Frequency of and variation in low-value care in primary care: a retrospective cohort study

Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review

OBJECTIVES

The objective of this systematic review was to offer a comprehensive overview and explore the associated outcomes from imaging referral guidelines on various key stakeholders, such as patients and radiologists.

MATERIALS AND METHODS

An electronic database search was conducted in Medline, Embase and Web of Science to retrieve citations published between 2013 and 2023. The search was constructed using medical subject headings and keywords. Only full-text articles and reviews written in English were included. The quality of the included papers was assessed using the mixed methods appraisal tool. A narrative synthesis was undertaken for the selected articles.

RESULTS

The search yielded 4384 records. Following the abstract, full-text screening, and removal of duplication, 31 studies of varying levels of quality were included in the final analysis. Imaging referral guidelines from the American College of Radiology were most commonly used. Clinical decision support systems were the most evaluated mode of intervention, either integrated or standalone. Interventions showed reduced patient radiation doses and waiting times for imaging. There was a general reduction in radiology workload and utilisation of diagnostic imaging. Low-value imaging utilisation decreased with an increase in the appropriateness of imaging referrals and ratings and cost savings. Clinical effectiveness was maintained during the intervention period without notable adverse consequences.

CONCLUSION

Using evidence-based imaging referral guidelines improves the quality of healthcare and outcomes while reducing healthcare costs. Imaging referral guidelines are one essential component of improving the value of radiology in the healthcare system.

CLINICAL RELEVANCE STATEMENT

There is a need for broader dissemination of imaging referral guidelines to healthcare providers globally in tandem with the harmonisation of the application of these guidelines to improve the overall value of radiology within the healthcare system.

KEY POINTS

The application of imaging referral guidelines has an impact and effect on patients, radiologists, and health policymakers. The adoption of imaging referral guidelines in clinical practice can impact healthcare costs and improve healthcare quality and outcomes. Implementing imaging referral guidelines contributes to the attainment of value-based radiology.

Gender Disparities in Adverse Events Resulting From Low-Value Practices in Family Practice in Spain: A Retrospective Cohort Study

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.

'Give me something meaningful': GPs perspectives on how to improve an audit and feedback report provided by health insurers - an exploratory qualitative study

BACKGROUND

Audit and feedback (A&F) is a valuable quality improvement strategy, which can contribute to de-implementation of low-value care. In the Netherlands, all health insurers collaboratively provide A&F to general practitioners (GPs), the 'Primary Care Practice Report' (PCPR). Unfortunately, the use of this report by GPs is limited. This study examined the thoughts of GPs on the usability of the PCPR and GPs recommendations for improving the PCPR.

METHOD

We used an interpretative qualitative design, with think-aloud tasks to uncover thoughts of GPs on the usability of the PCPR and semistructured interview questions to ask GPs' recommendations for improvement of the PCPR. Interviews were audiorecorded and transcribed ad verbatim. Data were analysed using thematic content analysis.

RESULTS

We identified two main themes: 'poor usability of the PCPR', and 'minimal motivation to change based on the PCPR'. The GPs found the usability of the PCPR poor due to the feedback not being clinically meaningful, the data not being recent, individual and reliable, the performance comparators offer insufficient guidance to assess clinical performance, the results are not discussed with peers and the definitions and visuals are unclear. The GPs recommended improving these issues. The GPs motivation to change based on the PCPR was minimal.

CONCLUSIONS

The GPs evaluated the PCPR as poorly usable and were minimally motivated to change. The PCPR seems developed from the perspective of the reports' commissioners, health insurers, and does not meet known criteria for effective A&F design and user-centred design. Importantly, the GPs did state that well-designed feedback could contribute to their motivation to improve clinical performance.Furthermore, the GPs stated that they receive a multitude of A&F reports, which they hardly use. Thus, we see a need for policy makers to invest in less, but more usable A&F reports.

Identifying drivers of health care value: a scoping review of the literature

BACKGROUND

As health care spending reaches unsustainable levels, improving value has become an increasingly important policy priority. Relatively little research has explored factors driving value. As a first step towards filling this gap, we performed a scoping review of the literature to identify potential drivers of health care value.

METHODS

Searches of PubMed, Embase, Google Scholar, Policy File, and SCOPUS were conducted between February and March 2020. Empirical studies that explored associations between any range of factors and value (loosely defined as quality or outcomes relative to cost) were eligible for inclusion. We created a template in Microsoft Excel for data extraction and evaluated the quality of included articles using the Critical Appraisal Skills Programme (CASP) quality appraisal tool. Data was synthesized using narrative methods.

RESULTS

Twenty-two studies were included in analyses, of which 20 focused on low value service utilization. Independent variables represented a range of system-, hospital-, provider-, and patient-level characteristics. Although results were mixed, several consistent findings emerged. First, insurance incentive structures may affect value. For example, patients in Accountable Care Organizations had reduced rates of low value care utilization compared to patients in traditionally structured insurance plans. Second, higher intensity of care was associated with higher rates of low value care. Third, culture is likely to contribute to value. This was suggested by findings that recent medical school graduation and allopathic training were associated with reduced low value service utilization and that provider organizations had larger effects on value than did individual physicians.

CONCLUSIONS

System, hospital, provider, and community characteristics influence low value care provision. To improve health care value, strategies aiming to reduce utilization of low value services and promote high value care across various levels will be essential.

Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study

BACKGROUND

Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown.

AIM

To assess the prevalence of low-value pharmaceutical care among Dutch GPs.

DESIGN AND SETTING

Retrospective cohort study using data from patient records.

METHOD

The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription.

RESULTS

Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001).

CONCLUSION

The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Visualizing the Invisible: Invisible Waste in Diagnostic Imaging

There is extensive waste in diagnostic imaging, at the same time as there are long waiting lists. While the problem of waste in diagnostics has been known for a long time, the problem persists. Accordingly, the objective of this study is to investigate various types of waste in imaging and why they are so pervasive and persistent in today's health services. After a short overview of different conceptions and types of waste in diagnostic imaging (in radiology), we identify two reasons why these types of waste are so difficult to address: (1) they are invisible in the healthcare system and (2) wasteful imaging is driven by strong external forces and internal drivers. Lastly, we present specific measures to address wasteful imaging. Visualizing and identifying the waste in diagnostic imaging and its ingrained drivers is one important way to improve the quality and efficiency of healthcare services.

Adherence to Clinical Practice Guideline Recommendations on Low-Value Injury Care: A Multicenter Retrospective Cohort Study

OBJECTIVES

Low-value clinical practices have been identified as one of the most important areas of excess healthcare spending. Nevertheless, there is a knowledge gap on the scale of this problem in injury care. We aimed to identify clinical practice guideline (CPG) recommendations pertaining to low-value injury care, estimate how frequently they are used in practice, and evaluate interhospital variations in their use.

METHODS

We identified low-value clinical practices from internationally recognized CPGs. We conducted a retrospective cohort study using data from a Canadian trauma system (2014-2019) to calculate frequencies and assess interhospital variations.

RESULTS

We identified 29 low-value practices. Fourteen could be measured using trauma registry data. The 3 low-value clinical practices with the highest absolute and relative frequencies were computed tomography (CT) in adults with minor head injury (n = 5591, 24%), cervical spine CT (n = 2742, 31%), and whole-body CT in minor or single-system trauma (n = 530, 32%). We observed high interhospital variation for decompressive craniectomy in diffuse traumatic brain injury. Frequencies and interhospital variations were low for magnetic resonance imaging, intracranial pressure monitoring, inferior vena cava filter use, and surgical management of blunt abdominal injuries.

CONCLUSIONS

We observed evidence of poor adherence to CPG recommendations on low-value CT imaging and high practice variation for decompressive craniectomy. Results suggest that adherence to recommendations for the 10 other low-value practices is high. These data can be used to advance the research agenda on low-value injury care and inform the development of interventions targeting reductions in healthcare overuse in this population.

What can we learn from the SARS-COV-2 pandemic about the value of specific radiological examinations?

BACKGROUND

The SARS-COV-2 pandemic provides a natural intervention to assess practical priority setting and internal evaluation of specific health services, such as radiological services. Norway makes an excellent case as it had a very low infection rate and very few cases of COVID-19. Accordingly, the objective of this study is to use the changes in performed outpatient radiological examinations during the first stages of the SARS-COV-2 pandemic to assess the practical evaluation of specific radiological examinations in Norway.

METHODS

Data was collected retrospectively from the Norwegian Health Economics Administration (HELFO) in the years 2015-2020. Data included the number of performed outpatient imaging examinations at public hospitals and private imaging centers in Norway and was divided in to three periods based on the level of restrictions on elective health services. Results were analyzed with descriptive statistics.

RESULTS

In the first period there was a 45% reduction in outpatient radiology compared to the same time period in 2015-2019 while in period 2 and 3 there was a 25 and 6% reduction respectively. The study identified a list of specific potential low-value radiological examinations. While some of these are covered by the Choosing Wisely campaign, others are not.

CONCLUSION

By studying the priority setting practice during the initial phases of the pandemic this study identifies a set of potential low value radiological examinations during the initial phases of the SARS-COV-2 pandemic. These examinations are candidates for closer assessments for health services quality improvement.

Overuse of diagnostic testing in healthcare: a systematic review

BACKGROUND

Overuse of diagnostic testing substantially contributes to healthcare expenses and potentially exposes patients to unnecessary harm. Our objective was to systematically identify and examine studies that assessed the prevalence of diagnostic testing overuse across healthcare settings to estimate the overall prevalence of low-value diagnostic overtesting.

METHODS

PubMed, Web of Science and Embase were searched from inception until 18 February 2020 to identify articles published in the English language that examined the prevalence of diagnostic testing overuse using database data. Each of the assessments was categorised as using a patient-indication lens, a patient-population lens or a service lens.

RESULTS

118 assessments of diagnostic testing overuse, extracted from 35 studies, were included in this study. Most included assessments used a patient-indication lens (n=67, 57%), followed by the service lens (n=27, 23%) and patient-population lens (n=24, 20%). Prevalence estimates of diagnostic testing overuse ranged from 0.09% to 97.5% (median prevalence of assessments using a patient-indication lens: 11.0%, patient-population lens: 2.0% and service lens: 30.7%). The majority of assessments (n=85) reported overuse of diagnostic testing to be below 25%. Overuse of diagnostic imaging tests was most often assessed (n=96). Among the 33 assessments reporting high levels of overuse (≥25%), preoperative testing (n=7) and imaging for uncomplicated low back pain (n=6) were most frequently examined. For assessments of similar diagnostic tests, major variation in the prevalence of overuse was observed. Differences in the definitions of low-value tests used, their operationalisation and assessment methods likely contributed to this observed variation.

CONCLUSION

Our findings suggest that substantial overuse of diagnostic testing is present with wide variation in overuse. Preoperative testing and imaging for non-specific low back pain are the most frequently identified low-value diagnostic tests. Uniform definitions and assessments are required in order to obtain a more comprehensive understanding of the magnitude of diagnostic testing overuse.

An Association Between Cardiologist Billing Patterns, Health Care Use, and Outcomes in Cardiac Patients

Background

Whether individual cardiologist billings are associated with differences in ambulatory care management and clinical outcomes in patients with coronary artery disease (CAD) and heart failure (HF) remains poorly understood.

Methods

We conducted a population-based, retrospective cohort study of cardiologists who treat patients with CAD or HF using administrative claims data in Ontario, Canada. The primary exposure was cardiologist billing quintile. We then stratified median billing amounts into quintiles, from lowest (quintile 1) to highest billing physicians (quintile 5).

Results

The main outcomes of interest were cardiac diagnostic and therapeutic procedures that occurred within 365 days of the index visit. Our 2 cohorts respectively consisted of 170,959 patients with CAD seen by 1 of 423 cardiologists and 56,262 HF patients seen by 1 of 413 cardiologists. CAD patients of higher-billing cardiologists had higher rates of echocardiograms (adjusted odds ratio [aOR], 1.65; 95% confidence interval [CI], 1.39 to 1.94 for quintile 5 vs quintile 2) and stress tests (aOR, 1.50; 95% CI, 1.28-1.75) at 1 year, with a similar pattern for HF patients of echocardiogram (aOR, 1.40; 95% CI, 1.23-1.59; P < 0.001) and stress test (aOR, 1.32; 95% CI, 1.15-1.51) use. CAD patients of cardiologists in quintile 1 had a higher mortality rate (aOR, 1.16; 95% CI, 1.03-1.31), and HF patients of cardiologists in billing quintile 4 had a lower hospitalization rate at 1 year (OR, 0.94; 95% CI, 0.89-0.99; P = 0.02).

Conclusions

Cardiac patients seen by the highest-billing cardiologists received more noninvasive cardiac testing compared with lower-billing cardiologists.

Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination

IMPORTANCE

The association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date.

OBJECTIVE

To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE).

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019.

EXPOSURES

Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE.

MAIN OUTCOMES AND MEASURES

Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested).

RESULTS

Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score-matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age, 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively.

CONCLUSIONS AND RELEVANCE

Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.

Identifying and de-implementing low-value care in primary care: the GP's perspective-a cross-sectional survey

OBJECTIVE

General practitioners have an important role in reducing low-value care as gatekeepers of the health system. The aim of this study was to assess the experiences of Dutch general practitioners regarding low-value care and to identify their needs to decrease low-value primary care.

DESIGN

We performed a cross-sectional study.

PARTICIPANTS

We sent a survey to 500 general practitioners.

SETTING

Primary care in the Netherlands.

PRIMARY AND SECONDARY OUTCOMES

The survey contained questions about the provision of low-value care and on clinical cases about lumbosacral spine X-rays in patients with low back pain and vitamin B₁₂ laboratory tests without an evidence-based indication. We also asked general practitioners what they needed to reduce low-value care.

RESULTS

A total of 182 general practitioners (37%) responded. 67% indicated that low-value care practices are regularly provided in general practice. 57% of the general practitioners have seen negative consequences of low-value care, in particular side effects of medication. The most provided low-value care practices are medication prescriptions such as antibiotics and laboratory tests such as vitamin B₁₂ tests. The most reported drivers are patient-related. General practitioners want to maintain a good relationship with their patients by offering their patients an intervention instead of watchful waiting. Lack of time also plays a major role. In order to reduce low-value care, general practitioners suggested that educating patients on the value of tests and treatments might help. Supporting general practitioners and other healthcare professionals with clear guidelines as well as having more time for consultation were also mentioned by general practitioners.

CONCLUSION

General practitioners are aware of providing unnecessary care despite their role as gatekeepers and have reasons for this. They need support in order to change their practice. This support might consist of better education of healthcare professionals and providing more time for consultation. Local and national media, such as websites and television, could be used to educate patients while guidelines could support professionals in reducing low-value care.

Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement

IMPORTANCE

The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood.

OBJECTIVE

To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults.

DESIGN

Retrospective analysis of overall means and clinician-level variation in performance on three new measures.

SUBJECTS

Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017.

MEASURES

Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication.

RESULTS

Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively.

CONCLUSIONS

Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement

IMPORTANCE

The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood.

OBJECTIVE

To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults.

DESIGN

Retrospective analysis of overall means and clinician-level variation in performance on three new measures.

SUBJECTS

Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017.

MEASURES

Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication.

RESULTS

Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively.

CONCLUSIONS

Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

Assessing volume and variation of low-value care practices in the Netherlands

BACKGROUND

There have been contributions to quantify the volume of low-value care practices in the USA, Canada and Australia but we have no knowledge about the volume in Europe. The purpose of this study was to assess the volume and variation of Dutch low-value care practices.

METHODS

We conducted a cross-sectional study with data of a Dutch healthcare insurance company from general practioners (GP's) and hospitals in the Netherlands from 2016. We used all billing claims made by healthcare providers of 3.5 million Dutch inhabitants. We studied Choosing Wisely recommendations in order to select low-value care practices. We used the percentage low-value care practices per hospital and number of low-value care practices per GP as outcomes.

RESULTS

We assessed the volume of low-back imaging by GPs, screening of patients over 75 years for colorectal cancer and diagnosing varices with Doppler or Plethysmography. We found that 0.4% (range 0-7%) of the eligible patients received low-value screening for colorectal cancer and 8.0% (range 0-88%) of eligible patients received low-value diagnosing of varices. About 52.4% of the GPs ordered X-rays and 11.2% ordered magnetic resonance imagings of the lumbosacral spine. Most healthcare providers did not provide the measured low-value care practices. However, 1 in 12 GPs ordered at least one low-back X-ray a week.

CONCLUSIONS

The three Choosing Wisely recommendations showed a lot of practice variation; many healthcare providers did not order these low-value diagnostic tests; a minor part did order a substantial amount, low-back spine radiology in particular. These healthcare providers should start reducing these activities.

Measuring the frequency and variation of unnecessary care across Canada

BACKGROUND

Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions.

METHODS

Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years.

RESULTS

Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years.

CONCLUSIONS

The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.

Frequency and Associations of Prescription Nonsteroidal Anti-inflammatory Drug Use Among Patients With a Musculoskeletal Disorder and Hypertension, Heart Failure, or Chronic Kidney Disease

IMPORTANCE

International nephrology societies advise against nonsteroidal anti-inflammatory drug (NSAID) use in patients with hypertension, heart failure, or chronic kidney disease (CKD); however, recent studies have not investigated the frequency or associations of use in these patients.

OBJECTIVES

To estimate the frequency of and variation in prescription NSAID use among high-risk patients, to identify characteristics associated with prescription NSAID use, and to investigate whether use is associated with short-term, safety-related outcomes.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, administrative claims databases were linked to create a cohort of primary care visits for a musculoskeletal disorder involving patients 65 years and older with a history of hypertension, heart failure, or CKD between April 1, 2012, and March 31, 2016, in Ontario, Canada.

EXPOSURE

Prescription NSAID use was defined as at least 1 patient-level Ontario Drug Benefit claim for a prescription NSAID dispensing within 7 days after a visit.

MAIN OUTCOMES AND MEASURES

Multiple cardiovascular and renal safety-related outcomes were observed between 8 and 37 days after each visit, including cardiac complications (any emergency department visit or hospitalization for cardiovascular disease), renal complications (any hospitalization for hyperkalemia, acute kidney injury, or dialysis), and death.

RESULTS

The study identified 2 415 291 musculoskeletal-related primary care visits by 814 049 older adults (mean [SD] age, 75.3 [4.0] years; 61.1% female) with hypertension, heart failure, or CKD, of which 224 825 (9.3%) were followed by prescription NSAID use. The median physician-level prescribing rate was 11.0% (interquartile range, 6.7%-16.7%) among 7365 primary care physicians. Within a sample of 35 552 matched patient pairs, each consisting of an exposed and nonexposed patient matched on the logit of their propensity score for prescription NSAID use (exposure), the study found similar rates of cardiac complications (288 [0.8%] vs 279 [0.8%]), renal complications (34 [0.1%] vs 33 [0.1%]), and death (27 [0.1%] vs 30 [0.1%]). For cardiovascular and renal-safety related outcomes, there was no difference between exposed patients (308 [0.9%]) and nonexposed patients (300 [0.8%]) (absolute risk reduction, 0.0003; 95% CI, -0.001 to 0.002; P = .74).

CONCLUSIONS AND RELEVANCE

While prescription NSAID use in primary care was frequent among high-risk patients, with widespread physician-level variation, use was not associated with increased risk of short-term, safety-related outcomes.

Physician Characteristics Associated With Ordering 4 Low-Value Screening Tests in Primary Care

IMPORTANCE

Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently.

OBJECTIVES

To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians.

EXPOSURES

Physician sex, years since medical school graduation, and primary care model.

MAIN OUTCOMES AND MEASURES

This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2).

RESULTS

The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users.

CONCLUSIONS AND RELEVANCE

This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.

Moving low value care lists into action: prioritizing candidate health technologies for reassessment using administrative data

Background

Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR).

Methods

An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC).

Results

The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] “do not do” recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely “Top 5” lists) were identified. Using appropriate coding systems for BC’s administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment.

Conclusions

This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3459-1) contains supplementary material, which is available to authorized users.

Routine use of chest x-ray for low-risk patients undergoing a periodic health examination: a retrospective cohort study

BACKGROUND

Many evidence-based recommendations advocate against the use of routine chest x-rays for asymptomatic, low-risk outpatients; however, it is unclear how regularly chest x-rays are ordered in primary care. Our study aims to describe the frequency of, and variation in, routine chest x-ray use in low-risk outpatients among primary care physicians.

METHODS

In this retrospective cohort study, Ontario residents aged 18 years and older with a periodic health examination (PHE) between Apr. 1, 2010, and Mar. 31, 2015, were identified via administrative claims data. Patients with a recent history (last 3 years) of any of the following were excluded: cardiac or pulmonary disease, high-risk comorbidity (e.g., diabetes), consultations/visits or procedures involving cardiac or pulmonary specialists, cancer and severe chest trauma. The primary outcome, a routine chest x-ray, was defined as at least 1 chest x-ray claim within 7 days after a PHE.

RESULTS

While a routine chest x-ray followed only 2.42% of 2 847 508 PHEs, one-quarter of family physicians (499/2031) ordered chest x-rays for more than 5.0% of their PHEs (interquartile range 1.5%-5.0%) and accounted for 62.9% of all tests observed. Routine chest x-ray use declined by 2.0% per quarter (adjusted rate ratio 0.98, 95% confidence interval [CI] 0.97-0.98). Older age (45-64 yr v. 18-44 yr, adjusted odds ratio [OR] 1.82, 95% CI 1.78-1.86; ≥ 65 yr v. 18-44 yr, adjusted OR 2.48, 95% CI 2.39-2.58) and male sex of the patient (OR 2.19, 95% CI 2.14-2.24) and male sex of the provider (OR 1.55, 95% CI 1.51-1.59) were significantly associated with increased odds of a routine chest x-ray being ordered.

INTERPRETATION

It is relatively uncommon for a chest x-ray to be ordered as part of a PHE in Ontario; however, the substantial variation observed among physicians suggests potential for interventions targeted at the most frequent users.

Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination

Importance

Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown.

Objective

To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE.

Design, Setting, and Participants

A population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE.

Exposures

Receipt of an ECG within 30 days of an AHE.

Main Outcomes and Measures

Primary outcome was receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months.

Results

A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P < .001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts.

Conclusions and Relevance

Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.