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Bhatia RS, Bouck Z, Ivers NM, Mecredy G, Singh J, Pendrith C, Ko DT, Martin D, Wijeysundera HC, Tu JV, Wilson L, Wintemute K, Dorian P, Tepper J, Austin PC, Glazier RH, Levinson W. Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination. JAMA Intern Med 2017; 177:1326-1333. [PMID: 28692719 PMCID: PMC5710571 DOI: 10.1001/jamainternmed.2017.2649] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/01/2017] [Indexed: 01/18/2023]
Abstract
Importance Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown. Objective To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE. Design, Setting, and Participants A population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE. Exposures Receipt of an ECG within 30 days of an AHE. Main Outcomes and Measures Primary outcome was receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months. Results A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P < .001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts. Conclusions and Relevance Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.
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Affiliation(s)
- R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, 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 (ICES), Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Graham Mecredy
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Jasjit Singh
- University of Ottawa Medical School, Ottawa, Ontario, Canada
| | - Ciara Pendrith
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dennis T. Ko
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Schulich Heart Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute (SRI), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Harindra C. Wijeysundera
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute (SRI), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Jack V. Tu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Schulich Heart Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Lynn Wilson
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kimberly Wintemute
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Dorian
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Joshua Tepper
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - Richard H. Glazier
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Wendy Levinson
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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152
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Soneji S, Tanner NT, Silvestri GA, Lathan CS, Black W. Racial and Ethnic Disparities in Early-Stage Lung Cancer Survival. Chest 2017; 152:587-597. [PMID: 28450031 PMCID: PMC5812758 DOI: 10.1016/j.chest.2017.03.059] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/24/2017] [Accepted: 03/27/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Black patients with lung cancer diagnosed at early stages-for which surgical resection offers a potential cure-experience worse overall survival than do their white counterparts. We undertook a population-based study to estimate the racial and ethnic disparity in death from competing causes and assessed its contribution to the gap in overall survival among patients with early-stage lung cancer. METHODS We collected survival time data for 105,121 Hispanic, non-Hispanic Asian, non-Hispanic black, and non-Hispanic white patients with early-stage (IA, IB, IIA, and IIB) lung cancer diagnosed between 2004 and 2013 from the Surveillance, Epidemiology, and End-Results registries. We modeled survival time using competing risk regression and included as covariates sex, age at diagnosis, race/ethnicity, stage at diagnosis, histologic type, type of surgical resection, and radiation sequence. RESULTS Adjusting for demographic, clinical, and treatment characteristics, non-Hispanic blacks experienced worse overall survival compared with non-Hispanic whites (adjusted hazard ratio [aHR], 1.05; 95% CI, 1.02-1.08), whereas Hispanics and non-Hispanic Asians experienced better overall survival (aHR, 0.93; 95% CI, 0.89-0.98; and aHR, 0.82; 95% CI, 0.79-0.86, respectively). Worse survival from competing causes of death, such as cardiovascular disease and other cancers-rather than from lung cancer itself-led to the disparity in overall survival among non-Hispanic blacks (adjusted relative risk, 1.07; 95% CI, 1.02-1.12). CONCLUSIONS Narrowing racial and ethnic disparities in survival among patients with early-stage lung cancer will rely on more than just equalizing access to surgical resection and will need to include better management and treatment of smoking-related comorbidities and diseases.
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Affiliation(s)
- Samir Soneji
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; Geisel School of Medicine at Dartmouth, Lebanon, NH; Norris Cotton Cancer Center, Lebanon, NH.
| | - Nichole T Tanner
- Medical University of South Carolina Thoracic Oncology Research Group and Division of Pulmonary Critical Care Medicine; Ralph H. Johnson Veterans Affairs Hospital and Health Equity and Rural Outreach Innovation Center, Charleston, SC
| | - Gerard A Silvestri
- Medical University of South Carolina Thoracic Oncology Research Group and Division of Pulmonary Critical Care Medicine
| | - Christopher S Lathan
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - William Black
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Radiology, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH; Geisel School of Medicine at Dartmouth, Lebanon, NH; Norris Cotton Cancer Center, Lebanon, NH
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153
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Kashanian JA, Mazur DJ, Hehemann MC, Morrison CD, Oberlin DT, Raup VT, Choi AW, Trinh B, Said MA, Keeter MK, Brannigan RE. Author Reply. Urology 2017; 108:20-21. [PMID: 28844580 DOI: 10.1016/j.urology.2017.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- James A Kashanian
- Department of Urology, Weill Cornell Medicine, Weill Cornell Medical College, New York, NY
| | - Daniel J Mazur
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Marah C Hehemann
- Department of Urology, Loyola University Health System, Maywood, IL
| | - Christopher D Morrison
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniel T Oberlin
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Valary T Raup
- Department of Surgery, Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew W Choi
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brian Trinh
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Mohammed A Said
- Department of Urology, Emory University School of Medicine, Atlanta, GA
| | - Mary Kate Keeter
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Robert E Brannigan
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL
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154
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Nothelle SK, Sharma R, Oakes AH, Jackson M, Segal JB. Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review. J Am Med Dir Assoc 2017; 18:806.e1-806.e17. [PMID: 28764876 DOI: 10.1016/j.jamda.2017.06.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/03/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized. METHODS We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data. RESULTS Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians. CONCLUSIONS Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.
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Affiliation(s)
- Stephanie K Nothelle
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Ritu Sharma
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Allison H Oakes
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins University Center for Health Services and Outcomes Research, Baltimore, MD
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155
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 533] [Impact Index Per Article: 76.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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156
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Hom J, Kumar A, Evans KH, Svec D, Richman I, Fang D, Smeraglio A, Holubar M, Johnson T, Shah N, Renault C, Ahuja N, Witteles R, Harman S, Shieh L. A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback. Postgrad Med J 2017; 93:725-729. [PMID: 28663352 DOI: 10.1136/postgradmedj-2016-134617] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 04/18/2017] [Accepted: 06/04/2017] [Indexed: 11/03/2022]
Abstract
PURPOSE Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns. DESIGN Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments. RESULTS The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001). CONCLUSIONS We successfully implemented a novel high value care curriculum that specifically targets intern physicians.
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Affiliation(s)
- Jason Hom
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Andre Kumar
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kambria H Evans
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - David Svec
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ilana Richman
- Center for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Daniel Fang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Andrea Smeraglio
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Marisa Holubar
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Tyler Johnson
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neil Shah
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Cybele Renault
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neera Ahuja
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Stephanie Harman
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Lisa Shieh
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Mafi JN, Wee CC, Davis RB, Landon BE. Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States. JAMA Intern Med 2017; 177:838-845. [PMID: 28395013 PMCID: PMC5540052 DOI: 10.1001/jamainternmed.2017.0410] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Hospital-employed physicians provide primary care within the hospital or within community-based office practices. Yet, little is understood regarding the influence of hospital location and ownership on the delivery of low-value care. OBJECTIVE To assess the association of hospital location and hospital ownership with the provision of low-value health services. DESIGN, SETTING, AND PARTICIPANTS This study compared low-value service use after primary care visits at hospital-based outpatient practices from January 1, 1997, to December 31, 2011, vs community-based office practices and at hospital-owned vs physician-owned community-based office practices from January 1, 1997, to December 31, 2013. Logistic regression models adjusted for patient and health care professional characteristics and year, and weighted results were used to reflect population estimates. Results were also stratified by symptom acuity and whether a generalist physician (eg, general internist or family practitioner) was the patient's primary care provider. This study used nationally representative data from the National Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2013) and the National Hospital Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2011) on outpatient visits to generalist physicians. Participants were patients seen with 3 common primary care conditions, namely, upper respiratory tract infection, back pain, and headache. MAIN OUTCOMES AND MEASURES The use of antibiotics (for upper respiratory tract infection), computed tomography or magnetic resonance imaging (for back pain and headache), radiographs (for upper respiratory tract infection and back pain), and specialty referrals (for all 3 conditions). RESULTS This study identified 31 162 visits for upper respiratory tract infection, back pain, and headache, representing an estimated 739 million US primary care visits from 1997 to 2013. Compared with visits with community-based physicians, patients in visits to hospital-based physicians were younger (mean age, 44.5 vs 49.1 years; P < .001) and less frequently saw their primary care provider (52.7% vs 81.9%, P < .001). Although antibiotic use was similar in both settings, hospital-based visits had more orders for computed tomography and magnetic resonance imaging (8.3% vs 6.3%, P = .01), radiographs (12.8% vs 9.9%, P < .001), and specialty referrals (19.0% vs 7.6%, P < .001) than community-based visits. Multivariable adjustment and symptom acuity stratification revealed similar findings. Visits with a generalist other than the patient's primary care provider were associated with greater provision of low-value care but mainly within hospital-based settings. Practice patterns were similar among hospital-owned vs physician-owned community-based practices with the exception of specialty referrals, which were more frequent in hospital-owned community-based practices. CONCLUSIONS AND RELEVANCE Visits to US hospital-based practices are associated with greater use of low-value computed tomography and magnetic resonance imaging, radiographs, and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. These findings raise concerns about the provision of low-value care at hospital-associated primary care practices.
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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 University of California, Los Angeles (UCLA)2RAND Corporation, Santa Monica, California
| | - Christina C Wee
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Roger B Davis
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bruce E Landon
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts4Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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158
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Schpero WL, Morden NE, Sequist TD, Rosenthal MB, Gottlieb DJ, Colla CH. For Selected Services, Blacks And Hispanics More Likely To Receive Low-Value Care Than Whites. Health Aff (Millwood) 2017; 36:1065-1069. [PMID: 28583965 PMCID: PMC5568010 DOI: 10.1377/hlthaff.2016.1416] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
US minority populations receive fewer effective health services than whites. Using Medicare administrative data for 2006-11, we found no consistent, corresponding protection against the receipt of ineffective health services. Compared with whites, blacks and Hispanics were often more likely to receive the low-value services studied.
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Affiliation(s)
- William L Schpero
- William L. Schpero is a PhD student in the Department of Health Policy and Management, Yale School of Public Health, in New Haven, Connecticut
| | - Nancy E Morden
- Nancy E. Morden is an associate professor of community and family medicine at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, in Lebanon, New Hampshire
| | - Thomas D Sequist
- Thomas D. Sequist is an associate professor of medicine and health care policy at Harvard Medical School, in Boston, Massachusetts
| | - Meredith B Rosenthal
- Meredith B. Rosenthal is a professor of health economics and policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston
| | - Daniel J Gottlieb
- Daniel J. Gottlieb is a research associate at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
| | - Carrie H Colla
- Carrie H. Colla is an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
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159
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Voorn VMA, Marang-van de Mheen PJ, van der Hout A, Hofstede SN, So-Osman C, van den Akker-van Marle ME, Kaptein AA, Stijnen T, Koopman-van Gemert AWMM, Dahan A, Vliet Vlieland TPMM, Nelissen RGHH, van Bodegom-Vos L. The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial. Implement Sci 2017; 12:72. [PMID: 28558843 PMCID: PMC5450044 DOI: 10.1186/s13012-017-0601-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/16/2017] [Indexed: 01/07/2023] Open
Abstract
Background Perioperative autologous blood salvage and preoperative erythropoietin are not (cost) effective to reduce allogeneic transfusion in primary hip and knee arthroplasty, but are still used. This study aimed to evaluate the effectiveness of a theoretically informed multifaceted strategy to de-implement these low-value blood management techniques. Methods Twenty-one Dutch hospitals participated in this pragmatic cluster-randomized trial. At baseline, data were gathered for 924 patients from 10 intervention and 1040 patients from 11 control hospitals undergoing hip or knee arthroplasty. The intervention included a multifaceted de-implementation strategy which consisted of interactive education, feedback on blood management performance, and a comparison with benchmark hospitals, aimed at orthopedic surgeons and anesthesiologists. After the intervention, data were gathered for 997 patients from the intervention and 1096 patients from the control hospitals. The randomization outcome was revealed after the baseline measurement. Primary outcomes were use of blood salvage and erythropoietin. Secondary outcomes included postoperative hemoglobin, length of stay, allogeneic transfusions, and use of local infiltration analgesia (LIA) and tranexamic acid (TXA). Results The use of blood salvage (OR 0.08, 95% CI 0.02 to 0.30) and erythropoietin (OR 0.30, 95% CI 0.09 to 0.97) reduced significantly over time, but did not differ between intervention and control hospitals (blood salvage OR 1.74 95% CI 0.27 to 11.39, erythropoietin OR 1.33, 95% CI 0.26 to 6.84). Postoperative hemoglobin levels were significantly higher (β 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (β −0.36, 95% CI −0.64 to −0.09) in hospitals receiving the multifaceted strategy, compared with control hospitals and after adjustment for baseline. Transfusions did not differ between the intervention and control hospitals (OR 1.06, 95% CI 0.63 to 1.78). Both LIA (OR 0.0, 95% CI 0.0 to 0.0) and TXA (OR 0.3, 95% CI 0.2 to 0.5) were significantly associated with the reduction in blood salvage over time. Conclusions Blood salvage and erythropoietin use reduced over time, but not differently between intervention and control hospitals. The reduction in blood salvage was associated with increased use of local infiltration analgesia and tranexamic acid, suggesting that de-implementation is assisted by the substitution of techniques. The reduction in blood salvage and erythropoietin did not lead to a deterioration in patient-related secondary outcomes. Trial registration www.trialregister.nl, NTR4044 Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0601-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Veronique M A Voorn
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.,Department of Orthopedic Surgery, Groene Hart Hospital, Bleulandweg 10, 2803, HH, Gouda, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Anja van der Hout
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.,Department of Clinical Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1-3, 1081, BT, Amsterdam, The Netherlands
| | - Stefanie N Hofstede
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Cynthia So-Osman
- Department of Transfusion Medicine, Sanquin Blood Supply, Plesmanlaan 1a, 2333, BZ, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Bleulandweg 10, 2803, HH, Gouda, The Netherlands
| | - M Elske van den Akker-van Marle
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Ad A Kaptein
- Department of Medical Psychology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics & Bioinformatics, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | | | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Thea P M M Vliet Vlieland
- Department of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Rob G H H Nelissen
- Department of Orthopedics, Leiden University Medical Center, J11-R, P.O. Box 9600, 2300, RC, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, J10-S, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
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160
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Hospital Contributions to Variability in the Use of ICUs Among Elderly Medicare Recipients. Crit Care Med 2017; 45:75-84. [PMID: 27526267 DOI: 10.1097/ccm.0000000000002025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Hospitals vary widely in ICU admission rates across numerous medical diagnoses. The extent to which variability in ICU use is specific to individual diagnoses or is a function of the hospital, regardless of disease, is unknown. DESIGN Retrospective cohort study. SETTING A total of 1,120 acute care hospitals with ICU capabilities. PATIENTS Medicare beneficiaries 65 years old or older admitted for five medical diagnoses (acute myocardial infarction, congestive heart failure, stroke, pneumonia, and chronic obstructive pulmonary disease) and a surgical diagnosis (hip fracture treated with arthroplasty) in 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used multilevel models to calculate risk- and reliability-adjusted ICU admission rates, examined the correlation in ICU admission rates across diagnosis and calculated intraclass correlation coefficients and median odds ratios to quantify the variability in ICU admission rate that was attributable to hospitals. We also examined the ability of a high ICU-use hospital for one condition to predict high ICU use for other conditions. We identified 348,462 patients with one of the eligible conditions. ICU admission rates were positively correlated within hospitals for included medical diagnoses (r range, 0.38-0.59; p < 0.01). The top hospital quartile of ICU use for congestive heart failure had a sensitivity of 50-60% and specificity of 79-81% for detecting top quartile hospitals for each other conditions. After adjustment for patient and hospital characteristics, hospitals accounted for 17.6% (95% CI, 16.2-19.1%) of variability in ICU admission, corresponding to a median odds ratio of 2.3, compared to 25.8% (95% CI, 24.5-27.1%) and median odds ratio 2.8 for diagnosis. This suggests a patient with median baseline risk of ICU admission would more than double his/her odds of ICU admission if moving to a higher utilizing hospital. CONCLUSIONS Hospitals account for a significant proportion of variation independent of measured patient and hospital characteristics, suggesting the need for further work to evaluate the causes of variation at the hospital level and potential consequences of variation across hospitals.
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161
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Zywiel MG, Liu TC, Bozic KJ. Value-based Healthcare: The Challenge of Identifying and Addressing Low-value Interventions. Clin Orthop Relat Res 2017; 475:1305-1308. [PMID: 28255949 PMCID: PMC5384941 DOI: 10.1007/s11999-017-5298-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 02/21/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Michael G. Zywiel
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, 1400 Barbara Jordan Blvd., Suite 1.114, Austin, TX 78723 USA
| | - Tiffany C. Liu
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, 1400 Barbara Jordan Blvd., Suite 1.114, Austin, TX 78723 USA
| | - Kevin J. Bozic
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, 1400 Barbara Jordan Blvd., Suite 1.114, Austin, TX 78723 USA
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162
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Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
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Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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163
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Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low-Value Back Imaging Associated With The ‘Choosing Wisely’ Campaign, 2012–14. Health Aff (Millwood) 2017; 36:671-679. [DOI: 10.1377/hlthaff.2016.1263] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Arthur S. Hong
- Arthur S. Hong ( ) is a research fellow in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, in Boston, Massachusetts
| | - Dennis Ross-Degnan
- Dennis Ross-Degnan is an associate professor and director of research in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Fang Zhang
- Fang Zhang is an assistant professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - J. Frank Wharam
- J. Frank Wharam is an associate professor in and director of the Division of Health Policy and Insurance Research, Department of Population Medicine, at Harvard Medical School and Harvard Pilgrim Health Care Institute
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164
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Colla CH, Morden NE, Sequist TD, Mainor AJ, Li Z, Rosenthal MB. Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations. Health Serv Res 2017; 53:730-746. [PMID: 28217968 DOI: 10.1111/1475-6773.12665] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care. DATA SOURCES 2009-2011 national Medicare and commercial insurance administrative data. DESIGN We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics. METHODS We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these. PRINCIPAL FINDINGS Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians. CONCLUSIONS Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.
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Affiliation(s)
| | | | - Thomas D Sequist
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Partners Healthcare System, Boston, MA.,Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, MA
| | | | - Zhonghe Li
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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165
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Chang E, Buist DS, Handley M, Pardee R, Gundersen G, Reid RJ. Physician Service Attribution Methods for Examining Provision of Low-Value Care. EGEMS 2017; 4:1276. [PMID: 28203612 PMCID: PMC5302861 DOI: 10.13063/2327-9214.1276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objectives: There has been significant research on provider attribution for quality and cost. Low-value care is an area of heightened focus, with little of the focus being on measurement; a key methodological decision is how to attribute delivered services and procedures. We illustrate the difference in relative and absolute physician- and panel-attributed services and procedures using overuse in cervical cancer screening. Study Design: A retrospective, cross-sectional study in an integrated health care system. Methods: We used 2013 physician-level data from Group Health Cooperative to calculate two utilization attributions: (1) panel attribution with the procedure assigned to the physician’s predetermined panel, regardless of who performed the procedure; and (2) physician attribution with the procedure assigned to the performing physician. We calculated the percentage of low-value cervical cancer screening tests and ranked physicians within the clinic using the two utilization attribution methods. Results: The percentage of low-value cervical cancer screening varied substantially between physician and panel attributions. Across the whole delivery system, median panel- and physician-attributed percentages were 15 percent and 10 percent, respectively. Among sampled clinics, panel-attributed percentages ranged between 10 percent and 17 percent, and physician-attributed percentages ranged between 9 percent and 13 percent. Within a clinic, median panel-attributed screening percentage was 17 percent (range 0 percent–27 percent) and physician-attributed percentage was 11 percent (range 0 percent–24 percent); physician rank varied by attribution method. Conclusions: The attribution method is an important methodological decision when developing low-value care measures since measures may ultimately have an impact on national benchmarking and quality scores. Cross-organizational dialogue and transparency in low-value care measurement will become increasingly important for all stakeholders.
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Affiliation(s)
| | - Diana Sm Buist
- Group Health Research Institute, Group Health Cooperative
| | | | - Roy Pardee
- Group Health Research Institute, Group Health Cooperative
| | | | - Robert J Reid
- Group Health Research Institute, Group Health Cooperative; Trillium Health Partners - Institute for Better Health
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166
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Ciarrapico AM, Ugenti R, Di Minco L, Santori E, Altobelli S, Coco I, D'Onofrio S, Simonetti G. Diagnostic imaging and spending review: extreme problems call for extreme measures. Radiol Med 2017; 122:288-293. [PMID: 28070842 DOI: 10.1007/s11547-016-0721-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/19/2016] [Indexed: 12/18/2022]
Abstract
The number of diagnostic imaging tests has increased dramatically over the past decade and about 5 billion diagnostic examinations are performed worldwide each year. According to Health Ministry, Italy, is in second place for the number of CT and MR tests per thousand inhabitants in 2014 with a score of 83.3 (only Germany has a higher score, 95.2) that is a long way off from the European average of 46.5. It has also the highest ratio of magnetic resonances per person with 24,6 machines per million inhabitants, followed only by Greece and Finland. The development of the New Health Information System (NSIS) in 2010 made uniformly readable the non-homogeneous clinical data from all the different Italian regions and permitted a detailed analysis of all diagnostic imaging within the public outpatient care setting in Italy in 2012. Despite that MRI examinations represented only the 10% of the total number of imaging tests performed, their cost reached 30% of the health-care expenditure for outpatient diagnostic imaging with an overwhelming contribution coming from musculoskeletal MR which accounted for the 73% of the performed MR tests. It is reasonable to assume that these phenomena are likely due to a lack of appropriateness in MR requests that is difficult to analyze due to an absence or invalid query on the prescriptions which together accounted for the 98.7% of cases. Taking into account the above-mentioned situation, this is possibly why the Ministry of Health decided to perform "linear cuts" in expenditure for some diagnostic examinations.
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Affiliation(s)
- Anna Micaela Ciarrapico
- Political Economy, Faculty of Medicine and Surgery, Department of Biomedicine and Prevention, University of "Tor Vergata", Viale Oxford 81, 00100, Rome, Italy
| | - Rossana Ugenti
- General Directorate of Health Professions and Human Resources of the SSN, Ministry of Health, Via Ribotta, 5, Rome, 00100, Italy
| | - Lidia Di Minco
- General Directorate of Digitization, of the Health Information System and Statistics, Ministry of Health, Via Ribotta, 5, 00100, Rome, Italy
| | - Elisabetta Santori
- General Directorate of Digitization, of the Health Information System and Statistics, Ministry of Health, Via Ribotta, 5, 00100, Rome, Italy
| | - Simone Altobelli
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy.
| | - Irene Coco
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy
| | - Silvia D'Onofrio
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy
| | - Giovanni Simonetti
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy
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167
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Ducatman AM, Tacker DH, Ducatman BS, Long D, Perrotta PL, Lawther H, Pennington K, Lander O, Warden M, Failinger C, Halbritter K, Pellegrino R, Treese M, Stead JA, Glass E, Cianciaruso L, Nau KC. Quality Improvement Intervention for Reduction of Redundant Testing. Acad Pathol 2017; 4:2374289517707506. [PMID: 28725791 PMCID: PMC5497914 DOI: 10.1177/2374289517707506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 01/09/2023] Open
Abstract
Laboratory data are critical to analyzing and improving clinical quality. In the setting of residual use of creatine kinase M and B isoenzyme testing for myocardial infarction, we assessed disease outcomes of discordant creatine kinase M and B isoenzyme +/troponin I (-) test pairs in order to address anticipated clinician concerns about potential loss of case-finding sensitivity following proposed discontinuation of routine creatine kinase and creatine kinase M and B isoenzyme testing. Time-sequenced interventions were introduced. The main outcome was the percentage of cardiac marker studies performed within guidelines. Nonguideline orders dominated at baseline. Creatine kinase M and B isoenzyme testing in 7496 order sets failed to detect additional myocardial infarctions but was associated with 42 potentially preventable admissions/quarter. Interruptive computerized soft stops improved guideline compliance from 32.3% to 58% (P < .001) in services not receiving peer leader intervention and to >80% (P < .001) with peer leadership that featured dashboard feedback about test order performance. This successful experience was recapitulated in interrupted time series within 2 additional services within facility 1 and then in 2 external hospitals (including a critical access facility). Improvements have been sustained postintervention. Laboratory cost savings at the academic facility were estimated to be ≥US$635 000 per year. National collaborative data indicated that facility 1 improved its order patterns from fourth to first quartile compared to peer norms and imply that nonguideline orders persist elsewhere. This example illustrates how pathologists can provide leadership in assisting clinicians in changing laboratory ordering practices. We found that clinicians respond to local laboratory data about their own test performance and that evidence suggesting harm is more compelling to clinicians than evidence of cost savings. Our experience indicates that interventions done at an academic facility can be readily instituted by private practitioners at external facilities. The intervention data also supplement existing literature that electronic order interruptions are more successful when combined with modalities that rely on peer education combined with dashboard feedback about laboratory order performance. The findings may have implications for the role of the pathology laboratory in the ongoing pivot from quantity-based to value-based health care.
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Affiliation(s)
- Alan M. Ducatman
- School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Danyel H. Tacker
- Department of Pathology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Barbara S. Ducatman
- Department of Pathology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Dustin Long
- University of Alabama School of Public Health, Birmingham, AL, USA
| | - Peter L. Perrotta
- Department of Pathology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Hannah Lawther
- Department of Radiology, Mayo School of Graduate Medical Education, Scottsdale, AZ, USA
| | - Kelly Pennington
- Department of Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN, USA
| | - Owen Lander
- Department of Emergency Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Mary Warden
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Conard Failinger
- Heart Institute, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kevin Halbritter
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Ronald Pellegrino
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Marney Treese
- Department of Emergency Medicine, Jefferson Medical Center, Ranson, WV, USA
| | - Jeffrey A. Stead
- Department of Pathology, Jefferson Medical Center Medical Center, Ranson, WV, USA
- Department of Pathology, Berkeley Medical Center, Martinsburg, WV, USA
| | - Eric Glass
- Department of Emergency Medicine, Berkeley Medical Center, Martinsburg, WV, USA
| | | | - Konrad C. Nau
- Department of Family Medicine and Office of the Dean, Robert C Byrd Health Sciences Center-Eastern campus, Harpers Ferry, WV, USA
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168
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Blozik E, Brüngger B, Reich O. [Medical Overuse in Switzerland: How Frequent is Preoperative Chest Radiography?]. PRAXIS 2017; 106:343-349. [PMID: 28357906 DOI: 10.1024/1661-8157/a002628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Zusammenfassung. Hintergrund: Präoperatives Thorax-Röntgen bei Patienten ohne Verdacht auf intrathorakale Pathologie wird auf der Top-5-Liste der «Smarter Medicine»-Initiative aufgeführt. Diese Studie untersucht den Anteil unnützer präoperativer Röntgenthorax-Aufnahmen in der Schweiz. Methoden: Sekundäranalyse von Abrechnungsdaten von hospitalisierten Patienten in der obligatorischen Krankenpflegeversicherung. Die Häufigkeit präoperativer Thorax-Röntgen wurde stratifiziert nach Soziodemografie und den chronischen Erkrankungsgruppen «kardiovaskuläre Erkrankung» und «Atemwegserkrankung» untersucht. Ergebnisse: Von 47 215 hospitalisierten Individuen erhielten 6 121 (13 %) ein ambulantes präoperatives Thorax-Röntgen. Es zeigte sich erhebliche interkantonale Variation. Diskussion: Unsere Untersuchung ergab keine Hinweise auf einen übermässigen Einsatz von unnützen präoperativem Thorax-Röntgen in der Schweiz. Die interkantonalen Schwankungen könnten auf unerwünschte Varianz hinweisen. Die Studie liefert Argumente, zukünftige Top-5-Listendaten aus der Versorgungsrealität miteinzubeziehen.
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Affiliation(s)
- Eva Blozik
- 1 Gesundheitswissenschaften, Helsana Gruppe, Zürich
- 2 Institut für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- 3 Lehrbereich Allgemeinmedizin, Universitätsklinikum Freiburg, Freiburg i. Br., Deutschland
| | | | - Oliver Reich
- 1 Gesundheitswissenschaften, Helsana Gruppe, Zürich
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169
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Pendrith C, Bhatia M, Ivers NM, Mecredy G, Tu K, Hawker GA, Jaglal SB, Wilson L, Wintemute K, Glazier RH, Levinson W, Bhatia RS. Frequency of and variation in low-value care in primary care: a retrospective cohort study. CMAJ Open 2017; 5:E45-E51. [PMID: 28401118 PMCID: PMC5378544 DOI: 10.9778/cmajo.20160095] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Low-value care, defined as care with a lack of benefit, can lead to higher health care costs, inconvenience to patients and, in some cases, harm to patients. The objectives of this study are to conduct exploratory analyses to understand how frequently selected low-value tests are ordered, to assess the degree of variation in ordering that exists across regions and practices, and to identify services that may warrant further investigation and targeted interventions. METHODS We conducted a population-based retrospective cohort study using administrative health care databases from Ontario to identify rates of use of the following low-value services between fiscal years 2008/09 and 2012/13: computed tomography (CT) or magnetic resonance imaging (MRI) after a diagnosis of low back pain, Papanicolaou testing in women less than 21 years of age or older than 69 years of age and repeated dual-energy X-ray absorptiometry (DEXA) scanning within 2 years of an index scan. Regional and practice-level rates were calculated. Bivariate analyses were conducted to explore associations between patient factors and repeat DEXA scans. RESULTS Repeated DEXA scans were the most common service (21.0%), whereas cervical cancer screening among women less than 21 years of age or older than 69 years of age (8.0%) and CT or MRI imaging for low back pain (4.5%) were less common. There was substantial variation across practices with rates of repeated DEXA scans, ranging from 4.0% to 54.9%, and cervical cancer screening, ranging from 0.9% to 35.2%. Patients with a high-risk index DEXA were more likely to receive a repeat scan (28.1%) than those with a baseline (8.9%) or low-risk (8.1%) scan. INTERPRETATION There is significant, practice-level variation in the frequency of low-value testing for DEXA scans, back imaging and cervical cancer screening. There is a particular need for interventions that aim to reduce unnecessary DEXA scans.
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Affiliation(s)
- Ciara Pendrith
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Meghan Bhatia
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Noah M Ivers
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Graham Mecredy
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Karen Tu
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Gillian A Hawker
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Susan B Jaglal
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Lynn Wilson
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Kimberly Wintemute
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Richard H Glazier
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - Wendy Levinson
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
| | - R Sacha Bhatia
- Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont
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170
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Black N. From cutting costs to eliminating waste: reframing the challenge. J Health Serv Res Policy 2016; 22:73-75. [PMID: 28429979 DOI: 10.1177/1355819616685739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nick Black
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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171
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Chua KP, Schwartz AL, Volerman A, Conti RM, Huang ES. Use of Low-Value Pediatric Services Among the Commercially Insured. Pediatrics 2016; 138:e20161809. [PMID: 27940698 PMCID: PMC5127068 DOI: 10.1542/peds.2016-1809] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Claims-based measures of "low-value" pediatric services could facilitate the implementation of interventions to reduce the provision of potentially harmful services to children. However, few such measures have been developed. METHODS We developed claims-based measures of 20 services that typically do not improve child health according to evidence-based guidelines (eg, cough and cold medicines). Using these measures and claims from 4.4 million commercially insured US children in the 2014 Truven MarketScan Commercial Claims and Encounters database, we calculated the proportion of children who received at least 1 low-value pediatric service during the year, as well as total and out-of-pocket spending on these services. We report estimates based on "narrow" measures designed to only capture instances of service use that were low-value. To assess the sensitivity of results to measure specification, we also reported estimates based on "broad measures" designed to capture most instances of service use that were low-value. RESULTS According to the narrow measures, 9.6% of children in our sample received at least 1 of the 20 low-value services during the year, resulting in $27.0 million in spending, of which $9.2 million was paid out-of-pocket (33.9%). According to the broad measures, 14.0% of children in our sample received at least 1 of the 20 low-value services during the year. CONCLUSIONS According to a novel set of claims-based measures, at least 1 in 10 children in our sample received low-value pediatric services during 2014. Estimates of low-value pediatric service use may vary substantially with measure specification.
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Affiliation(s)
- Kao-Ping Chua
- Sections of Academic Pediatrics, and
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; and
| | | | - Anna Volerman
- Sections of Academic Pediatrics, and
- Section of General Internal Medicine, Department of Medicine, and
| | - Rena M Conti
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; and
- Pediatric Hematology/Oncology, Department of Pediatrics
| | - Elbert S Huang
- Section of General Internal Medicine, Department of Medicine, and
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172
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Chang CH, Bynum JPW, Onega T, Colla CH, Lurie JD, Tosteson ANA. Screening Mammography Use Among Older Women Before and After the 2009 U.S. Preventive Services Task Force Recommendations. J Womens Health (Larchmt) 2016; 25:1030-1037. [PMID: 27427790 DOI: 10.1089/jwh.2015.5701] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It is uncertain how changes in the U.S. Preventive Services Task Force breast cancer screening recommendations (from annual to biennial mammography screening in women aged 50-74 and grading the evidence as insufficient for screening in women aged 75 and older) have affected mammography use among Medicare beneficiaries. MATERIALS AND METHODS Cohort study of 12 million Medicare fee-for-service women aged 65-74 and 75 and older to measure changes in 3-year screening use, 2007-2009 (before) and 2010-2012 (after), defined by two measures-proportion screened and frequency of screening by age, race/ethnicity, and hospital referral region. RESULTS Fewer women were screened, but with similar frequency after 2009 for both age groups (after vs. before: age 65-74: 60.1% vs. 60.8% screened, 2.1 vs. 2.1 mammograms per screened woman; age 75 and older: 31.7% vs. 33.6% screened, 1.9 vs. 1.9 mammograms per screened woman; all p < 0.05). Black women were the only subgroup with an increase in screening use, and for both age groups (after vs. before: age 65-74: 55.4% vs. 54.0% screened and 2.0 vs. 1.9 mammograms per screened woman; age 75 and older: 28.5% vs. 27.9% screened and 1.8 vs. 1.8 mammograms per screened woman; all p < 0.05). Regional change patterns in screening were more similar between age groups (Pearson correlation r = 0.781 for proportion screened; r = 0.840 for frequency of screening) than between black versus nonblack women (Pearson correlation r = 0.221 for proportion screened; r = 0.212 for frequency of screening). CONCLUSIONS Changes in screening mammography use for Medicare women are not fully aligned with the 2009 recommendations.
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Affiliation(s)
- Chiang-Hua Chang
- 1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire
| | - Julie P W Bynum
- 1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire.,2 Department of Medicine, Dartmouth-Hitchcock Medical Center , Lebanon , New Hampshire
| | - Tracy Onega
- 1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire.,3 Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center , Lebanon , New Hampshire
| | - Carrie H Colla
- 1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire.,3 Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center , Lebanon , New Hampshire
| | - Jon D Lurie
- 1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire.,2 Department of Medicine, Dartmouth-Hitchcock Medical Center , Lebanon , New Hampshire
| | - Anna N A Tosteson
- 1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire.,2 Department of Medicine, Dartmouth-Hitchcock Medical Center , Lebanon , New Hampshire.,3 Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center , Lebanon , New Hampshire
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173
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de Vries EF, Struijs JN, Heijink R, Hendrikx RJP, Baan CA. Are low-value care measures up to the task? A systematic review of the literature. BMC Health Serv Res 2016; 16:405. [PMID: 27539054 PMCID: PMC4990838 DOI: 10.1186/s12913-016-1656-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 08/10/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Reducing low-value care is a core component of healthcare reforms in many Western countries. A comprehensive and sound set of low-value care measures is needed in order to monitor low-value care use in general and in provider-payer contracts. Our objective was to review the scientific literature on low-value care measurement, aiming to assess the scope and quality of current measures. METHODS A systematic review was performed for the period 2010-2015. We assessed the scope of low-value care recommendations and measures by categorizing them according to the Classification of Health Care Functions. Additionally, we assessed the quality of the measures by 1) analysing their development process and the level of evidence underlying the measures, and 2) analysing the evidence regarding the validity of a selected subset of the measures. RESULTS Our search yielded 292 potentially relevant articles. After screening, we selected 23 articles eligible for review. We obtained 115 low-value care measures, of which 87 were concentrated in the cure sector, 25 in prevention and 3 in long-term care. No measures were found in rehabilitative care and health promotion. We found 62 measures from articles that translated low-value care recommendations into measures, while 53 measures were previously developed by institutions as the National Quality Forum. Three measures were assigned the highest level of evidence, as they were underpinned by both guidelines and literature evidence. Our search yielded no information on coding/criterion validity and construct validity for the included measures. Despite this, most measures were already used in practice. CONCLUSION This systematic review provides insight into the current state of low-value care measures. It shows that more attention is needed for the evidential underpinning and quality of these measures. Clear information about the level of evidence and validity helps to identify measures that truly represent low-value care and are sufficiently qualified to fulfil their aims through quality monitoring and in innovative payer-provider contracts. This will contribute to creating and maintaining the support of providers, payers, policy makers and citizens, who are all aiming to improve value in health care.
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Affiliation(s)
- Eline F. de Vries
- Department Tranzo (Scientific Center for Care and Welfare), Tilburg University, Tilburg School of Social and Behavioral Sciences, P.O. Box 90153, 5000 LE Tilburg, The Netherlands
| | - Jeroen N. Struijs
- Department of Quality of Care and Health Economics, National Institute of Public Health and the Environment (RIVM), Center for Nutrition, Prevention and Health Services, P.O. Box 1, 3720 BA Bilthoven, The Netherlands
| | - Richard Heijink
- Department of Quality of Care and Health Economics, National Institute of Public Health and the Environment (RIVM), Center for Nutrition, Prevention and Health Services, P.O. Box 1, 3720 BA Bilthoven, The Netherlands
| | - Roy J. P. Hendrikx
- Department Tranzo (Scientific Center for Care and Welfare), Tilburg University, Tilburg School of Social and Behavioral Sciences, P.O. Box 90153, 5000 LE Tilburg, The Netherlands
| | - Caroline A. Baan
- Department Tranzo (Scientific Center for Care and Welfare), Tilburg University, Tilburg School of Social and Behavioral Sciences, P.O. Box 90153, 5000 LE Tilburg, The Netherlands
- Department of Quality of Care and Health Economics, National Institute of Public Health and the Environment (RIVM), Center for Nutrition, Prevention and Health Services, P.O. Box 1, 3720 BA Bilthoven, The Netherlands
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174
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Hall AE. Adjusting the Measurement of the Output of the Medical Sector for Quality: A Review of the Literature. Med Care Res Rev 2016; 74:639-667. [PMID: 27516451 DOI: 10.1177/1077558716663388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Bureau of Economic Analysis recently created new price indexes for health care in its health care satellite account and now faces the problem of how to adjust them for quality. I review the literature on this topic and divide the articles that created quality-adjusted price indexes for individual medical conditions into those that use primarily outcomes-based adjustments and those that use only process-based adjustments. Outcomes-based adjustments adjust the indexes based on observed aggregate health outcomes, usually mortality. Process-based adjustments adjust the indexes based on the treatments provided and medical knowledge of their effectiveness. Outcomes-based adjustments are easier to implement, while process-based adjustments are more demanding in terms of data and medical knowledge. In general, the research literature shows adjusting for quality in the measurement of output in the medical sector to be quantitatively important.
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Affiliation(s)
- Anne E Hall
- 1 Bureau of Economic Analysis, Suitland Federal Center, Suitland, MD, USA
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175
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Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. Med Care Res Rev 2016; 74:507-550. [PMID: 27402662 DOI: 10.1177/1077558716656970] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.
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Affiliation(s)
- Carrie H Colla
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | | | - Thomas Sequist
- 2 Harvard Medical School, Boston, MA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Partners HealthCare, Boston, MA, USA
| | - Nancy Morden
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,5 Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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176
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Pines JM, Lotrecchiano GR, Zocchi MS, Lazar D, Leedekerken JB, Margolis GS, Carr BG. A Conceptual Model for Episodes of Acute, Unscheduled Care. Ann Emerg Med 2016; 68:484-491.e3. [PMID: 27397857 DOI: 10.1016/j.annemergmed.2016.05.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/17/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Abstract
We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts' comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery.
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Affiliation(s)
- Jesse M Pines
- Departments of Emergency Medicine and Health Policy and Management, The George Washington University, Washington, DC; Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Gaetano R Lotrecchiano
- Departments of Clinical Research and Leadership and Pediatrics, The George Washington University, Washington, DC; Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Mark S Zocchi
- Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC.
| | - Danielle Lazar
- Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Jacob B Leedekerken
- Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Gregg S Margolis
- Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC
| | - Brendan G Carr
- Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC; Sidney Kimmel Medical College, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
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177
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Charlesworth CJ, Meath THA, Schwartz AL, McConnell KJ. Comparison of Low-Value Care in Medicaid vs Commercially Insured Populations. JAMA Intern Med 2016; 176:998-1004. [PMID: 27244044 PMCID: PMC4942278 DOI: 10.1001/jamainternmed.2016.2086] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Reducing unnecessary tests and treatments is a potentially promising approach for improving the value of health care. However, relatively little is known about whether insurance type or local practice patterns are associated with delivery of low-value care. OBJECTIVES To compare low-value care in the Medicaid and commercially insured populations, test whether provision of low-value care is associated with insurance type, and assess whether local practice patterns are associated with the provision of low-value care. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of claims data from the Oregon Division of Medical Assistance Programs and the Oregon All-Payer All-Claims database included Medicaid and commercially insured adults aged 18 to 64 years. The study period was January 1, 2013, through December 31, 2013. MAIN OUTCOMES AND MEASURES Low-value care was assessed using 16 claims-based measures. Logistic regression was used to test the association between Medicaid vs commercial insurance coverage and low-value care and the association between Medicaid and commercial low-value care rates within primary care service areas (PCSAs). RESULTS This study included 286 769 Medicaid and 1 376 308 commercial enrollees in 2013. Medicaid enrollees were younger (167 847 [58.5%] of Medicaid enrollees were aged 18-34 years vs 505 628 [36.7%] of those with commercial insurance) but generally had worse health status compared with those with commercial insurance. Medicaid enrollees were also more likely to be female (180 363 [62.9%] vs 702 165 [51.0%]) and live in a rural area (120 232 [41.9%] vs 389 964 [28.3%]). A total of 10 304 of 69 338 qualifying Medicaid patients (14.9%; 95% CI, 14.6%-15.1%) received at least 1 low-value service during 2013; the corresponding rate for commercially insured patients was 35 739 of 314 023 (11.4%; 95% CI, 11.3%-11.5%). No consistent association was found between insurance type and low-value care. Compared with commercial patients, Medicaid patients were more likely to receive low-value care for 10 measures and less likely to receive low-value care for 5 others. For 7 of 11 low-value care measures, Medicaid patients were significantly more likely to receive low-value care if they resided in a PCSA with a higher rate of low-value care for commercial patients. CONCLUSIONS AND RELEVANCE Oregon Medicaid and commercially insured patients received moderate amounts of low-value care in 2013. No consistent association was found between insurance type and low-value care. However, Medicaid and commercial rates of low-value care were associated with one another within PCSAs. Low-value care may be more closely related to local practice patterns than to reimbursement generosity or insurance benefit structures.
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Affiliation(s)
| | - Thomas H A Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Aaron L Schwartz
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland3Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
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178
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Blunt Policy Instruments Deliver Blunt Policy Outcomes: Why Cost Sharing is Not Effective at Controlling Utilization and Improving Health System Efficiency. Med Care 2016; 54:107-9. [PMID: 26761725 DOI: 10.1097/mlr.0000000000000500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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179
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Lew KN, Angelini GD, Hollingworth W. A time-series study of percutaneous closure of patent foramen ovale: premature adoption? Open Heart 2016; 3:e000313. [PMID: 26835140 PMCID: PMC4716454 DOI: 10.1136/openhrt-2015-000313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/25/2015] [Accepted: 10/13/2015] [Indexed: 12/27/2022] Open
Abstract
Objectives To evaluate the impact of National Institute for Health and Care Excellence (NICE) guidance in January 2005 and subsequent trial evidence on the adoption of percutaneous closure of patent foramen ovale (PCPFO). Methods A retrospective time series study was conducted using the Inpatient Hospital Episode Statistics (HES) England. A total of 3801 patients, aged ≥18 and ≤60 years, who had PCPFO from 1 April 2006 to 31 March 2012 in England. Percentage change annualised (PCA) in PCPFO procedure rates between initial NICE guidance and publication of trial results was analysed. Results Between Quarter 2, 2006 and Quarter 4, 2009, 2163 PCPFO procedures were performed, with an increasing PCA of 48.4%. The procedure rate peaked before the presentation of equivocal results from the first randomised controlled trial (RCT) in late 2010, and declined between Quarter 4, 2009 and Quarter 4, 2011 (PCA=−15.3%). Of more than 2300 patients recruited to three RCTs, only 71 were recruited in English hospitals. Conclusions PCPFO was rapidly adopted after the publication of initial NICE guidance despite the absence of RCT evidence of efficacy. Very few English patients participated in international RCTs of PCPFO, suggesting that NICE recommendations also failed to encourage the generation of RCT evidence.
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Affiliation(s)
- Kian Nian Lew
- Faculty of Medicine and Dentistry , University of Bristol , Bristol , UK
| | - Gianni D Angelini
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust , Bristol , UK
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180
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Ali A, Katz DL. Disease Prevention and Health Promotion: How Integrative Medicine Fits. Am J Prev Med 2015; 49:S230-40. [PMID: 26477898 PMCID: PMC4615581 DOI: 10.1016/j.amepre.2015.07.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/22/2015] [Accepted: 07/26/2015] [Indexed: 01/06/2023]
Abstract
As a discipline, preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention. The fields of preventive medicine and public health share the objectives of promoting general health, preventing disease, and applying epidemiologic techniques to these goals. This paper discusses a conceptual approach between the overlap and potential synergies of integrative medicine principles and practices with preventive medicine in the context of these levels of prevention, acknowledging the relative deficiency of research on the effectiveness of practice-based integrative care. One goal of integrative medicine is to make the widest array of appropriate options available to patients, ultimately blurring the boundaries between conventional and complementary medicine. Both disciplines should be subject to rigorous scientific inquiry so that interventions that are efficacious and effective are systematically distinguished from those that are not. Furthermore, principles of preventive medicine can be infused into prevalent practices in complementary and integrative medicine, promoting public health in the context of more responsible practices. The case is made that an integrative preventive approach involves the responsible use of science with responsiveness to the needs of patients that persist when conclusive data are exhausted, providing a framework to make clinical decisions among integrative therapies.
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Affiliation(s)
- Ather Ali
- Yale School of Medicine, New Haven, Connecticut.
| | - David L Katz
- Yale University Prevention Research Center, Derby, Connecticut
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181
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Bhatia RS, Levinson W, Shortt S, Pendrith C, Fric-Shamji E, Kallewaard M, Peul W, Veillard J, Elshaug A, Forde I, Kerr EA. Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low-value care. BMJ Qual Saf 2015; 24:523-31. [PMID: 26092165 DOI: 10.1136/bmjqs-2015-004070] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/26/2015] [Indexed: 11/03/2022]
Abstract
The Choosing Wisely campaign began in the USA in 2012 to encourage physicians and patients to discuss inappropriate and potentially harmful tests, treatments and procedures. Since its inception, the campaign has grown substantially and has been adopted by 12 countries around the world. Of great interest to countries implementing the campaign, is the effectiveness of Choosing Wisely to reduce overutilisation. This article presents an integrated measurement framework that may be used to assess the impact of a Choosing Wisely campaign on physician and provider awareness and attitudes on low-value care, provider practice behaviour and overuse of low-value services.
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Affiliation(s)
- R Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Canada Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Ciara Pendrith
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
| | - Elana Fric-Shamji
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
| | | | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Adam Elshaug
- Menzies Centre for Health Policy, University of Sydney, Sydney, New South Wales, Australia
| | | | - Eve A Kerr
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, and Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
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