Multiple measurement of serum lipids in the elderly

Inappropriate repeats of six common tests in a Canadian city: a population cohort study within a laboratory informatics framework

OBJECTIVES

To identify inappropriate repeats of six common laboratory tests in a population sample of patients, using highly specific criteria based only on repeat time and test value.

METHODS

We used a laboratory informatics database to conduct a retrospective cohort study using a population sample of 103,000 patients in the city of Calgary with an index test in 2010 and uniform follow-up of 1 year. We examined six tests (cholesterol, hemoglobin A1c, thyroid-stimulating hormone, vitamin B12, vitamin D, and ferritin) with consensus-based or easily justified criteria for inappropriate repeats based solely on time to repeat and the index test value.

RESULTS

The percentages of tests repeated at 3, 6, and 12 months were 11%, 23%, and 41%, respectively. In total, 16% of these six tests were inappropriately repeated, representing an annual internal cost of $0.6 to $2.2 million Canadian dollars and corresponding to population-scaled national estimates for Canada and the United States of $160 million and $2.4 billion, respectively.

CONCLUSIONS

Objective definitions based on repeated testing identified 16% of six studied tests as inappropriate, delineating a subset of inappropriate testing that is well suited to automated identification and intervention and that provides a likely lower bound on the true burden of inappropriate testing.

Relationship between cardiovascular risk and lipid testing in one health care system: a retrospective cohort study

Background

The US Preventive Services Taskforce (USPSTF) recommends routine lipid screening beginning age 35 for men [1]. For women age 20 and older, as well as men age 20–34, screening is recommended if cardiovascular risk factors are present. Prior research has focused on underutilization but not overuse of lipid testing. The objective is to document over- and under-use of lipid testing in an insured population of persons at low, moderate and high cardiovascular disease (CVD) risk for persons not already on statins.

Methods

The study is a retrospective cohort study that included all adults without prior CVD who were continuously enrolled in a large integrated healthcare system from 2005 to 2010.

Measures included lipid test frequency extracted from administrative data and Framingham cardiovascular risk equations applied using electronic medical record data. Five year lipid testing patterns were examined by age, sex and CVD risk. Generalized linear models were used to estimate the relative risk for over testing associated with patient characteristics.

Results

Among males and females for whom testing is not recommended, 35.8 % and 61.5 % received at least one lipid test in the prior 5 years and 8.4 % and 24.4 % had two or more.

Over-testing was associated with age, race, comorbidity, primary care use and neighborhood income. Among individuals at moderate and high-risk (not already treated with statins) and for whom screening is recommended, between 21.4 % and 25.1 % of individuals received no screening in the prior 5 years.

Conclusions

Based on USPSTF lipid screening recommendations, this study documents substantial over-testing among individuals with low CVD risk and under-testing among individuals with moderate to high-risk not already on statins. Opportunity exists to better focus lipid screening efforts appropriate to CVD risk.

Continuity of medication management and continuity of care: Conceptual and operational considerations

Objective:

Continuity of care is considered foundational to high-quality care. Traditional continuity of care constructs may adequately characterize care quality in general populations, but may merit reconceptualization for patients with multiple chronic conditions. Specifically, interactions between multiple chronic condition patients and providers involve complex medication management; therefore care continuity measurement may be more relevant if focused on the provider subset who prescribes essential medications for chronic conditions—a construct we call continuity of medication management. Our objective was to explore conceptual distinctions between continuity of medication management and continuity of care, survey existing evidence in this area, and discuss implications of our findings for future research and intervention development.

Methods:

In this topical review, we discuss conceptual distinctions between continuity of medication management and continuity of care, review the limited continuity of medication management–related empirical evidence, and discuss implications for future research and interventions.

Results:

Continuity of medication management represents a potential conceptual and measurement advance by reflecting interpersonal continuity and management continuity, and may provide a means of identifying patients at high-risk of adverse events. Empirical evidence also establishes support for continuity of medication management as a meaningful measure of care continuity. Finally, continuity of medication management may also be a potential target for future intervention to improve care delivery among multiple chronic condition patients.

Conclusion:

If continuity of medication management is validated in diverse populations, correlated with patient outcomes, and responsive to change, then it may be an important target for improving the health and health care of multiple chronic condition patients.

Limited life expectancy among a subgroup of medicare beneficiaries receiving screening colonoscopies

BACKGROUND & AIMS

Life expectancy is an important consideration when assessing appropriateness of preventive programs for older individuals. Most studies on this subject have used age cutoffs as a proxy for life expectancy. We analyzed patterns of utilization of screening colonoscopy in Medicare enrollees by using estimated life expectancy.

METHODS

We used a 5% random national sample of Medicare claims data to identify average-risk patients who underwent screening colonoscopies from 2008 to 2010. Colonoscopies were considered to be screening colonoscopies in the absence of diagnoses for nonscreening indications, which were based on either colonoscopies or any claims in the preceding 3 months. We estimated life expectancies by using a model that combined age, sex, and comorbidity. Among patients who underwent screening colonoscopies, we calculated the percentage of those with life expectancies <10 years.

RESULTS

Among the 57,597 Medicare beneficiaries 66 years old or older who received at least 1 screening colonoscopy, 24.8% had an estimated life expectancy of <10 years. There was a significant positive association between total Medicare per capita costs in hospital referral regions and the proportion of patients with limited life expectancies (<10 years) at the time of screening colonoscopy (R = 0.25; P < .001, Pearson correlation test). In a multivariable analysis, men were substantially more likely than women to have limited life expectancy at the time of screening colonoscopy (odds ratio, 2.25; 95% confidence interval, 2.16-2.34).

CONCLUSIONS

Nearly 25% of Medicare beneficiaries, especially men, had life expectancies <10 years at the time of screening colonoscopies. Life expectancy should therefore be incorporated in decision-making for preventive services.

Provider continuity prior to the diagnosis of advanced lung cancer and end-of-life care

Background

Little is known about the effect of provider continuity prior to the diagnosis of advanced lung cancer and end-of-life care.

Methods

Retrospective analysis of 69,247 Medicare beneficiaries aged 67 years or older diagnosed with Stage IIIB or IV lung cancer between January 1, 1993 and December 31, 2005 who died within two years of diagnosis. We examined visit patterns to a primary care physician (PCP) and/or any provider one year prior to the diagnosis of advanced lung cancer as measures of continuity of care. Outcome measures were hospitalization, ICU use and chemotherapy use during the last month of life, and hospice use during the last week of life.

Results

Seeing a PCP or any provider in the year prior to the diagnosis of advanced lung cancer increased the likelihood of hospitalization, ICU care, chemotherapy and hospice use during the end of life. Patients with 1–3, 4–7 or >7 visits to their PCP in the year prior to the diagnosis of lung cancer had 1.0 (reference), 1.08 (95% CI; 1.04–1.13), and 1.14 (95% CI; 1.08–1.19) odds of hospitalization during the last month of life, respectively. Odds of hospice use during the last week of life were higher in patients with visits to multiple PCPs (OR 1.10: 95% CI; 1.06–1.15) compared to those whose visits were all to the same PCP.

Conclusion

Provider continuity in the year prior to the diagnosis of advanced lung cancer was not associated with lower use of aggressive care during end of life. Our study did not have information on patient preferences and result should be interpreted accordingly.