 USA
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141
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Reid RO, Rabideau B, Sood N. Impact of consumer-directed health plans on low-value healthcare. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:741-748. [PMID: 29261240 PMCID: PMC6132267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess the impact of consumer-directed health plan (CDHP) enrollment on low-value healthcare spending. STUDY DESIGN We performed a quasi-experimental analysis using insurance claims data from 376,091 patients aged 18 to 63 years continuously enrolled in a plan from a large national commercial insurer from 2011 to 2013. We measured spending on 26 low-value healthcare services that offer unclear or no clinical benefit. METHODS Employing a difference-in-differences approach, we compared the change in spending on low-value services for patients switching from a traditional health plan to a CDHP with the change in spending on low-value services for matched patients remaining in a traditional plan. RESULTS Switching to a CDHP was associated with a $231.60 reduction in annual outpatient spending (95% CI, -$341.65 to -$121.53); however, no significant reductions were observed in annual spending on the 26 low-value services (--$3.64; 95% CI, -$9.60 to $2.31) or on these low-value services relative to overall outpatient spending (-$7.86 per $10,000 in outpatient spending; 95% CI, -$18.43 to $2.72). Similarly, a small reduction was noted for low-value spending on imaging (-$1.76; 95% CI, -$3.39 to -$0.14), but not relative to overall imaging spending, and no significant reductions were noted in low-value laboratory spending. CONCLUSIONS CDHPs in their current form may represent too blunt an instrument to specifically curtail low-value healthcare spending.
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Affiliation(s)
| | | | - Neeraj Sood
- University of Southern California, Verna and Peter Dauterive Hall 210, 635 Downey Way, Los Angeles, CA 90089. E-mail:
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142
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Raspe H. [The Choosing Wisely Initiative (CWI): Background, aims and problems of a professional campaign against oversupply]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2017; 129:12-17. [PMID: 29153355 DOI: 10.1016/j.zefq.2017.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The Choosing Wisely Initiative (CWI) started in 2012 follows a proposal by Howard Brody (2010). Using CWI, the US ABIM Foundation continued its work to strengthen medical professionalism. The text describes CWI's development, aims, mission, and dissemination. It discusses some of its limits and problems. An appendix tabulates similarities and differences between CWI and a (2016) subsequent initiative from the German Society of Internal Medicine (DGIM: Klug Entscheiden Empfehlungen/decide wisely recommendations).
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Affiliation(s)
- Heiner Raspe
- Gastwissenschaftler am Institut für Ethik, Geschichte und Theorie der Medizin, Soetenkamp 16, 48149 Münster, Germany.
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143
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Horvath K, Siebenhofer A. The Choosing Wisely Initiative: A critical analysis with a special focus on primary care. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2017; 129:31-36. [PMID: 29153354 DOI: 10.1016/j.zefq.2017.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The Choosing Wisely initiative (CWI), a campaign led by the American Board of Internal Medicine (ABIM) Foundation, promotes doctor-patient communication and reducing waste in healthcare. At present, many of the top 5 lists from the Choosing Wisely Initiative appear to be primarily eminence-based and influenced by self-interest. The implementation of recommendations from these lists may mean taking a step backwards to the time before evidence-based medicine. On the other hand, despite all the challenges that the Choosing Wisely initiatives are currently facing, it is difficult to deny that they also hold great potential in terms of making healthcare systems more efficient and beneficial to patients. The aim of the ongoing work in Germany and Austria is to create conditions that are necessary if CW initiatives are to evolve into a model tool that will help introduce the principles of evidence-based medicine into daily practice.
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Affiliation(s)
- Karl Horvath
- Institut für Allgemeinmedizin und evidenzbasierte Versorgungsforschung, Medizinische Universität Graz, Österreich
| | - Andrea Siebenhofer
- Institut für Allgemeinmedizin und evidenzbasierte Versorgungsforschung, Medizinische Universität Graz, Österreich; Institut für Allgemeinmedizin, Goethe-Universität Frankfurt am Main, Deutschland.
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144
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Brack AP, Guo M, Ma I, Naugler C. Use of the Mean Abnormal Result Rate (MARR) to Gauge Changes in Family Physicians' Selectivity of Laboratory Test Ordering, 2010-2015. Am J Clin Pathol 2017; 148:436-440. [PMID: 29016723 DOI: 10.1093/ajcp/aqx087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The mean abnormal result rate (MARR) has recently been advanced as a metric of laboratory test appropriateness. We used the MARR metric to examine patterns of change in family physician test requisitions over time. METHODS We accessed the Laboratory Information System of Calgary Laboratory Services for family physician-ordered testing on outpatients to gather aggregate test and abnormal result counts from 2010 to 2015. RESULTS Over the 6 years, there was an annual average of 3,401,553 tests for 411,295 distinct patients on their first test requisition for the year. The MARR increased from 8.1% to 9.0% through this period. CONCLUSIONS The MARR for Calgary and surrounding area gives tentative evidence of a gradual increase in physician test selectivity in recent years. Further data from other catchment areas are needed before making assertions about broader trends in physician awareness of laboratory resource use.
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Affiliation(s)
- Andrew P Brack
- Calgary Laboratory Services, Calgary, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Maggie Guo
- Calgary Laboratory Services, Calgary, Canada
| | - Irene Ma
- Calgary Laboratory Services, Calgary, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Christopher Naugler
- Calgary Laboratory Services, Calgary, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Abstract
IMPORTANCE Clinicians who order unnecessary radiographic imaging may cause financial harm to patients who have increasing levels of cost sharing. Clinician predictors of low-value imaging are largely unknown. OBJECTIVE To characterize clinician predictors of low-value imaging for acute uncomplicated back pain and headache, including clinicians who saw both conditions. DESIGN, SETTING, AND PARTICIPANTS Multivariate logistic regression modeling of imaging rates after acute uncomplicated back pain and headache visits as indicated by January 2010 to December 2014 commercial insurance claims and demographic data from a large US health insurer. Participants included 100 977 clinicians (primary care physicians, specialist physicians, and chiropractors). MAIN OUTCOMES AND MEASURES Imaging after acute uncomplicated back pain and headache visits was recorded. We identified whether the clinician's prior patient received imaging, whether the clinician was an owner of imaging equipment, and the varying impact by clinician specialty. We then used high rates of low-value back imaging as a predictor for low-value headache imaging. RESULTS Clinicians conducted 1 007 392 visits for 878 720 adults ages 18 to 64 years with acute uncomplicated back pain; 52 876 primary care physicians conducted visits for 492 805 adults ages 18 to 64 years with acute uncomplicated headache; 34 190 primary care clinicians conducted 405 721 visits for 344 991 adults ages 18 to 64 years with headache and had also conducted at least 4 visits from patients with back pain. If a primary care physician's prior patient received low-value back imaging, the patient had 1.81 higher odds of low-value imaging (95% CI, 1.77-1.85). This practice effect was larger for chiropractors (odds ratio [OR], 2.80; 95% CI, 2.74-2.86) and specialists (OR, 2.98; 95% CI, 2.88-3.07). For headache, a prior low-value head image predicted 2.00 higher odds of a subsequent head imaging order (95% CI, 1.95-2.06). Clinician ownership of imaging equipment was a consistent independent predictor of low-value imaging (OR, 1.65-7.76) across clinician type and imaging scenario. Primary care physicians with the highest rates of low-value back imaging also had 1.53 (95% CI, 1.45-1.61) higher odds of ordering low-value headache imaging. CONCLUSIONS AND RELEVANCE Clinician characteristics such as ordering low-value imaging on a prior patient, high rates of low-value imaging in another clinical scenario, and ownership of imaging equipment are strong predictors of low-value back and headache imaging. Findings should inform policies that target potentially unnecessary and financially burdensome care.
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Affiliation(s)
- Arthur S Hong
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Science, University of Texas Southwestern Medical Center, Dallas
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - J Frank Wharam
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
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146
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Costs and Trends in Utilization of Low-value Services Among Older Adults With Commercial Insurance or Medicare Advantage. Med Care 2017; 55:931-939. [DOI: 10.1097/mlr.0000000000000809] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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148
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Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Acharya Y, Alford J, Duffy R, Adler-Milstein J. Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial. BMJ Qual Saf 2017; 27:355-364. [DOI: 10.1136/bmjqs-2017-006699] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/08/2017] [Accepted: 10/07/2017] [Indexed: 11/04/2022]
Abstract
BackgroundLittle is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.MethodsWe conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.ResultsThe intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.ConclusionClinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.Trial registration numberNCT02247050; Pre-results.
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149
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Xu WY, Jung JK. Socioeconomic Differences in Use of Low-Value Cancer Screenings and Distributional Effects in Medicare. Health Serv Res 2017; 52:1772-1793. [PMID: 27624875 PMCID: PMC5583315 DOI: 10.1111/1475-6773.12559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Consuming low-value health care not only highlights inefficient resource use but also brings an important concern regarding the economics of disparities. We identify the relation of socioeconomic characteristics to the use of low-value cancer screenings in Medicare fee-for-service (FFS) settings, and quantify the amount subsidized from nonusers and taxpayers to users of these screenings. DATA SOURCES 2007-2013 Medicare Current Beneficiary Survey, Medicare FFS claims, and the Area Health Resource Files. STUDY DESIGN Our sample included enrollees in FFS Part B for the entire calendar year. We excluded beneficiaries with a claims-documented or self-reported history of targeted cancers, or those enrolled in Medicaid or Medicare Advantage plans. We identified use of low-value Pap smears, mammograms, and prostate-specific antigen tests based on established algorithms, and estimated a logistic model with year dummies separately for each test. DATA COLLECTION/EXTRACTION METHODS Secondary data analyses. PRINCIPAL FINDINGS We found a statistically significant positive association between privileged socioeconomic characteristics and use of low-value screenings. Having higher income and supplemental private insurance strongly predicted more net subsidies from Medicare. CONCLUSIONS FFS enrollees who are better off in terms of sociodemographic characteristics receive greater subsidies from taxpayers for using low-value cancer screenings.
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Affiliation(s)
- Wendy Yi Xu
- Division of Health Services Management and PolicyCollege of Public HealthThe Ohio State UniversityCunz Hall 208, 1841 Neil AvenueColumbus43210OH
| | - Jeah Kyoungrae Jung
- Department of Health Policy and AdministrationCollege of Health and Human DevelopmentThe Pennsylvania State UniversityUniversity ParkPA
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McAlister FA, Lin M, Bakal J, Dean S. Frequency of low-value care in Alberta, Canada: a retrospective cohort study. BMJ Qual Saf 2017; 27:340-346. [PMID: 28912198 DOI: 10.1136/bmjqs-2017-006778] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/30/2017] [Accepted: 08/31/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine how frequently 10 low-value services highlighted by Choosing Wisely are done and what factors influence their provision. METHODS This is a retrospective cohort study using routinely collected health data from five linked data sets from 2012 to 2015 in the Canadian province of Alberta to determine the frequency with which 10 low-value services were provided. RESULTS Between 2012 and 2015, 162 143 people (4% of all 3 814 536 adult Albertans and 5% of the 3 423 135 who saw a physician at least once in that time frame) received at least one of the 10 low-value services, including 29.8% of Albertans older than 75 years (57 811 of 194 068). The proportion of adults receiving low-value services ranged from carotid artery imaging in 0.1% of asymptomatic adults without cerebrovascular disease, to prostate-specific antigen (PSA) testing in 55.5% of men 75 years or older without a history of prostate cancer. Although age, Charlson scores and frequency of primary care visits were associated with low-value service provision, the directions of the association differed across services; however, higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians in the patient's region were associated with an increased risk of receiving all of the low-value services we examined. The low-value services which resulted in the greatest costs to the healthcare system were cervical cancer screening in women older than 65 without history of cervical dysplasia or genital cancer, PSA testing in men older than 75 without history of prostate cancer and preoperative stress testing/cardiac imaging before non-cardiac surgery. CONCLUSIONS Even within a universal coverage healthcare system, the proportion of patients receiving low-value services varied widely (from <0.1% to 56%). Increased use was associated with higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Meng Lin
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jeff Bakal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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