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Lee MS, Batiste C, Onwuzurike J, Elkoustaf R, Wu YL, Chen W, Kahwaji J, Sahota A, Lee RL. Pretransplant cardiac stress testing and transplant wait time in kidney transplantation candidates. Open Heart 2024; 11:e002738. [PMID: 39277185 PMCID: PMC11404252 DOI: 10.1136/openhrt-2024-002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 09/04/2024] [Indexed: 09/17/2024] Open
Abstract
OBJECTIVE Routine screening for cardiovascular disease before kidney transplantation remains controversial. This study aims to compare cardiac testing rates in patients with end-stage renal disease, referred and not referred for transplantation, and assess the impact of testing on transplant wait times. METHODS This is a retrospective cohort study of 22 687 end-stage renal disease patients from 2011 to 2022, within an integrated health system. Cardiac testing patterns, and the association between cardiac testing and transplant wait times and post-transplant mortality were evaluated. RESULTS Of 22 687 patients (median age 66 years, 41.1% female), 6.9% received kidney transplants, and 21.0% underwent evaluation. Compared with dialysis patients, transplant patients had a 5.6 times higher rate of stress nuclear myocardial perfusion imaging with single-photon emission (rate ratio (RR) 5.64, 95% CI 5.37 to 5.92), a 6.5 times higher rate of stress echocardiogram (RR 6.51, 95% CI 5.65 to 7.51) and 16% higher cardiac catheterisation (RR 1.16, 95% CI 1.06 to 1.27). In contrast, revascularisation rates were significantly lower in transplant patients (RR 0.46, 95% CI 0.36 to 0.58). Transplant wait times were longer for patients who underwent stress testing (median 474 days with no testing vs 1053 days with testing) and revascularisation (1796 days for percutaneous intervention and 2164 days for coronary artery bypass surgery). No significant association was observed with 1-year post-transplant mortality (adjusted OR 1.99, 95% CI 0.46 to 8.56). CONCLUSIONS This study found a higher rate of cardiac testing in dialysis patients evaluated for kidney transplants. Cardiac testing was associated with longer transplant wait time, but no association was observed between testing and post-transplant mortality.
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Affiliation(s)
- Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Columbus Batiste
- Department of Cardiology, Kaiser Permanente Riverside Medical Center, Riverside, California, USA
| | - James Onwuzurike
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Rachid Elkoustaf
- Department of Cardiology, Kaiser Permanente Riverside Medical Center, Riverside, California, USA
| | - Yi-Lin Wu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Wansu Chen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Joseph Kahwaji
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Amandeep Sahota
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Roland L Lee
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
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Radomski TR, Lovelace EZ, Sileanu FE, Zhao X, Rose L, Schwartz AL, Schleiden LJ, Pickering AN, Gellad WF, Fine MJ, Thorpe CT. Use and Cost of Low-Value Services Among Veterans Dually Enrolled in VA and Medicare. J Gen Intern Med 2024; 39:2215-2224. [PMID: 38977515 PMCID: PMC11347549 DOI: 10.1007/s11606-024-08911-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Over half of veterans enrolled in the Veterans Health Administration (VA) are also enrolled in Medicare, potentially increasing their opportunity to receive low-value health services within and outside VA. OBJECTIVES To characterize the use and cost of low-value services delivered to dually enrolled veterans from VA and Medicare. DESIGN Retrospective cross-sectional. PARTICIPANTS Veterans enrolled in VA and fee-for-service Medicare (FY 2017-2018). MAIN MEASURES We used VA and Medicare administrative data to identify 29 low-value services across 6 established domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing, and surgery. We determined the count of low-value services per 100 veterans delivered in VA and Medicare in FY 2018 overall, by domain, and by individual service. We applied standardized estimates to determine each service's cost. KEY RESULTS Among 1.6 million dually enrolled veterans, the mean age was 73, 97% were men, and 77% were non-Hispanic White. Overall, 63.2 low-value services per 100 veterans were delivered, affecting 32% of veterans; 22.9 services per 100 veterans were delivered in VA and 40.3 services per 100 veterans were delivered in Medicare. The total cost was $226.3 million (M), of which $62.6 M was spent in VA and $163.7 M in Medicare. The most common low-value service was prostate-specific antigen testing at 17.3 per 100 veterans (VA 55.9%, Medicare 44.1%). The costliest low-value service was percutaneous coronary intervention (VA $10.1 M, Medicare $32.8 M). CONCLUSIONS Nearly 1 in 3 dually enrolled veterans received a low-value service in FY18, with twice as many low-value services delivered in Medicare vs VA. Interventions to reduce low-value services for veterans should consider their substantial use of such services in Medicare.
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Affiliation(s)
- Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Center for Research On Health Care, Pittsburgh, PA, USA.
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center (HERC), VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Aaron L Schwartz
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy and Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Aimee N Pickering
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
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3
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Shih P, Sandberg S, Balla J, Basok BI, Brady JJ, Croal B, De Vos N, Karlsson M, Kedars P, Ozben T, Pijanovic M, Plebani M, Orth M. Direct-to-consumer testing as consumer initiated testing: compromises to the testing process and opportunities for quality improvement. Clin Chem Lab Med 2024; 0:cclm-2024-0876. [PMID: 39141796 DOI: 10.1515/cclm-2024-0876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 08/16/2024]
Abstract
Direct-to-consumer testing (DTCT) refers to commercial laboratory tests initiated by laypersons without the involvement of healthcare professionals. As this market grows in size and variety of products, a clear definition of DTCT to ground the conceptualization of their harms and benefits is needed. We describe how three different modalities of DTCT (home self-testing, self-sampled tests, and direct access tests) present caveats to the traditional testing process ('brain-to-brain loop'), and how this might differ between medical vs. non-medical laboratories. We make recommendations for ways to improve quality and reduce errors with respect to DTCT. The potential benefits and harms of DTCT will invariably depend on the context and situation of individual consumers and the types of tests involved. Importantly, implications for both consumers and the healthcare system should be considered, such as the effects on improving health outcomes and reducing unnecessary testing and use of clinical resources. 'Consumer initiation' must be a central defining characteristic of DTCT, to clearly demarcate the key drawbacks as well as opportunities of this type of testing from a laboratory specialists' perspective. The concept of 'consumer initiated testing' should also help define DTCT regulation, and provide a locus of efforts to support consumers as the main decision-makers in the purchasing and conducting of these tests in the absence of clinician gatekeeping.
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Affiliation(s)
- Patti Shih
- Australian Centre for Health Engagement Evidence and Values, School of Health & Society, 8691 University of Wollongong , Wollongong, Australia
| | - Sverre Sandberg
- Noklus, Bergen, Norway
- Department of Public Global Health and Primary Care, University of Bergen, Bergen, Norway
- Noklus, The Norwegian Organization for Quality Improvement of Laboratory Examinations, Haraldsplass Diakonale Sykehus AS, Bergen, Norway
- Department of Public Global Health and Primary Care, University of Bergen, Bergen, Hordaland, Norway
| | - Jan Balla
- Klinicka biochemia a imunochemia, Analyticko-diagnosticke laboratorium, Kovacska, Presov, Slovakia
| | - Banu Isbilen Basok
- Faculty of Medicine, University of Health Sciences Izmir, Izmir, Türkiye
| | - Jennifer J Brady
- Department of Clinical Biochemistry, Children's Health Ireland at Temple St, Dublin 1, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Bernard Croal
- Aberdeen Royal Infirmary, NHS Grampian-Clinical Biochemistry, Aberdeen, Aberdeen, UK
| | - Nathalie De Vos
- LHUB-ULB Clinical Chemistry, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Mathias Karlsson
- Department of Medical Sciences, Section of Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Piret Kedars
- Central Laboratory, East Tallinn Central Hospital, Tallinn, Harjumaa, Estonia
| | - Tomris Ozben
- Department of Clinical Biochemistry, Medical Faculty, Akdeniz University, Antalya, Türkiye
- Faculty of Medicine and Surgery, Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Mario Plebani
- Dipartimento di Medicina di Laboratorio, Universita di Padova, Azienda Ospedaliera di Padova, Padova, Italy
| | - Matthias Orth
- Institut für Laboratoriumsmedizin, Vinzenz von Paul Kliniken gGmbH, Stuttgart, Baden-Württemberg, Germany
- Medical Faculty Mannheim, Ruprecht-Karls-Universität Heidelberg, Mannheim, Germany
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4
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Sebastião M, Pesch J, Kühlein T, Hueber S. 'The health care system is more like a business'-medical overuse from the patients' perspective in Germany: a qualitative study. BMJ Open 2024; 14:e084065. [PMID: 39019629 PMCID: PMC11288157 DOI: 10.1136/bmjopen-2024-084065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/27/2024] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVES Medical overuse exposes patients to unnecessary risks of harm. It is an open question whether and how patients perceive the concept of medical overuse, its causes and negative consequences. DESIGN A qualitative study design, using elements of the Grounded Theory Approach by Strauss and Corbin. SETTING Between May 2017 and January 2020, we recruited participants and conducted face-to-face interviews in the participants' homes. Data collection took place in Bavaria, Germany. PARTICIPANTS We recruited 16 participants (female=8, male=8) with various characteristics for the study. We used different strategies such as flyers in supermarkets, pharmacies, participants spreading information about the study or local multipliers (snowball sampling). RESULTS The participants mostly defined medical overuse as too much being done but understood the concept superficially. During the interviews, most participants could describe examples of medical overuse. They named a variety of direct and indirect drivers with economic factors suspected to be the main driver. As a consequence of medical overuse, participants named the physical and emotional harm (eg, side effects of medication). They found it difficult to formulate concrete solutions. In general, they saw themselves more in a passive role than being responsible for bringing about change and solutions themselves. Medical overuse is a 'problem of the others'. The participants emphasised that health education is important in reducing medical overuse. CONCLUSIONS Medical overuse was little discussed among participants, although many participants reported experiences of too much medicine. Health education and strengthening the patients' self-responsibility can play a vital role in reducing medical overuse.
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Affiliation(s)
- Maria Sebastião
- Institute of General Practice, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Josefine Pesch
- Institute of General Practice, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Thomas Kühlein
- Institute of General Practice, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Susann Hueber
- Institute of General Practice, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
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Mira JJ, Carratala-Munuera C, Vicente MA, Astier-Peña MP, García-Torres D, Soriano C, Sánchez-García A, Chilet-Rosell E, Gil-Guillén VF, López-Pineda A, Pérez-Jover V. Gender Disparities in Adverse Events Resulting From Low-Value Practices in Family Practice in Spain: A Retrospective Cohort Study. Int J Public Health 2024; 69:1607030. [PMID: 39081783 PMCID: PMC11286494 DOI: 10.3389/ijph.2024.1607030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 07/03/2024] [Indexed: 08/02/2024] Open
Abstract
Objectives: This study aimed to evaluate gender-based disparities in preventable adverse events due to low-value practices (LVPs) in primary care. Methods: A retrospective cohort study in Alicante, Spain. Results: A total of 1,516 patient records were examined, finding that older individuals and women experienced more LVP-related events. Female patients faced a higher volume of such events than males with the same health issue. Interaction analysis revealed patients treated by male physicians had more severe events, while those attended by females experienced milder ones. Adverse events were more frequent in LVPs associated with gender-based reasons. Conclusion: These results highlight the need for tailored healthcare professional awareness programs on overuse's impact on safety. Addressing outcome differences between male and female patients should inform awareness campaigns.
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Affiliation(s)
- José Joaquín Mira
- Alicante-Sant Joan Health District, Alicante, Spain
- ATENEA Research, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), San Juan de Alicante, Spain
- Health Psychology Department, Miguel Hernandez University of Elche, Elche, Spain
- RICAPPS—Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud, Sant Joan Alacant, Spain
| | - Concepción Carratala-Munuera
- RICAPPS—Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud, Sant Joan Alacant, Spain
- Clinical Medicine Department, Miguel Hernandez University of Elche, Elche, Spain
| | | | - Maria Pilar Astier-Peña
- Universitas Health Centre, Zaragoza, Spain
- Public Health Service of Aragon, University of Zaragoza, Grupo de Investigación en Bioética de Aragón, Instituto de Investigación Sanitaria de Aragón, Aragón, Spain
| | - Daniel García-Torres
- Alicante-Sant Joan Health District, Alicante, Spain
- ATENEA Research, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), San Juan de Alicante, Spain
| | | | | | - Elisa Chilet-Rosell
- Public Health, History of Medicine and Gynecology Department, Miguel Hernandez University of Elche, Elche, Spain
| | - Vicente F. Gil-Guillén
- RICAPPS—Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud, Sant Joan Alacant, Spain
- Clinical Medicine Department, Miguel Hernandez University of Elche, Elche, Spain
| | - Adriana López-Pineda
- RICAPPS—Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud, Sant Joan Alacant, Spain
- Clinical Medicine Department, Miguel Hernandez University of Elche, Elche, Spain
| | - Virtudes Pérez-Jover
- Health Psychology Department, Miguel Hernandez University of Elche, Elche, Spain
- Calitè Research, Applied Psychology Research Centre, Miguel Hernández University, Elche, Spain
- Hospital Psychology Research Group, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General Universitario de Alicante, Alicante, Spain
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6
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Stewart C, Davenport MS, Miglioretti DL, Smith-Bindman R. Types of Evidence Needed to Assess the Clinical Value of Diagnostic Imaging. NEJM EVIDENCE 2024; 3:EVIDra2300252. [PMID: 38916414 DOI: 10.1056/evidra2300252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
AbstractThe evidence underlying the use of advanced diagnostic imaging is based mainly on diagnostic accuracy studies and not on well-designed trials demonstrating improved patient outcomes. This has led to an expansion of low-value and potentially harmful patient care and raises ethical issues around the widespread implementation of tests with incompletely known benefits and harms. Randomized clinical trials are needed to support the safety and effectiveness of imaging tests and should be required for clearance of most new technologies. Large, diverse cohort studies are needed to quantify disease risk associated with many imaging findings, especially incidental findings, to enable evidence-based management. The responsibility to minimize the use of tests with unknown or low value requires engagement of clinicians, medical societies, and the public.
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Affiliation(s)
- Carly Stewart
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Matthew S Davenport
- Department of Radiology, Michigan Medicine, Ann Arbor
- Department of Urology, Michigan Medicine, Ann Arbor
| | - Diana L Miglioretti
- Department of Public Health Sciences, University of California, Davis, Davis
| | - Rebecca Smith-Bindman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco
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7
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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Care cascades following low-value cervical cancer screening in dually enrolled Veterans. J Am Geriatr Soc 2024; 72:2091-2099. [PMID: 38721922 PMCID: PMC11226371 DOI: 10.1111/jgs.18956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/08/2024] [Accepted: 04/18/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare. METHODS This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low-value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient- and facility-level covariates using inverse probability of treatment weighting. RESULTS Among 20,972 cohort-eligible Veterans, 494 (2.4%) underwent low-value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4-37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, -265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare. CONCLUSIONS Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low-value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low-value care, it is important to examine downstream care stemming from initial low-value services across all systems from which individuals receive care.
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Affiliation(s)
- Aimee N Pickering
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Liam Rose
- Health Economics Resource Center (HERC), VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Aaron L Schwartz
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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8
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Oakman G, Anderson A, Oosthuizen JDW, Olaussen A. Pathology requesting in a regional Australian Emergency Department; an observational study comparing current practice with college guidelines. Aust J Rural Health 2024. [PMID: 38867647 DOI: 10.1111/ajr.13151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION In 2018, the Australasian College for Emergency Medicine (ACEM) and the Royal College of Pathologists of Australasia (RCPA) produced a guideline to encourage appropriate pathology requesting in the Emergency Department (ED). OBJECTIVE To assess adherence to the ACEM/RCPA pathology testing guideline in a regional ED. METHODS, DESIGN, SETTING AND PARTICIPANTS This was a retrospective observational study conducted at a regional Australian ED over 7 days. Adults with a presenting complaint encompassed by the guideline were included. All blood tests were audited against the guideline recommendations and classified as indicated or non-indicated. Chi-squared analyses were performed to explore the association between presenting complaint and non-indicated testing. MAIN OUTCOME MEASURE The primary outcome was the number of non-indicated blood tests. RESULTS Forty percent of tests ordered were not clinically indicated, with non-indicated testing occurring during 87% of encounters. The C-reactive protein (CRP) was the test most frequently ordered outside of guidelines (94% non-indicated). Patients presenting with lower abdominal pain accounted for nearly one-quarter of all non-indicated tests. CONCLUSIONS Blood tests were commonly requested outside of the guideline recommendations and interventions to improve pathology stewardship are required.
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Affiliation(s)
- Georgina Oakman
- Critical Care SRMO, Northeast Health Wangaratta, Wangaratta, Victoria, Australia
| | - Alastair Anderson
- Critical Care SRMO, Northeast Health Wangaratta, Wangaratta, Victoria, Australia
| | - Johann De Witt Oosthuizen
- Clinical Director of Emergency Services, Northeast Health Wangaratta, Wangaratta, Victoria, Australia
| | - Alexander Olaussen
- Emergency Services Senior Medical Officer, Northeast Health Wangaratta, Wangaratta, Victoria, Australia
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Usher-Smith JA, Godoy A, Kitt J, Farquhar F, Waller J, Sharp SJ, Shinkins B, Cartledge J, Kimuli M, Burge SW, Burbidge S, Eckert C, Hancock N, Marshall C, Rogerson S, Rossi SH, Smith A, Simmonds I, Wallace T, Ward M, Callister MEJ, Stewart GD. Short-term psychosocial outcomes of adding a non-contrast abdominal computed tomography (CT) scan to the thoracic CT within lung cancer screening. BJU Int 2024; 133:539-547. [PMID: 38097529 DOI: 10.1111/bju.16260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES To evaluate psychological, social, and financial outcomes amongst individuals undergoing a non-contrast abdominal computed tomography (CT) scan to screen for kidney cancer and other abdominal malignancies alongside the thoracic CT within lung cancer screening. SUBJECTS AND METHODS The Yorkshire Kidney Screening Trial (YKST) is a feasibility study of adding a non-contrast abdominal CT scan to the thoracic CT within lung cancer screening. A total of 500 participants within the YKST, comprising all who had an abnormal CT scan and a random sample of one-third of those with a normal scan between 14/03/2022 and 24/08/2022 were sent a questionnaire at 3 and 6 months. Outcomes included the Psychological Consequences Questionnaire (PCQ), the short-form of the Spielberger State-Trait Anxiety Inventory, and the EuroQoL five Dimensions five Levels scale (EQ-5D-5L). Data were analysed using regression adjusting for participant age, sex, socioeconomic status, education, baseline quality of life (EQ-5D-5L), and ethnicity. RESULTS A total of 380 (76%) participants returned questionnaires at 3 months and 328 (66%) at 6 months. There was no difference in any outcomes between participants with a normal scan and those with abnormal scans requiring no further action. Individuals requiring initial further investigations or referral had higher scores on the negative PCQ than those with normal scans at 3 months (standardised mean difference 0.28 sd, 95% confidence interval 0.01-0.54; P = 0.044). The difference was greater in those with anxiety or depression at baseline. No differences were seen at 6 months. CONCLUSION Screening for kidney cancer and other abdominal malignancies using abdominal CT alongside the thoracic CT within lung cancer screening is unlikely to cause significant lasting psychosocial or financial harm to participants with incidental findings.
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Affiliation(s)
- Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Angela Godoy
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Jessica Kitt
- Department of Surgery, University of Cambridge, Cambridge, UK
| | | | - Jo Waller
- Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Bethany Shinkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Sarah W Burge
- Department of Oncology, University of Cambridge, Cambridge, UK
| | | | - Claire Eckert
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Neil Hancock
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | | | | | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK
| | | | - Irene Simmonds
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Tom Wallace
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew Ward
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Matthew E J Callister
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Health Science, University of Leeds, Leeds, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
- CRUK Cambridge Centre, Cambridge, UK
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10
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Colla CH, Ganguli I. Low-Value Care: A Multilayer Problem Requiring Multilayer Solutions. Ann Intern Med 2024; 177:676-677. [PMID: 38648645 DOI: 10.7326/m24-0862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Affiliation(s)
| | - Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard University, Boston, Massachusetts
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11
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Gupta R, Xie BE, Zhu M, Segal JB. Randomized Experiments to Reduce Overuse of Health Care: A Scoping Review. Med Care 2024; 62:263-269. [PMID: 38315879 PMCID: PMC10939761 DOI: 10.1097/mlr.0000000000001978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Health care overuse is pervasive in countries with advanced health care delivery systems. We hypothesize that effective interventions to reduce low-value care that targets patients or clinicians are mediated by psychological and cognitive processes that change behaviors and that interventions targeting these processes are varied. Thus, we performed a scoping review of experimental studies of interventions, including the interventions' objectives and characteristics, to reduce low-value care that targeted psychological and cognitive processes. METHODS We systematically searched databases for experimental studies of interventions to change cognitive orientations and affective states in the setting of health care overuse. Outcomes included observed overuse or a stated intention to use services. We used existing frameworks for behavior change and mechanisms of change to categorize the interventions and the mediating processes. RESULTS Twenty-seven articles met the inclusion criteria. Sixteen studied the provision of information to patients or clinicians, with most providing cost information. Six studies used educational interventions, including the provision of feedback about individual practice. Studies rarely used counseling, behavioral nudges, persuasion, and rewards. Mechanisms for behavior change included gain in knowledge or confidence and motivation by social norms. CONCLUSIONS In this scoping review, we found few experiments testing interventions that directly target the psychological and cognitive processes of patients or clinicians to reduce low-value care. Most studies provided information to patients or clinicians without measuring or considering mediating factors toward behavior change. These findings highlight the need for process-driven experimental designs, including trials of behavioral nudges and persuasive language involving a trusting patient-clinician relationship, to identify effective interventions to reduce low-value care.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Meng Zhu
- Johns Hopkins Carey Business School, Baltimore, MD
- Pamplin College of Business, Virgina Tech, Blacksburg, VA
| | - Jodi B. Segal
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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12
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Kaim A, Singer C, Bergovoy-Yellin L, Luxenburg O, Vaknin S, Boldor N, Wilf-Miron R, Myers V. Exploring pre-MRI imaging tests: patient survey reveals potential implications for healthcare efficiency in Israel. Isr J Health Policy Res 2024; 13:7. [PMID: 38556863 PMCID: PMC10983758 DOI: 10.1186/s13584-024-00593-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/27/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Medical imaging tests are vital in healthcare but can be costly, impacting national health expenditures. Magnetic resonance imaging (MRI) is a crucial diagnostic tool for assessing medical conditions. However, the rising demand for MRI scans has frequently strained available resources. This study aimed to estimate the prevalence of different imaging tests in individuals who eventually had an MRI, in the Israeli public health system. METHODS An online survey of patient experience of scheduling an MRI was conducted in January-February 2023, among 557 Israeli adults, representing all four health maintenance organizations (HMOs). All participants had undergone an MRI in the public health system within the past year. RESULTS Results showed that 60% of participants underwent other imaging tests before their MRI scan. Of those, computed tomography (CT) scans (43%), X-rays (39%), and ultrasounds (32%) were the most common additional imaging procedures. In addition, of the 60% of participants, 23% had undergone more than one prior imaging examination. CONCLUSIONS These findings highlight the high prevalence of preliminary imaging tests prior to MRI, with many patients undergoing multiple tests for the same problem. The health system may need to evaluate whether current clinical guidelines defining the use of various imaging tests are cost-effective.
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Affiliation(s)
- Arielle Kaim
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5266202, Ramat-Gan, Israel.
- Department of Emergency and Disaster Management, Faculty of Medicine, School of Public Health, Tel Aviv University, P.O. Box 39040, 6139001, Tel Aviv, Israel.
| | - Clara Singer
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5266202, Ramat-Gan, Israel
| | - Lucia Bergovoy-Yellin
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5266202, Ramat-Gan, Israel
| | - Osnat Luxenburg
- Medical Technology, Health Information and Research Directorate, Ministry of Health, Jerusalem, Israel
| | - Sharona Vaknin
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5266202, Ramat-Gan, Israel
- Medical Technology, Health Information and Research Directorate, Ministry of Health, Jerusalem, Israel
| | - Noga Boldor
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5266202, Ramat-Gan, Israel
| | - Rachel Wilf-Miron
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5266202, Ramat-Gan, Israel
- Department of Health Promotion, Faculty of Medicine, School of Public Health, Tel Aviv University, P.O. Box 39040, 6139001, Tel Aviv, Israel
| | - Vicki Myers
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5266202, Ramat-Gan, Israel
- Department of Health Promotion, Faculty of Medicine, School of Public Health, Tel Aviv University, P.O. Box 39040, 6139001, Tel Aviv, Israel
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Krouss M, Israilov S, Mestari N, Talledo J, Alaiev D, Moskovitz JB, Faillace RT, Uppal A, Fagan I, Curcio J, Scott J, Bouton M, Ford K, Cohen V, Wei EK, Cho HJ. Choosing Wisely and Promoting High-Value Care and Staff Safety During the COVID-19 Pandemic in a Large Safety Net System. Qual Manag Health Care 2024; 33:94-100. [PMID: 37817318 DOI: 10.1097/qmh.0000000000000431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND OBJECTIVES As the COVID-19 pandemic brought surges of hospitalized patients, it was important to focus on reducing overuse of tests and procedures to not only reduce potential harm to patients but also reduce unnecessary exposure to staff. The objective of this study was to create a Choosing Wisely in COVID-19 list to guide clinicians in practicing high-value care at our health system. METHODS A Choosing Wisely in COVID-19 list was developed in October 2020 by an interdisciplinary High Value Care Council at New York City Health + Hospitals, the largest public health system in the United States. The first phase involved gathering areas of overuse from interdisciplinary staff across the system. The second phase used a modified Delphi scoring process asking participants to rate recommendations on a 5-point Likert scale based on criteria of degree of evidence, potential to prevent patient harm, and potential to prevent staff harm. RESULTS The top 5 recommendations included avoiding tracheal intubation without trial of noninvasive ventilation (4.4); not placing routine central venous catheters (4.33); avoiding routine daily laboratory tests and batching laboratory draws (4.19); not ordering daily chest radiographs (4.17); and not using bronchodilators in the absence of reactive airway disease (4.13). CONCLUSION We successfully developed Choosing Wisely in COVID-19 recommendations that focus on evidence and preventing patient and staff harm in a large safety net system to reduce overuse.
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Affiliation(s)
- Mona Krouss
- Author Affiliations: Department of Quality and Safety (Drs Krouss, Israilov, and Wei, Ms Mestari, and Mr. Talledo and Alaiev) and Medical Professional Affairs (Dr Bouton, Ms Ford, and Mr Cohen), New York City Health + Hospitals, New York City, New York; Department of Medicine, Icahn School of Medicine, New York City, New York (Drs Krouss and Curcio); Department of Emergency Medicine, New York City Health + Hospitals/Jacobi, Bronx, New York (Drs Moskovitz and Faillace); Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York (Dr Moskovitz); Department of Public Health, Hofstra School of Health and Human Services, Hempstead, New York (Dr Moskovitz); Department of Medicine, New York City Health + Hospitals/Bellevue, New York City, New York (Drs Uppal and Fagan); Department of Medicine, New York University Grossman School of Medicine, New York City, New York (Drs Uppal and Fagan); Department of Medicine, New York City Health + Hospitals/Elmhurst, Queens, New York (Dr Curcio); Department of Radiology, New York City Health + Hospitals/Kings County, Brooklyn, New York (Dr Scott); Department of Radiology, SUNY Downstate Medical Center, Brooklyn, New York (Dr Scott); Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (Dr Cho)
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14
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Nürnberger C, Kühlein T, Hueber S. What do people know and think about medical overuse? an online questionnaire study in Germany. PLoS One 2024; 19:e0299907. [PMID: 38451967 PMCID: PMC10919641 DOI: 10.1371/journal.pone.0299907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 02/17/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Medical overuse is defined as health care services that exceed the individual needs of patients and when the potential harms of medical interventions exceed their benefits. It has impacts on patients as well as on health care resources. To address medical overuse, it is important to understand the knowledge and experiences of overuse on the side of patients. RESEARCH QUESTIONS What is the citizens' understanding of overuse? How do they assess its relevance, causes, consequences and potential solutions? METHODS A quantitative online survey was conducted. The participants were asked to state what they understand by medical overuse. Statements on causes, consequences and possible solutions were evaluated. Recruitment was carried out via a panel of a market research institute (Schlesinger Group). RESULTS The survey was completed by 406 participants. In terms of age and gender, the sample corresponded to the distribution in the German population. The majority had never heard of medical overuse (58%). About 60% assumed that medical overuse means "too much medicine including overtreatment and overtesting". Medical overuse was mainly suspected for services not covered by the public health insurance system (56%), surgical interventions (45%) and medication prescriptions (37%). Reasons for medical overuse were seen in uncoordinated care and financial incentives, but also in the expectations of patients. The main problem with medical overuse was seen in rising health care costs, while harmful physical and mental consequences for patients were mentioned less often. In order to reduce medical overuse, little importance was attributed to a primary care based system or higher financial contribution of patients. Instead, stricter cost control on the side of physicians and better coordination between care providers were suggested as solutions. Differences in socio-demographic characteristics hardly showed any differences in response behavior. CONCLUSION More than half of the respondents had never heard of medical overuse. Overuse was mainly associated with financial causes and consequences. It was not seen that overuse can be harmful for patients directly. The limited awareness of the problem of overuse probably is a barrier to tackling it effectively. Communicating the topic to the public might therefore be an effective start to mitigate medical overuse. TAKE HOME MESSAGE Many citizens seem not to be familiar with the concept of medical overuse, especially not with the fact that it may directly cause harm to patients. Informing citizens about the harms of medical overuse might be helpful in mitigating it.
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Affiliation(s)
- Carolin Nürnberger
- Faculty of Medicine, Friedrich-Alexander-University Erlangen Nürnberg (FAU), Erlangen, Germany
- Institute of General Practice, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Thomas Kühlein
- Institute of General Practice, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Susann Hueber
- Institute of General Practice, Universitätsklinikum Erlangen, Erlangen, Germany
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15
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Ganguli I, Mackwood MB, Yang CWW, Crawford M, Mulligan KL, O'Malley AJ, Fisher ES, Morden NE. Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study. BMJ 2023; 383:e074908. [PMID: 37879735 PMCID: PMC10599254 DOI: 10.1136/bmj-2023-074908] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States. DESIGN Retrospective cohort study SETTING: 100% Medicare fee-for-service administrative data (2016-18). PARTICIPANTS Black and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States. MAIN OUTCOME MEASURES Receipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system's population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt. RESULTS The cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v 3.2%) and head computed tomography scans for dizziness (3.1% v 1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v 6.5%), prostate specific antigen tests (31.0% v 25.7%), and antibiotics for upper respiratory infections (36.6% v 32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems. CONCLUSIONS Black patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew B Mackwood
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Ching-Wen Wendy Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maia Crawford
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elliott S Fisher
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- UnitedHealthcare, Minnetonka, MN, USA
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16
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King AJ, Tang L, Davis BS, Preum SM, Bukowski LA, Zimmerman J, Kahn JM. Machine learning-based prediction of low-value care for hospitalized patients. INTELLIGENCE-BASED MEDICINE 2023; 8:100115. [PMID: 38130744 PMCID: PMC10735238 DOI: 10.1016/j.ibmed.2023.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Objective Low-value care (i.e., costly health care treatments that provide little or no benefit) is an ongoing problem in United States hospitals. Traditional strategies for reducing low-value care are only moderately successful. Informed by behavioral science principles, we sought to use machine learning to inform a targeted prompting system that suggests preferred alternative treatments at the point of care but before clinicians have made a decision. Methods We used intravenous administration of albumin for fluid resuscitation in intensive care unit (ICU) patients as an exemplar of low-value care practice, identified using the electronic health record of a multi-hospital health system. We divided all ICU episodes into 4-h periods and defined a set of relevant clinical features at the period level. We then developed two machine learning models: a single-stage model that directly predicts if a patient will receive albumin in the next period; and a two-stage model that first predicts if any resuscitation fluid will be administered and then predicts albumin only among the patients with a high probability of fluid use. Results We examined 87,489 ICU episodes divided into approximately 1.5 million 4-h periods. The area under the receiver operating characteristic curve was 0.86 for both prediction models. The positive predictive value was 0.21 (95% confidence interval: 0.20, 0.23) for the single-stage model and 0.22 (0.20, 0.23) for the two-stage model. Applying either model in a targeted prompting system could prevent 10% of albumin administrations, with an attending physician receiving one prompt every 4.2 days of ICU service. Conclusion Prediction of low-value care is feasible and could enable a point-of-care, targeted prompting system that offers suggestions ahead of the moment of need before clinicians have already decided. A two-stage approach does not improve performance but does interject new levers for the calibration of such a system.
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Affiliation(s)
- Andrew J. King
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Billie S. Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sarah M. Preum
- Department of Computer Science, Dartmouth College, Hanover, NH, USA
| | - Leigh A. Bukowski
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John Zimmerman
- Human-Computer Interaction Institute, Carnegie Mellon University School of Computer Science, Pittsburgh, PA, USA
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Platen M, Flessa S, Teipel S, Rädke A, Scharf A, Mohr W, Buchholz M, Hoffmann W, Michalowsky B. Impact of low-value medications on quality of life, hospitalization and costs - A longitudinal analysis of patients living with dementia. Alzheimers Dement 2023; 19:4520-4531. [PMID: 36905286 DOI: 10.1002/alz.13012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION This study aimed to analyze the impact of low-value medications (Lvm), that is, medications unlikely to benefit patients but to cause harm, on patient-centered outcomes over 24 months. METHODS This longitudinal analysis was based on baseline, 12 and 24 months follow-up data of 352 patients with dementia. The impact of Lvm on health-related quality of life (HRQoL), hospitalizations, and health care costs were assessed using multiple panel-specific regression models. RESULTS Over 24 months, 182 patients (52%) received Lvm at least once and 56 (16%) continuously. Lvm significantly increased the risk of hospitalization by 49% (odds ratio, confidence interval [CI] 95% 1.06-2.09; p = 0.022), increased health care costs by €6810 (CI 95% -707€-14,27€; p = 0.076), and reduced patients' HRQoL (b = -1.55; CI 95% -2.76 to -0.35; p = 0.011). DISCUSSION More than every second patient received Lvm, negatively impacting patient-reported HRQoL, hospitalizations, and costs. Innovative approaches are needed to encourage prescribers to avoid and replace Lvm in dementia care. HIGHLIGHTS Over 24 months, more than every second patient received low-value medications (Lvm). Lvm negatively impact physical, psychological, and financial outcomes. Appropriate measures are needed to change prescription behaviors.
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Affiliation(s)
- Moritz Platen
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Friedrich-Loeffler-Straße 70, Greifswald, Germany
| | - Stefan Teipel
- German Center for Neurodegenerative Diseases (DZNE), site Rostock, Gehlsheimer Str. 20, Rostock, Germany
- Department of Psychosomatic Medicine, University Hospital Rostock, Gehlsheimer Str. 20, Rostock, Germany
| | - Anika Rädke
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Annelie Scharf
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Wiebke Mohr
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Maresa Buchholz
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
- Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald (UMG), Ellernholzstrasse 1-2, Greifswald, Germany
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases (DZNE), site Greifswald, Ellernholzstrasse 1-2, Greifswald, Germany
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Dominguez JA, Pacheco LA, Moratalla E, Carugno JA, Carrera M, Perez-Milan F, Caballero M, Alcázar JL. Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:336-344. [PMID: 36730180 DOI: 10.1002/uog.26171] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/28/2022] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J A Dominguez
- IERA (Instituto Extremeño de Reproducción Asistida), Badajoz, Spain
| | | | - E Moratalla
- Department of Obstetrics and Gynecology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J A Carugno
- Minimally Invasive Gynecology Division, University of Miami, Miami, FL, USA
| | - M Carrera
- Department Obstetrics and Gynecology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - F Perez-Milan
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Caballero
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
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Hjortsø CJS, Møller MH, Perner A, Brøchner AC. Routine Versus On-Demand Blood Sampling in Critically Ill Patients: A Systematic Review. Crit Care Med 2023; 51:717-730. [PMID: 36951465 DOI: 10.1097/ccm.0000000000005852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES We aimed to provide an overview of the current evidence on routine versus on-demand blood sampling in critical care. We assessed the reported proportion of patients exposed to daily routine blood sampling, the tests performed, characteristics associated with more frequent blood sampling, and the reported benefits and harms of routine blood sampling compared with on-demand sampling. DATA SOURCES We systematically searched the Cochrane Library, the Excerpta Medica Database, and the Medical Literature Analysis and Retrieval System Online for studies assessing routine versus on-demand blood testing in critically ill patients from inception to September 2022. STUDY SELECTION Abstracts and full texts were assessed independently and in duplicate by two reviewers. STUDY EXTRACTION Data were extracted independently and in duplicate by two reviewers using predefined extraction forms. DATA SYNTHESIS Of 12,212 records screened, 298 full-text articles were assessed for eligibility. We included 70 studies; 50 nonrandomized interventional studies and 20 observational studies. Exposure to routine blood testing was 52-100% (very low certainty of evidence). Blood testing seemed to occur more frequently in medical intensive care settings with a median of 18 blood tests per patient day (interquartile range, 10-33) (very low certainty of evidence). Mixed biochemistry seemed to be the most frequently performed blood tests across all settings (five tests per patient day; interquartile range, 2-10) (very low certainty of evidence). Reductions in routine blood testing seemed to be associated with reduced transfusion rates and costs without apparent adverse patient outcomes (low certainty of evidence). CONCLUSIONS In this systematic review, routine blood testing in critically ill patients was common and varied considerably. A reduction in routine blood testing appeared to be associated with reduced transfusion rates and costs without adverse effects, but the evidence was very uncertain.
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Affiliation(s)
- Carl J S Hjortsø
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Cekuolis A, Schreiber-Dietrich D, Augustinienė R, Taut H, Squires J, Chaves EL, Dong Y, Dietrich CF. Incidental Findings in Pediatric Patients: How to Manage Liver Incidentaloma in Pediatric Patients. Cancers (Basel) 2023; 15:cancers15082360. [PMID: 37190288 DOI: 10.3390/cancers15082360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental imaging findings-the role of ultrasound". IFs in the liver of newborns and children are rare and much less commonly encountered than in adults; as a result, they are relatively much more frequently malignant and life-threatening, even when they are of benign histology. Conventional B-mode ultrasound is the well-established first line imaging modality for the assessment of liver pathology in pediatric patients. US technological advances, resulting in image quality improvement, contrast-enhanced ultrasound (CEUS), liver elastography and quantification tools for steatosis have expanded the use of ultrasound technology in daily practice. The following overview is intended to illustrate incidentally detected liver pathology covering all pediatric ages. It aims to aid the examiner in establishing the final diagnosis. Management of incidentally detected focal liver lesions (FLL) needs to take into account the diagnostic accuracy of each imaging modality, the patient's safety issues (including ionizing radiation and nephrotoxic contrast agents), the delay in diagnosis, the psychological burden on the patient and the cost for the healthcare system. Moreover, this paper should help the pediatric clinician and ultrasound practitioner to decide which pathologies need no further investigation, which ones require interval imaging and which cases require further and immediate diagnostic procedures.
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Affiliation(s)
- Andrius Cekuolis
- Ultrasound Section, Department of Pediatric Radiology, Radiology and Nuclear Medicine Centre, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | | | - Rasa Augustinienė
- Ultrasound Section, Department of Pediatric Radiology, Radiology and Nuclear Medicine Centre, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Heike Taut
- Children's Hospital, Universitätsklinikum Dresden, Technische Universität Dresden, 01062 Dresden, Germany
| | - Judy Squires
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Edda L Chaves
- Radiology Department, Hospital Regional Nicolas Solano, La Chorrera 1007, Panama
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permancence, 3013 Bern, Switzerland
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Akhtar H, Chaudhry SH, Bortolussi-Courval É, Hanula R, Akhtar A, Nauche B, McDonald EG. Diagnostic yield of CT head in delirium and altered mental status-A systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:946-958. [PMID: 36434820 DOI: 10.1111/jgs.18134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging. METHODS We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I2 statistic. Factors associated with an abnormal CT head were summarized qualitatively. RESULTS Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%-15.9%) and in ICU was 17.4% (95% CI: 10%-26.3%), with considerable heterogeneity (I2 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%-25.9%). The presence of focal neurological deficits was a consistent factor that increased yield. CONCLUSION Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS.
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Affiliation(s)
- Haris Akhtar
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Shazia H Chaudhry
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Anas Akhtar
- Department of General Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Bénédicte Nauche
- McGill University Health Centre Medical Libraries, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
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King JJC, Powell-Jackson T, Hargreaves J, Makungu C, Goodman C. Does increased provider effort improve quality of care? Evidence from a standardised patient study on correct and unnecessary treatment. BMC Health Serv Res 2023; 23:190. [PMID: 36823637 PMCID: PMC9948477 DOI: 10.1186/s12913-023-09149-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Poor quality of care, including overprovision (unnecessary care) is a global health concern. Greater provider effort has been shown to increase the likelihood of correct treatment, but its relationship with overprovision is less clear. Providers who make more effort may give more treatment overall, both correct and unnecessary, or may have lower rates of overprovision; we test which is true in the Tanzanian private health sector. METHODS Standardised patients visited 227 private-for-profit and faith-based facilities in Tanzania, presenting with symptoms of asthma and TB. They recorded history questions asked and physical examinations carried out by the provider, as well as laboratory tests ordered, treatments prescribed, and fees paid. A measure of provider effort was constructed on the basis of a checklist of recommended history taking questions and physical exams. RESULTS 15% of SPs received the correct care for their condition and 74% received unnecessary care. Increased provider effort was associated with increased likelihood of correct care, and decreased likelihood of giving unnecessary care. Providers who made more effort charged higher fees, through the mechanism of higher consultation fees, rather than increased fees for lab tests and drugs. CONCLUSION Providers who made more effort were more likely to treat patients correctly. A novel finding of this study is that they were also less likely to provide unnecessary care, suggesting it is not simply a case of some providers doing "more of everything", but that those who do more in the consultation give more targeted care.
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Affiliation(s)
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
| | - James Hargreaves
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
| | - Christina Makungu
- Ifakara Health Instiute, Plot 463, Kiko Avenue, P.O. Box 78 373, Mikocheni, Dar es Salaam, Tanzania
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1E 9SH, London, UK
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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Oakes AH, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within the Veterans Health Administration. J Gen Intern Med 2023; 38:285-293. [PMID: 35445352 PMCID: PMC9905526 DOI: 10.1007/s11606-022-07561-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/31/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Low-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA). OBJECTIVE To examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery. DESIGN Retrospective cohort study using VHA administrative data from fiscal years 2017-2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not. PARTICIPANTS National cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery. MAIN MEASURES Difference in rate of receipt and attributed cost of potential cascade services in Veterans who underwent low-value preoperative testing compared to those who did not KEY RESULTS: Among 635,824 Veterans undergoing low-risk procedures, 7.8% underwent preoperative EKG. Veterans who underwent a preoperative EKG experienced an additional 52.4 (95% CI 47.7-57.2) cascade services per 100 Veterans, resulting in $138.28 (95% CI 126.19-150.37) per Veteran in excess costs. Among 739,005 Veterans undergoing low- or intermediate-risk surgery, 3.9% underwent preoperative CXR. These Veterans experienced an additional 61.9 (95% CI 57.8-66.1) cascade services per 100 Veterans, resulting in $152.08 (95% CI $146.66-157.51) per Veteran in excess costs. For both cohorts, care cascades consisted largely of repeat tests, follow-up imaging, and follow-up visits, with low rates invasive services. CONCLUSIONS Among a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service. These findings may guide de-implementation policies within VHA and other integrated healthcare systems that target those services whose downstream effects are most prevalent and costly.
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Affiliation(s)
- Aimee N Pickering
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center (HERC), VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Aaron L Schwartz
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy and Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Allison H Oakes
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Enterprise Health Services Research, Enterprise Analytics Hub, Anthem Inc., Wilmington, DE, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Haile SA, Rose WN. An open-access laboratory medicine course for medical students. Acad Pathol 2023; 10:100066. [PMID: 36915644 PMCID: PMC10006535 DOI: 10.1016/j.acpath.2022.100066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/04/2022] [Accepted: 12/18/2022] [Indexed: 03/06/2023] Open
Abstract
The senior author created a 2-week online laboratory medicine course for fourth-year medical students to meet an unmet need at our institution for a brief survey course of clinical pathology in an online format. The course includes online videos, reading assignments, study questions, and a rubric for written assignments that apply the key principles to topics that are customized based on the specialty interests of each student. Anonymous course evaluation surveys were completed by 42 of 60 students (70%), and 92% of respondents stated that they strongly agree with the quality metrics statements in the survey. The complete course materials are shared in this article in the spirit of open access and may be used for medical students, pathology residents, and other learners.
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Affiliation(s)
- Sofia A. Haile
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - William N. Rose
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital, Madison, WI, USA
- Corresponding author. Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital, 600 Highland Ave, Madison, WI, 53792, USA.
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25
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Pickering AN, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Schwartz AL, Oakes AH, Hale JA, Schleiden LJ, Gellad WF, Fine MJ, Thorpe CT, Radomski TR. Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems. JAMA Netw Open 2022; 5:e2247180. [PMID: 36520431 PMCID: PMC9856440 DOI: 10.1001/jamanetworkopen.2022.47180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
Importance Older US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades. Objective To characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services. Design, Setting, and Participants This retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018. The study cohort consisted of male US veterans dually enrolled in the VHA and Medicare who were aged 75 years or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit. Data were analyzed from December 15, 2020, to October 20, 2022. Exposures Receipt of low-value PSA testing. Main Outcomes and Measures Differences in the use and cost of cascade services occurring 6 months after receipt of a low-value PSA test were assessed for veterans who underwent low-value PSA testing in the VHA and Medicare compared with those who did not, adjusted for patient- and facility-level covariates. Results This study included 300 393 male US veterans at risk of undergoing low-value PSA testing. They had a mean (SD) age of 82.6 (5.6) years, and the majority (264 411 [88.0%]) were non-Hispanic White. Of these veterans, 36 459 (12.1%) received a low-value PSA test through the VHA, which was associated with 31.2 (95% CI, 29.2 to 33.2) additional cascade services per 100 veterans and an additional $24.5 (95% CI, $20.8 to $28.1) per veteran compared with the control group. In the same cohort, 17 981 veterans (5.9%) received a PSA test through Medicare, which was associated with 39.3 (95% CI, 37.2 to 41.3) additional cascade services per 100 veterans and an additional $35.9 (95% CI, $31.7 to $40.1) per veteran compared with the control group. When compared directly, veterans who received a PSA test through Medicare experienced 9.9 (95% CI, 9.7 to 10.1) additional cascade services per 100 veterans compared with those who underwent testing within the VHA. Conclusions and Relevance The findings of this cohort study suggest that US veterans dually enrolled in the VHA and Medicare commonly experienced low-value PSA testing and subsequent care cascades through both systems in FYs 2017 and 2018. Care cascades occurred more frequently through Medicare compared with the VHA. These findings suggest that low-value PSA testing has substantial downstream implications for patients and may be especially challenging to measure when care occurs in multiple health care systems.
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Affiliation(s)
- Aimee N. Pickering
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Elijah Z. Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Aaron L. Schwartz
- Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medical Ethics Health Policy, University of Pennsylvania, Philadelphia
| | - Allison H. Oakes
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Trilliant Health, Birmingham, Alabama
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Loren J. Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Thomas R. Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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DHRUVA SANKETS, BACHHUBER MARCUSA, SHETTY ASHWIN, GUIDRY HAYDEN, GUDUGUNTLA VINAY, REDBERG RITAF. A Policy Approach to Reducing Low-Value Device-Based Procedure Use. Milbank Q 2022; 100:1006-1027. [PMID: 36573334 PMCID: PMC9836248 DOI: 10.1111/1468-0009.12595] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.
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Affiliation(s)
- SANKET S. DHRUVA
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
| | - MARCUS A. BACHHUBER
- Louisiana State University Health Sciences Center School of Medicine
- Louisiana Department of Health
| | - ASHWIN SHETTY
- Louisiana State University Health Sciences Center School of Medicine
| | - HAYDEN GUIDRY
- Louisiana State University Health Sciences Center School of Medicine
| | | | - RITA F. REDBERG
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
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Kim DD, Daly AT, Koethe BC, Fendrick AM, Ollendorf DA, Wong JB, Neumann PJ. Low-Value Prostate-Specific Antigen Test for Prostate Cancer Screening and Subsequent Health Care Utilization and Spending. JAMA Netw Open 2022; 5:e2243449. [PMID: 36413364 PMCID: PMC9682424 DOI: 10.1001/jamanetworkopen.2022.43449] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Delivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios. OBJECTIVE To evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021. EXPOSURES At least 1 claim for low-value PSA tests for prostate cancer screening during the observation period. MAIN OUTCOMES AND MEASURES Utilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting. RESULTS Of 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population. CONCLUSIONS AND RELEVANCE In this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.
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Affiliation(s)
- David D. Kim
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Allan T. Daly
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin C. Koethe
- Biostatistics, Epidemiology, and Research Design (BERD) Center, ICRHPS, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - A. Mark Fendrick
- Department of Internal Medicine and Health Management and Policy, University of Michigan, Ann Arbor
| | - Daniel A. Ollendorf
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - John B. Wong
- Tufts University School of Medicine, Boston, Massachusetts
- Division of Clinical Decision Making, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
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Muacevic A, Adler JR. Reducing Unnecessary 'Admission' Chest X-rays: An Initiative to Minimize Low-Value Care. Cureus 2022; 14:e29817. [PMID: 36337809 PMCID: PMC9627105 DOI: 10.7759/cureus.29817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Internal medicine admission services often request a baseline admission chest X-ray (CXR) for patients already admitted to the emergency department (ED) and who are waiting for inpatient beds, despite rarely providing clinical value. Adverse consequences of such CXRs include unnecessary radiation exposure, cost, time, and false positives, which can trigger a diagnostic cascade. Extraneous CXRs performed on already-admitted ED patients can delay inpatient transfer, thereby increasing boarding and crowding, which in turn may affect mortality and satisfaction. In 2016, our ED and internal medicine hospitalist services implemented guidelines (reflecting those of the American College of Radiology) to reduce unnecessary admission CXRs. All relevant providers were educated on the guideline. The primary aim of this study was to determine if there were changes in the percentage of patients with pre-admission and admission CXRs following guideline implementation. Our secondary aim was to determine which patient characteristics predict getting a CXR. Methods All ED and internal medicine hospitalist providers were educated once about the guideline. We performed a retrospective analysis of pre- vs. post-guideline data. Patients were included if admitted to the internal medicine service during those timeframes with an admission diagnosis unrelated to the cardiac or pulmonary systems. A CXR performed during ED evaluation prior to the admission disposition time was recorded as "pre-admission," and if performed after disposition time it was recorded as "admission." A CXR was "unwarranted" if the admission diagnosis did not suggest a CXR was necessary. The numerator was the number of unnecessary admission CXRs ordered on patients with diagnoses unrelated to the cardiac or pulmonary systems (minus those with a pre-admission CXR); the denominator was the number of such admissions (minus those with a pre-admission CXR). Variables of interest that might influence whether a CXR was ordered were age, gender, respiratory rate ≥20, cardiac- or pulmonary-related chief complaint, ED diagnosis category, or past medical history. Results Among admitted patients with diagnoses that did not suggest a CXR was warranted, there was no change in the percentage of admission CXRs (21.7% to 25.6%, p = 0.2678), whereas the percentage with pre-admission CXRs decreased (66.6% to 60.7%, p = 0.0152). This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated (p = .0121). In multivariate analysis, risk factors for an unwarranted CXR were age >40 (risk ratio (RR) = 2.9) and past medical history of cardiovascular disease (e.g., myocardial infarction, atrial fibrillation), renal disease, or hyperkalemia. Conclusion This educational initiative was not associated with the intended decrease in ordering unwarranted admission CXRs among ED boarding patients, though there was an unanticipated decrease in pre-admission CXRs. This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated. Organizations interested in reducing processes with little clinical value might adopt a similar program while emphasizing the lack of benefit to admitted patients through iterative educational programs on hospital admitting services.
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Welch JM, Zhuang T, Shapiro LM, Harris AHS, Baker LC, Kamal RN. Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clin Orthop Relat Res 2022; 480:1851-1862. [PMID: 35608508 PMCID: PMC9473771 DOI: 10.1097/corr.0000000000002255] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use. QUESTIONS/PURPOSES (1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not? METHODS In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use. RESULTS When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually. CONCLUSION Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Jessica M. Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | | | - Alex H. S. Harris
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Laurence C. Baker
- Department of Health Research Policy, Stanford University, Stanford, CA, USA
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
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Radomski TR, Zhao X, Lovelace EZ, Sileanu FE, Rose L, Schwartz AL, Schleiden LJ, Oakes AH, Pickering AN, Yang D, Hale JA, Gellad WF, Fine MJ, Thorpe CT. Use and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration. JAMA Intern Med 2022; 182:832-839. [PMID: 35788786 PMCID: PMC9257674 DOI: 10.1001/jamainternmed.2022.2482] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/08/2022] [Indexed: 01/11/2023]
Abstract
Importance Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified. Objective To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased community care. Design, Setting, and Participants This cross-sectional study assessed a national population of VA-enrolled veterans. Data on enrollment, sociodemographic characteristics, comorbidities, and health care services delivered by VA facilities or paid for by the VA through VACC programs were compiled for fiscal year 2018 from the VA Corporate Data Warehouse. Data analysis was conducted from April 2020 to January 2022. Main Outcomes and Measures VA administrative data were applied using an established low-value service metric to quantify the use of 29 potentially low-value tests and procedures delivered in VA facilities and by VACC programs across 6 domains: cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other procedures. Sensitive and specific criteria were used to determine the low-value service counts per 100 veterans overall, by domain, and by individual service; count and percentage of each low-value service delivered by each setting; and estimated cost of each service. Results Among 5.2 million enrolled veterans, the mean (SD) age was 62.5 (16.0) years, 91.7% were male, 68.0% were non-Hispanic White, and 32.3% received any service through VACC. By specific criteria, 19.6 low-value services per 100 veterans were delivered in VA facilities or by VACC programs, involving 13.6% of veterans at a total cost of $205.8 million. Overall, the most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older (5.9 per 100 veterans); this was also the service with the greatest proportion delivered by VA facilities (98.9%). The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4% of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9% of spending). Conclusions and Relevance This cross-sectional study found that among veterans enrolled in the VA, more than 1 in 10 have received a low-value service from VA facilities or VACC programs, with approximately $200 million in associated costs. Such information on the use and costs of low-value services are essential to guide the VA's efforts to reduce delivery and spending on such care.
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Affiliation(s)
- Thomas R. Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Elijah Z. Lovelace
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Liam Rose
- Health Economics Resource Center, VA Palo Alto Healthcare System, California
| | - Aaron L. Schwartz
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy and Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Loren J. Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Allison H. Oakes
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Aimee N. Pickering
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Dylan Yang
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy
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Korenstein D, Scherer LD, Foy A, Pineles L, Lydecker AD, Owczarzak J, Magder L, Brown JP, Pfeiffer CD, Terndrup C, Leykum L, Stevens D, Feldstein DA, Weisenberg SA, Baghdadi JD, Morgan DJ. Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing. Am J Med 2022; 135:e182-e193. [PMID: 35307357 PMCID: PMC9728553 DOI: 10.1016/j.amjmed.2022.02.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization. METHODS We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins. RESULTS Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty. CONCLUSIONS Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.
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Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Laura D Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS); Division of Cardiology, University of Colorado School of Medicine, Aurora; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Colo
| | - Andrew Foy
- Department of Medicine; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pa
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Alison D Lydecker
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jessica P Brown
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Christopher D Pfeiffer
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland; Division of Hospital and Specialty Medicine, VA Portland Health Care System, Ore
| | - Christopher Terndrup
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland
| | - Luci Leykum
- Department of Medicine, Dell Medical School, the University of Texas at Austin; South Texas Veterans Health Care System, San Antonio
| | - Deborah Stevens
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - David A Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Scott A Weisenberg
- Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore; VA Maryland Healthcare System, Baltimore
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore; VA Maryland Healthcare System, Baltimore
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Sajid IM, Frost K, Paul AK. 'Diagnostic downshift': clinical and system consequences of extrapolating secondary care testing tactics to primary care. BMJ Evid Based Med 2022; 27:141-148. [PMID: 34099498 DOI: 10.1136/bmjebm-2020-111629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 12/21/2022]
Abstract
Numerous drivers push specialist diagnostic approaches down to primary care ('diagnostic downshift'), intuitively welcomed by clinicians and patients. However, primary care's different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the 'false-positive paradox'. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population 'disease' burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended 'market failure' effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents 'value', neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
| | - Ash K Paul
- NHS South West London Health and Care Partnership STP, London, UK
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Schjøtt JD. Fornyet vurdering – stoler du på legen? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2022; 142:22-0093. [DOI: 10.4045/tidsskr.22.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Aby E, Olson APJ, Lim N. Response: serum ammonia use: unnecessary, frequent and costly. Frontline Gastroenterol 2022; 13:457-458. [PMID: 36051961 PMCID: PMC9380755 DOI: 10.1136/flgastro-2022-102169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Elizabeth Aby
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew P J Olson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Youens D, Doust J, Ha TN, O'Leary P, Slavotinek J, Wright C, Moorin R. Association of regulatory body actions and subsequent media coverage with use of services in a fee-for-service system: a longitudinal cohort study of CT scanning in Australia. BMJ Open 2022; 12:e057424. [PMID: 35450909 PMCID: PMC9024258 DOI: 10.1136/bmjopen-2021-057424] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/22/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The professional service review (PSR) is an Australian Government agency aiming to reduce inappropriate practices funded via Medicare, Australia's public insurer. Our objective was to examine changes in CT following the 2008-2009 PSR annual report, which noted excessive CT use. DESIGN Interrupted time series analysis examined trends in CT use following the 2008-2009 PSR report, estimating both change in the immediate rate of CT and the slope of the trend in usage postintervention. SETTING Medicare-funded imaging (most out-of-hospital imaging) in Australia. PARTICIPANTS Patients receiving Medicare-funded CT and other imaging. INTERVENTION The 2008-2009 PSR report highlighted concerns regarding excessive CT use. Two providers were financially penalised for CT overuse with these cases detailed in the PSR report and highlighted in an associated Report to the Professions, distributed to 50 000 providers. Media articles on radiation risks followed. OUTCOMES Quarterly rates of out-of-hospital CT, MRI (as a comparator), and all other Medicare-funded diagnostic imaging examinations 2001-2019. RESULTS CT scanning increased from 4663.5 per 100 000 person-years in 2001 to 14 506 in 2019 (211% increase), with substantial variation by type and anatomical region. The 2008-2009 PSR report was followed by an immediate reduction in CT scanning of 237.7 CTs per 100 000 people per quarter (95% CI -333.4 to -141.9) though growth in use soon continued at the preintervention rate. The degree of change in utilisation following the report differed between states/territories and by scan type, both in terms of the immediate change and the slope. For other diagnostic imaging modalities, there was an increase in the slope, while for MRI there was no change in either parameter. CONCLUSION Actions consisting of financial disincentives for service overtesting and provider/public education components may limit excessive use of diagnostic imaging in fee-for-service systems, however, effects observed here were only short lived.
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Affiliation(s)
- David Youens
- School of Population Health, Curtin University, Bentley, Western Australia, Australia
| | - Jenny Doust
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Thi Ninh Ha
- School of Population Health, Curtin University, Bentley, Western Australia, Australia
| | - Peter O'Leary
- School of Population Health, Curtin University, Bentley, Western Australia, Australia
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
- PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, Western Australia, Australia
| | - John Slavotinek
- SA Medical Imaging, SA Health, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Cameron Wright
- School of Population Health, Curtin University, Bentley, Western Australia, Australia
- School of Population Health, Curtin University, Crawley, Western Australia, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Rachael Moorin
- School of Population Health, Curtin University, Bentley, Western Australia, Australia
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
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Roberts DJ, Sypes EE, Nagpal SK, Niven D, Mamas M, McIsaac DI, van Walraven C, Shorr R, Graham ID, Stelfox HT, Grimshaw J. Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e053920. [PMID: 35393307 PMCID: PMC8991042 DOI: 10.1136/bmjopen-2021-053920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Overuse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system inefficiencies and costs. We seek to systematically review the evidence for overuse of different cardiovascular healthcare services in high-income countries. METHODS AND ANALYSIS We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2010 onwards. Two investigators will independently review titles and abstracts and full-text studies. We will include published English-language studies conducted in high-income countries that enrolled adults (mean/median age ≥18 years) and reported the incidence or prevalence of overuse of cardiovascular tests, medications or procedures; adjusted risk factors for overuse; or adjusted associations between overuse and outcomes (reported estimates of morbidity, mortality, costs or lengths of hospital stay). Acceptable methods of defining low-value care will include literature review and multidisciplinary iterative panel processes, healthcare services with reproducible evidence of a lack of benefit or harm, or clinical practice guideline or Choosing Wisely recommendations. Two investigators will independently extract data and evaluate study risk of bias in duplicate. We will calculate summary estimates of the incidence and prevalence of overuse of different cardiovascular healthcare services across studies unstratified and stratified by country; method of defining low-value care; the percentage of included females, different races, and those with low and high socioeconomic status or cardiovascular risk; and study risks of bias using random-effects models. We will also calculate pooled estimates of adjusted risk factors for overuse and adjusted associations between overuse and outcomes overall and stratified by country using random-effects models. We will use the Grading of Recommendations, Assessment, Development and Evaluation to determine certainty in estimates. ETHICS AND DISSEMINATION No ethics approval is required for this study as it deals with published data. Results will be presented at meetings and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021257490.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Daniel I McIsaac
- Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carl van Walraven
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeremy Grimshaw
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Leigh JP, Sypes EE, Straus SE, Demiantschuk D, Ma H, Brundin-Mather R, de Grood C, FitzGerald EA, Mizen S, Stelfox HT, Niven DJ. Determinants of the de-implementation of low-value care: a multi-method study. BMC Health Serv Res 2022; 22:450. [PMID: 35387673 PMCID: PMC8985316 DOI: 10.1186/s12913-022-07827-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background There is an urgent need to understand the determinants (i.e., barriers and facilitators) of de-implementation. The purpose of this study was to develop a comprehensive list of determinants of the de-implementation of low-value care from the published literature and to compare this list to determinants identified by a group of stakeholders with lived experience with de-implementation. Methods This was a two-phase multi-method study. First, a systematic review examined published barriers and facilitators to de-implementation. Articles were identified through searches within electronic databases, reference lists and the grey literature. Citations were screened independently and in duplicate and included if they were: 1) written in English; and 2) described a barrier or facilitator to de-implementation of any clinical practice in adults (age ≥ 18 years). ‘Raw text’ determinants cited within included articles were extracted and synthesized into a list of representative determinants using conventional content analysis. Second, semi-structured interviews were conducted with decision-makers (unit managers and medical directors) and healthcare professionals working in adult critical care medicine to explore the overlap between the determinants found in the systematic review to those experienced in critical care medicine. Thematic content analysis was used to identify key themes emerging from the interviews. Results In the systematic review, reviewers included 172 articles from 35,368 unique citations. From 437 raw text barriers and 280 raw text facilitators, content analysis produced 29 distinct barriers and 24 distinct facilitators to de-implementation. Distinct barriers commonly cited within raw text included ‘lack of credible evidence to support de-implementation’ (n = 90, 21%), ‘entrenched norms and clinicians’ resistance to change (n = 43, 21%), and ‘patient demands and preferences’ (n = 28, 6%). Distinct facilitators commonly cited within raw text included ‘stakeholder collaboration and communication’ (n = 43, 15%), and ‘availability of credible evidence’ (n = 33, 12%). From stakeholder interviews, 23 of 29 distinct barriers and 20 of 24 distinct facilitators from the systematic review were cited as key themes relevant to de-implementation in critical care. Conclusions The availability and quality of evidence that identifies a clinical practice as low-value, as well as healthcare professional willingness to change, and stakeholder collaboration are common and important determinants of de-implementation and may serve as targets for future de-implementation initiatives. Trial registration The systematic review was registered in PROSPERO CRD42016050234. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07827-4.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - Henry Ma
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Chloe de Grood
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Emily A FitzGerald
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Sara Mizen
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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Bandovas JP, Leal B, Reis-de-Carvalho C, Sousa DC, Araújo JC, Peixoto P, Henriques SO, Vaz Carneiro A. Broadening risk factor or disease definition as a driver for overdiagnosis: A narrative review. J Intern Med 2022; 291:426-437. [PMID: 35253285 PMCID: PMC9314822 DOI: 10.1111/joim.13465] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).
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Affiliation(s)
- João Pedro Bandovas
- Department of General Surgery, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Beatriz Leal
- Department of Anesthestics, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
| | - Catarina Reis-de-Carvalho
- Department of Obstetrics, Gynecology and Reproductive Medicine, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - David Cordeiro Sousa
- Vision Sciences Study Center, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Vitreoretinal Unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - João Cruz Araújo
- Family Medicine Department, Unidade de Saúde Familiar Gualtar, Braga, Portugal
| | - Pedro Peixoto
- Department of Family Medicine, Unidade de Saúde Familiar do Mar, Póvoa de Varzim, Portugal
| | | | - António Vaz Carneiro
- Institute for Evidence Based Healthcare, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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Rejas Bueno M, Bacaicoa López de Sabando A, Sánchez Robles GA. [Health Professionals expectations' about the benefit of regular Primary Care interventions]. Aten Primaria 2022; 54:102235. [PMID: 35124558 PMCID: PMC8829084 DOI: 10.1016/j.aprim.2021.102235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/01/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Examine the expectations expressed by healthcare professionals about the benefit of several primary prevention interventions that are usually carried out in The Primary Care Consultations with evidence from moderate-high validity studies. DESIGN Descriptive Cross-sectional Study by Survey. SITTING Spanish Primary Healthcare Centers, between February 6 and May 5, 2020. PARTICIPANTS General Practitioner and other practicing Primary Care professionals. MAIN MEASUREMENTS a) the number and percentage of participants whose estimate of benefit deviates from the benefit supported by the evidence; b) the magnitudes of OVERestimation, NORMOestimation and UNDERestimation of each participant and each professional subgroup. RESULTS Of the 701 respondents (67% women), 694 answered all eight questions and 4 between one and seven. The overestimation of benefit in the 8 interventions ranged from 86% to 90% of all medical participants and between 90% and 96% of all nursing participants. CONCLUSIONS Most of the surveyed (healthcare) professionals overestimate both, prevention activities and preventive treatments, this may lead them to instil false hope in patients, to put patients at risk of serious side effects arising from such interventions and to squander resources.
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Young RA. What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare. J Eval Clin Pract 2022; 28:341-344. [PMID: 33760312 DOI: 10.1111/jep.13545] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/07/2021] [Accepted: 01/14/2021] [Indexed: 11/26/2022]
Abstract
Sturmberg and Martin make a compelling case for primary healthcare (PHC) to be the foundation for universal healthcare (UHC). They state that a system should have necessary resources, but what does that mean? Basic economic theory postulates that all resources are limited and that choices must be made between competing options. For a UHC system to be successful and resilient, it must accept that healthcare is a limited right, there will always be inequalities in healthcare delivery and outcomes, primary care physicians and their teams must accept the added burden of balancing the needs of their personal patients with the greater system, leaders and observers of healthcare systems must accept that moderation and balance will often be the best outcome even though they are difficult to measure, and leaders of healthcare systems must accept that they cannot control the system, but contribute by providing context and limited constraints, information, and resources. A deeper understanding of complex adaptive systems will best guide these necessary changes.
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Affiliation(s)
- Richard A Young
- John Peter Smith Family Medicine Residency Program, Fort Worth, Texas, USA
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Latifi N, Redberg RF, Grady D. The Next Frontier of Less Is More-From Description to Implementation. JAMA Intern Med 2022; 182:103-105. [PMID: 34870674 DOI: 10.1001/jamainternmed.2021.6908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Niloofar Latifi
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rita F Redberg
- Department of Medicine, University of California, San Francisco.,Editor, JAMA Internal Medicine
| | - Deborah Grady
- Department of Medicine, University of California, San Francisco.,Deputy Editor, JAMA Internal Medicine
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Ganguli I, Thakore N, Rosenthal MB, Korenstein D. Longitudinal Content Analysis of the Characteristics and Expected Impact of Low-Value Services Identified in US Choosing Wisely Recommendations. JAMA Intern Med 2022; 182:127-133. [PMID: 34870673 PMCID: PMC8649907 DOI: 10.1001/jamainternmed.2021.6911] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The US Choosing Wisely campaign has had substantial reach in mobilizing efforts to reduce low-value care, achieved largely by engaging physician specialty societies in stewardship. While some early recommendations were criticized for avoiding revenue-generating services, there is limited evidence of how the composition of recommendations shifted as more societies contributed. OBJECTIVE To analyze the characteristics and expected impact of Choosing Wisely recommendations. DESIGN, SETTING, AND PARTICIPANTS This qualitative study included content and trend analyses of all 626 Choosing Wisely recommendations by US physician societies as of March 1, 2021. Data were analyzed between March and May 2021. MAIN OUTCOMES AND MEASURES Primary outcomes were proportions of identified low-value services by characteristics (society type, service type, indication, do vs avoid, and clinical context) and expected impact (effect on the revenue of society members, cost, number of individuals at risk, direct harm potential, and cascade potential). RESULTS Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging (168 [26.8%]) and laboratory studies (156 [24.9%]) in the context of chronic conditions (169 [27.0%]) and healthy patients with risk factors alone (126 [20.1%]). Most of the identified low-value services were revenue neutral for the recommending society (402 [64.2%]) and the plurality were low cost (<$200; 284 [45.4%]); low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations (1.2 percentage points per year; P = .001). Nearly half (280 [44.7%]) of recommendations identified services with high direct harm potential, and 388 (62.0%) identified those with high potential for cascades (ie, triggering downstream services). CONCLUSIONS AND RELEVANCE The results of this qualitative study suggest that the Choosing Wisely recommendations identified services with a range of expected impacts. Stakeholders could explicitly set priorities for future recommendations, while clinical leaders and payers might target intervention efforts on recommendations with the greatest potential for impact based on spending across populations, direct harms, and cascades.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Deborah Korenstein
- Department of Medicine and Primary Care, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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Radomski TR, Decker A, Khodyakov D, Thorpe CT, Hanlon JT, Roberts MS, Fine MJ, Gellad WF. Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults. JAMA Netw Open 2022; 5:e2148599. [PMID: 35166780 PMCID: PMC8848205 DOI: 10.1001/jamanetworkopen.2021.48599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Metrics that detect low-value care in common forms of health care data, such as administrative claims or electronic health records, primarily focus on tests and procedures but not on medications, representing a major gap in the ability to systematically measure low-value prescribing. OBJECTIVE To develop a scalable and broadly applicable metric that contains a set of quality indicators (EVOLV-Rx) for use in health care data to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders' perspectives. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used an online modified-Delphi method to convene an expert panel of 15 physicians and pharmacists. This panel, comprising clinicians, health system leaders, and researchers, was tasked with rating and discussing candidate low-value prescribing practices that were derived from medication safety criteria; peer-reviewed literature; and qualitative studies of patient, caregiver, and physician perspectives. The RAND ExpertLens online platform was used to conduct the activities of the panel. The panelists were engaged for 3 rounds between January 1 and March 31, 2021. MAIN OUTCOMES AND MEASURES Panelists used a 9-point Likert scale to rate and then discuss the scientific validity and clinical usefulness of the criteria to detect low-value prescribing practices. Candidate low-value prescribing practices were rated as follows: 1 to 3, indicating low validity or usefulness; 3.5 to 6, uncertain validity or usefulness; and 6.5 to 9, high validity or usefulness. Agreement among panelists and the degree of scientific validity and clinical usefulness were assessed using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method. RESULTS Of the 527 low-value prescribing recommendations identified, 27 discrete candidate low-value prescribing practices were considered for inclusion in EVOLV-Rx. After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥6.5). After round 2 panel deliberations, the criteria to detect 19 candidate practices were revised. After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for both scientific validity and clinical usefulness. Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥6.5) but uncertain clinical usefulness (scores <6.5) ratings, whereas 6 received uncertain scientific validity rating (scores <6.5). CONCLUSIONS AND RELEVANCE This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults. Applying EVOLV-Rx may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care across the full spectrum of health services.
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Affiliation(s)
- Thomas R. Radomski
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Alison Decker
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Dmitry Khodyakov
- RAND Corporation, Pardee RAND Graduate School, Santa Monica, California
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill
| | - Joseph T. Hanlon
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Mark S. Roberts
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Michael J. Fine
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Parchman ML, Palazzo LG, Mogk JM, Webbon JC, Demosthenes L, Vossenkemper E, Hoke G, Moskovitz J, Dunlap L, Diaz del Carpio R. What strategies are used by clinician champions to reduce low-value care? SAGE Open Med 2022; 10:20503121211069855. [PMID: 35646351 PMCID: PMC9133862 DOI: 10.1177/20503121211069855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background Clinician champions are front-line clinicians who advocate for and influence practice change in their local context. The strategies they use when leading efforts to reduce the use of low-value care have not been well described. The purpose of this study is to identify and describe strategies used by six clinician champions who led a low-value care initiative in their clinical setting. Methods Qualitative data collected during an overuse reduction initiative led by clinician champions were used to identify strategies, guided by the Expert Recommendations for Implementing Change compilation of strategies. Clinician champions were asked to rank the importance of these activities and indicate which one of the six most important activities they would be willing to discuss in an interview. A 30-min semi-structured interview was conducted with each clinician about the activity they selected and thematically analyzed. Results Twelve Expert Recommendations for Implementing Change strategies were identified. The top six strategies discussed during interviews were: build a coalition, conduct a local needs assessment, develop a formal implementation blueprint, conduct educational meetings, use facilitation, and develop clinical reminders. Common themes that emerged across all interviews were the use of data to engage clinicians in conversations, including the patient's perspective in designing the interventions, and investing the time upfront to plan and launch the initiative because of the inherent challenges of relinquishing a service. Conclusions Clinician champions identified multiple strategies as important when de-implementing a low-value service. Many were used to engage in conversations with stakeholders, including leadership, providers, and patients, to increase buy-in and support, challenge beliefs, promote behavior change, and gather insights about next steps in their effort. Future work is needed to better understand how prepare clinicians for this role and to understand the mechanisms through which these strategies might be effective.
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Affiliation(s)
- Michael L Parchman
- Kaiser Permanente Washington Health
Research Institute, Seattle, WA, USA
| | - Lorella G Palazzo
- Kaiser Permanente Washington Health
Research Institute, Seattle, WA, USA
| | - Jessica M Mogk
- Kaiser Permanente Washington Health
Research Institute, Seattle, WA, USA
| | - Janna C Webbon
- Kaiser Permanente Washington Health
Research Institute, Seattle, WA, USA
| | - Lauren Demosthenes
- University of South Carolina School of
Medicine Greenville, Greenville, SC, USA
| | | | - George Hoke
- University of Virginia School of
Medicine, Charlottesville, VA, USA
| | - Joshua Moskovitz
- Department of Emergency Medicine,
Albert Einstein College of Medicine, New York, NY, USA
- Department of Public Health, Hofstra
School of Health and Human Services, New York, NY, USA
| | - Leslie Dunlap
- University of New Mexico Hospital,
Albuquerque, NM, USA
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Segal JB, Sen AP, Glanzberg-Krainin E, Hutfless S. Factors Associated With Overuse of Health Care Within US Health Systems. JAMA HEALTH FORUM 2022; 3:e214543. [PMID: 35977230 PMCID: PMC8903118 DOI: 10.1001/jamahealthforum.2021.4543] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022] Open
Abstract
Question What features of health care systems in the US are associated with overuse of health care? Findings In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital. Meaning In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care. Importance Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions. Objective To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery. Design, Setting, and Participants In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018. Exposures We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites. Main Outcomes and Measures Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0. Results There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively. Conclusions and Relevance In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.
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Affiliation(s)
- Jodi B. Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Aditi P. Sen
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Eliana Glanzberg-Krainin
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Susan Hutfless
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Patel K, Winchester D. Evaluation of choosing wisely recommendations on preprocedural cardiovascular testing. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100107. [PMID: 38560075 PMCID: PMC10978204 DOI: 10.1016/j.ahjo.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 04/04/2024]
Abstract
Study objective The Choosing Wisely (CW) initiative currently has multiple recommendations focused on avoiding preprocedural testing in asymptomatic patients prior to low-risk surgery. The purpose of this study was to measure the potential impact of the CW recommendations as they relate to preprocedural testing prior to cataract surgery. Design Retrospective cohort study. Setting Single academic medical center. Participants Patients undergoing cataract surgery from 01/02/2018 to 12/31/2018. Interventions N/A. Main outcome measures Prevalence of preprocedural testing in elevated versus low cardiac risk patients as defined by the Revised Cardiac Risk Index (RCRI). Results Of a total 909 patients, 90 (9.9%) had some form of preprocedural testing ordered; testing was more common among elevated risk (n = 50/315, 15.9%) compared to low-risk patients (n = 40/594, 6.7%; p < 0.0001). Of the tests ordered, 9 were abnormal (4 in the low-risk cohort, 5 in the elevated risk cohort). ECGs were the vast majority of tests ordered (n = 88/90). No stress test orders or periprocedural adverse cardiovascular (CV) events were observed. Anesthesiology clinicians ordered 95.6% of preprocedural testing. "Routine" was the justification given for the substantial majority of tests ordered in both cohorts (90% low-risk, 86% elevated risk). Conclusion Our investigation confirms that cataract surgery has exceptionally low rates of postprocedural CV events. In contemporary practice, preprocedural CV testing for cataract surgery is not highly prevalent, rarely abnormal, and also not well justified by ordering clinicians. Our results may be considered as justification for revisions of some CW recommendations to potentially target higher prevalence areas of low-value care.
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Affiliation(s)
- Keval Patel
- College of Medicine, University of Florida, Gainesville, FL, United States
| | - David Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
- Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, FL, United States
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Minúe Lorenzo S, Astier-Peña MP, Coll Benejam T. [Diagnostic error and overdiagnosis in Primary Care. Proposals for the improvement of clinical practice family medicine]. Aten Primaria 2021; 53 Suppl 1:102227. [PMID: 34961577 PMCID: PMC8721341 DOI: 10.1016/j.aprim.2021.102227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 10/24/2022] Open
Abstract
Family doctors see a wide range of patients, with a wide range of complexity, in a short time and with few diagnostic resources. This situation makes primary care professionals more vulnerable to diagnostic errors. For this reason, an adequate clinical reasoning process is the most powerful tool family doctors have to safely guide the patient care process. Considering these errors as missed opportunities for a correct diagnosis, which may cause harm to the patient, leads us as professionals to review how to improve this process. The review includes, among other aspects, identifying cognitive biases, analysing the ways in which work is organised in primary care teams, and situations in the care context that may contribute to such errors. In this article we describe the most frequent diagnostic errors and their causal factors in primary care, the impact of cognitive process failures, situations of overdiagnosis and the diagnostic and therapeutic cascades associated with them. Finally, we propose a set of tools to improve decision-making in the diagnostic process in primary care.
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Affiliation(s)
- Sergio Minúe Lorenzo
- Escuela Andaluza de Salud Pública, Jefe del Servicio Integrado de Salud basado en la Atención Primaria de Salud. Centro Colaborador de la OMS, Granada, España
| | - Maria Pilar Astier-Peña
- Servicio Aragonés de Salud, Universidad de Zaragoza, GIBA-IIS Aragón, Zaragoza, España; Grupo de Seguridad del Paciente de la Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Barcelona, España.
| | - Txema Coll Benejam
- Grupo de Seguridad del Paciente de la Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Barcelona, España; Atención Primaria, Área de Salut de Menorca, IB-SALUT, Mahón, Menorca, España
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Tang A, Mooney CM, Mittal A, Dzubnar JM, Knopf KB, Khoury AL. High Compliance With Choosing Wisely Breast Surgical Guidelines at a Safety-Net Hospital. J Surg Res 2021; 272:96-104. [PMID: 34953372 DOI: 10.1016/j.jss.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/22/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Professional organizations recently set guidelines for avoiding surgeries of low utility and overutilization for the Choosing Wisely campaign. These include re-excision for invasive cancer close to margins, double mastectomy in patients with unilateral breast cancer, axillary lymph node dissection in patients with limited nodal disease, and sentinel lymph node biopsy (SLNB) in patients ≥70 years with early-stage breast cancer. Variable adherence to these recommendations led us to evaluate implementation rates of low-value surgical guidelines at a safety-net hospital. METHODS We retrospectively analyzed breast cancer patients who underwent surgery from 2015 to 2020. Each patient was assessed for eligibility for omission of the listed surgeries. Trends were evaluated by cohorts before and after a fellowship-trained breast surgeon joined the faculty in 2018. Outcomes were compared using Fisher's exact test. RESULTS Among 195 patients, none underwent re-excision for close margins of invasive cancer. Only 6.7% of patients (3/45) received contralateral mastectomy and 1.8% of eligible patients (3/169) received axillary lymph node dissection. Overall, 60% of patients ≥ 70 years with stage 1 hormone-positive breast cancer (9/15) received SLNB. There was a downward trend from 71% of eligible patients receiving SLNB in 2015-2018 to 50% in 2019-2020. CONCLUSIONS De-implementation of traditional surgical practices, deemed as low-value care, toward newer guidelines is achievable even at community hospitals serving a low socioeconomic community. By avoiding overtreatment, hospitals can achieve effective resource allocation which allow for social distributive justice among patients with breast cancer and ensure strategic use of scarce health economic resources while preserving patient outcomes.
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Affiliation(s)
- Annie Tang
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Colin M Mooney
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Ananya Mittal
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Jessica M Dzubnar
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Kevin B Knopf
- Department of Medicine, Alameda Health System - Highland Hospital, Oakland, California
| | - Amal L Khoury
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California.
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Redundant laboratory testing on referral from general practice to the outpatient clinic: a post-hoc analysis. BJGP Open 2021; 6:BJGPO.2021.0134. [PMID: 34620597 PMCID: PMC8958751 DOI: 10.3399/bjgpo.2021.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/06/2021] [Indexed: 11/27/2022] Open
Abstract
Background Inappropriately repeated laboratory testing is a commonly occurring problem. However, this has not been studied extensively in the outpatient clinic after referral by GPs. Aim The aim of this study was to investigate how often laboratory tests ordered by the GP were repeated on referral to the outpatient clinic, and how many of the normal test results remained normal on repetition. Design & setting This is a post-hoc analysis of a study on laboratory testing strategies in patients newly referred to the outpatient clinic between April 2015 and April 2017. Method All patients who had a referral letter including laboratory test results ordered by the GP were included. These results were compared with the laboratory test results ordered in the outpatient clinic. Results Data were available for 295 patients, 191 of which had post-visit testing done. In this group, 56% of tests ordered by the GP were repeated. Tests with abnormal results were repeated more frequently than tests with normal results (65% versus 53%; P<0.001). A longer test interval was associated with slightly smaller odds of tests being repeated (odds ratio [OR] 0.97, 95% confidence interval [CI] = 0.95 to 0.99; P = 0.003). Of the tests with normal test results that were repeated, 90% remained normal. This was independent of testing interval or testing strategy. Conclusion Laboratory tests ordered by the GP are commonly repeated on referral to the outpatient clinic. The number of test results remaining normal on repetition suggests a high level of redundancy in laboratory test repetition.
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Mira JJ, Carrillo I, Pérez-Pérez P, Astier-Peña MP, Caro-Mendivelso J, Olivera G, Silvestre C, Nuín MA, Aranaz-Andrés JM. Avoidable Adverse Events Related to Ignoring the Do-Not-Do Recommendations: A Retrospective Cohort Study Conducted in the Spanish Primary Care Setting. J Patient Saf 2021; 17:e858-e865. [PMID: 34009877 PMCID: PMC8612910 DOI: 10.1097/pts.0000000000000830] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to measure the frequency and severity of avoidable adverse events (AAEs) related to ignoring do-not-do recommendations (DNDs) in primary care. METHODS A retrospective cohort study analyzing the frequency and severity of AAEs related to ignoring DNDs (7 from family medicine and 3 from pediatrics) was conducted in Spain. Data were randomly extracted from computerized electronic medical records by a total of 20 general practitioners and 5 pediatricians acting as reviewers; data between February 2018 and September 2019 were analyzed. RESULTS A total of 2557 records of adult and pediatric patients were reviewed. There were 1859 (72.7%) of 2557 (95% confidence interval [CI], 71.0%-74.4%) DNDs actions in 1307 patients (1507 were performed by general practitioners and 352 by pediatricians). Do-not-do recommendations were ignored more often in female patients (P < 0.0001). Sixty-nine AAEs were linked to ignoring DNDs (69/1307 [5.3%]; 95% CI, 4.1%-6.5%). Of those, 54 (5.1%) of 1062 were in adult patients (95% CI, 3.8%-6.4%) and 15 (6.1%) of 245 in pediatric patients (95% CI, 3.1%-9.1%). In adult patients, the majority of AAEs (51/901 [5.7%]; 95% CI, 4.2%-7.2%) occurred in patients 65 years or older. Most AAEs were characterized by temporary minor harm both in adult patients (28/54 [51.9%]; 95% CI, 38.5%-65.2%) and pediatric patients (15/15 [100%]). CONCLUSIONS These findings provide a new perspective about the consequences of low-value practices for the patients and the health care systems. Ignoring DNDs could place patients at risk, and their safety might be unnecessarily compromised. TRIAL REGISTRATION NUMBER NCT03482232.
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Affiliation(s)
- José Joaquín Mira
- From the Health District Alicante-Sant Joan, Alicante
- Miguel Hernández University, Elche
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Sant Joan d’Alacant
| | - Irene Carrillo
- Miguel Hernández University, Elche
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Sant Joan d’Alacant
| | - Pastora Pérez-Pérez
- Patient Safety Observatory, Andalusian Agency for Health Care Quality, Seville
| | - Maria Pilar Astier-Peña
- Family and Community Medicine, “La Jota” Health Centre, Zaragoza I Sector, Aragonese Health Service (SALUD)
- University of Zaragoza, Aragon Health Research Institute (IISA), Zaragoza
| | | | | | - Carmen Silvestre
- Healthcare Effectiveness and Safety Service, Navarre Health Service-Osasunbidea
| | | | - Jesús M. Aranaz-Andrés
- Preventive Medicine Service, Hospital Universitario Ramón y Cajal
- Institute Ramón y Cajal for Health Research (IRYCIS), Madrid, Spain
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