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Ellenbogen MI, Feldman LS, Prichett L, Zhou J, Brotman DJ. Development of a disease-based hospital-level diagnostic intensity index. Diagnosis (Berl) 2024; 0:dx-2023-0184. [PMID: 38643385 DOI: 10.1515/dx-2023-0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/01/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES Low-value care is associated with increased healthcare costs and direct harm to patients. We sought to develop and validate a simple diagnostic intensity index (DII) to quantify hospital-level diagnostic intensity, defined by the prevalence of advanced imaging among patients with selected clinical diagnoses that may not require imaging, and to describe hospital characteristics associated with high diagnostic intensity. METHODS We utilized State Inpatient Database data for inpatient hospitalizations with one or more pre-defined discharge diagnoses at acute care hospitals. We measured receipt of advanced imaging for an associated diagnosis. Candidate metrics were defined by the proportion of inpatients at a hospital with a given diagnosis who underwent associated imaging. Candidate metrics exhibiting temporal stability and internal consistency were included in the final DII. Hospitals were stratified according to the DII, and the relationship between hospital characteristics and DII score was described. Multilevel regression was used to externally validate the index using pre-specified Medicare county-level cost measures, a Dartmouth Atlas measure, and a previously developed hospital-level utilization index. RESULTS This novel DII, comprised of eight metrics, correlated in a dose-dependent fashion with four of these five measures. The strongest relationship was with imaging costs (odds ratio of 3.41 of being in a higher DII tertile when comparing tertiles three and one of imaging costs (95 % CI 2.02-5.75)). CONCLUSIONS A small set of medical conditions and related imaging can be used to draw meaningful inferences more broadly on hospital diagnostic intensity. This could be used to better understand hospital characteristics associated with low-value care.
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Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, 1500 Johns Hopkins School of Medicine , Baltimore, MD, USA
| | - Leonard S Feldman
- Departments of Medicine and Pediatrics, 1500 Johns Hopkins School of Medicine , Baltimore, MD, USA
| | - Laura Prichett
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, 1500 Johns Hopkins School of Medicine , Baltimore, MD, USA
| | - Junyi Zhou
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, 1500 Johns Hopkins School of Medicine , Baltimore, MD, USA
| | - Daniel J Brotman
- Department of Medicine, 1500 Johns Hopkins School of Medicine , Baltimore, MD, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Gupta R, Fein J, Newhouse JP, Schwartz AL. Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage. BMJ 2024; 384:e077797. [PMID: 38453187 PMCID: PMC10919211 DOI: 10.1136/bmj-2023-077797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories. DESIGN Cross sectional analysis. SETTING PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B. PARTICIPANTS 30 540 086 beneficiaries in traditional Medicare Part B. MAIN OUTCOME MEASURES Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules. RESULTS The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties. CONCLUSION PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.
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Affiliation(s)
- Ravi Gupta
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jay Fein
- Medidata Solutions, New York, NY, USA
| | - Joseph P Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Kennedy School, Cambridge, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
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Kullgren JT, Kim HM, Slowey M, Colbert J, Soyster B, Winston SA, Ryan K, Forman JH, Riba M, Krupka E, Kerr EA. Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2024; 184:281-290. [PMID: 38285565 PMCID: PMC10825788 DOI: 10.1001/jamainternmed.2023.7703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/22/2023] [Indexed: 01/31/2024]
Abstract
Importance Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. Objective To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. Design, Setting, and Participants Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. Intervention Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. Main Outcomes and Measures Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). Results The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. Trial Registration ClinicalTrials.gov Identifier: NCT03411525.
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Affiliation(s)
- Jeffrey T. Kullgren
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - H. Myra Kim
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Megan Slowey
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Joseph Colbert
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Barbara Soyster
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Kerry Ryan
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Jane H. Forman
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Melissa Riba
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Erin Krupka
- University of Michigan School of Information, Ann Arbor
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
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Müskens JL, Kool RB, Westert GP, Zaal M, Muller H, Atsma F, van Dulmen SA. Non-indicated vitamin B 12- and D-testing among Dutch hospital clinicians: a cross-sectional analysis in data registries. BMJ Open 2024; 14:e075241. [PMID: 38418241 PMCID: PMC10910490 DOI: 10.1136/bmjopen-2023-075241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 02/15/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES To assess the extent of non-indicated vitamin B12- and D-testing among Dutch clinicians and its variation among hospitals. DESIGN Cross-sectional study using registration data from 2015 to 2019. PARTICIPANTS Patients aged between 18 and 70 years who received a vitamin B12- or D-test. PRIMARY AND SECONDARY OUTCOME MEASURES The proportion of non-indicated vitamin B12- and D-testing among Dutch clinicians and its variation between hospitals (n=68) over 2015-2019. RESULTS Between 2015 and 2019, at least 79.0% of all vitamin B12-tests and 82.0% of vitamin D-tests lacked a clear indication. The number of vitamin B12-tests increased by 2.0% over the examined period, while the number of D-tests increased by 12.2%. The proportion of the unexplained variation in non-indicated vitamin B12- and D-tests that can be ascribed to differences between hospitals remained low. Intraclass correlation coefficients ranged between 0.072 and 0.085 and 0.081 and 0.096 for non-indicated vitamin B12- and D-tests, respectively. The included casemix variables patient age, gender, socioeconomic status and hospital size only accounted for a small part of the unexplained variation in non-indicated testing. Additionally, a significant correlation was observed in non-indicated vitamin B12- and D-testing among the included hospitals. CONCLUSION Hospital clinicians order vitamin B12- and D-tests without a clear indication on a large scale. Only a small proportion of the unexplained variation could be attributed to differences between hospitals.
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Affiliation(s)
- Joris Ljm Müskens
- IQ Health science department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rudolf Bertijn Kool
- IQ Health science department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Gert P Westert
- IQ Health science department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Hein Muller
- Dutch Hospital Data, Utrecht, The Netherlands
| | - Femke Atsma
- IQ Health science department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S A van Dulmen
- IQ Health science department, Radboud University Medical Centre, Nijmegen, The Netherlands
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Tamblyn R, Moraga T, Girard N, Chan FKI, Habib B, Boulet J. Clinical competence, communication ability and adherence to choosing wisely recommendations for lipid reducing drug use in older adults. BMC Geriatr 2023; 23:761. [PMID: 37986045 PMCID: PMC10662284 DOI: 10.1186/s12877-023-04429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Although lipid-lowering drugs are not recommended for primary prevention in patients 75+, prevalence of use is high and there is unexplained variation in prescribing between physicians. The objective of this study was to determine if physician communication ability and clinical competence are associated with prescribing lipid-lowering drugs for primary and secondary prevention. METHODS We used a cohort of 4,501 international medical graduates, 161,214 U.S. Medicare patients with hyperlipidemia (primary prevention) and 49,780 patients with a history of cardiovascular disease (secondary prevention) not treated with lipid-lowering therapy who were seen by study physicians in ambulatory care. Clinical competence and communication ability were measured by the ECFMG clinical assessment examination. Physician citizenship, age, gender, specialty and patient characteristics were also measured. The outcome was an incident prescription of lipid-lowering drug, evaluated using multivariable GEE logistic regression models for primary and secondary prevention for patients 75+ and 65-74. RESULTS Patients 75+ were less likely than those 65-74 to receive lipid-lowering drugs for primary (OR 0.62, 95% CI 0.59-0.66) and secondary (OR 0.70, 95% CI 0.63-0.78) prevention. For every 20% increase in clinical competence score, the odds of prescribing therapy for primary prevention to patients 75+ increased by 24% (95% CI 1.02-1.5). Communication ability had the opposite effect, reducing the odds of prescribing for primary prevention by 11% per 20% score increase (95% CI 0.8-0.99) for both age groups. Physicians who were citizens of countries with higher proportions of Hispanic (South/Central America) or Asian (Asia/Oceania) people were more likely to prescribe treatment for primary prevention, and internal medicine specialists were more likely to treat for secondary prevention than primary care physicians. CONCLUSION Clinical competence, communication ability and physician citizenship are associated with lipid-lowering drug prescribing for primary prevention in patients aged 75+.
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Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue., Montreal, QC, H3A 1G1, Canada.
- Department of Medicine, McGill University Health Center, Montreal, QC, Canada.
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada.
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Fiona K I Chan
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue., Montreal, QC, H3A 1G1, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - John Boulet
- Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, PA, USA
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Roscioli R, Wyllie T, Neophytou K, Dent L, Lowen D, Tan D, Dunne B, Hodgson R. How we can reduce the environmental impact of our operating theatres: a narrative review. ANZ J Surg 2023. [PMID: 37985608 DOI: 10.1111/ans.18770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/03/2023] [Accepted: 10/29/2023] [Indexed: 11/22/2023]
Abstract
Climate change is projected to become the leading cause of adverse health outcomes globally, and the healthcare system is a key contributor. Surgical theatres are three to six times more pollutant than other hospital areas, and produce anywhere from a fifth to a third of total hospital waste. Hospitals are increasingly expected to make operating theatres more sustainable, however guidelines to improve environmental sustainability are lacking, and previous research takes a narrow approach to operative sustainability. This paper presents a narrative review that, following a 'review of reviews' approach, aims to summarize the key recommendations to improve the environmental sustainability of surgical theatres. Key domains of discussion identified across the literature included minimisation of volatile anaesthetics, reduction of operating theatre power consumption, optimisation of surgical approach, re-use and re-processing of surgical instruments, waste management, and research, education and leadership. Implementation of individual items in these domains has seen significant reductions in the environmental impact of operative practice. This comprehensive summary of recommendations lays the framework from which providers can assess the sustainability of their practice and for the development of encompassing guidelines to build an environmentally sustainable surgical service.
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Affiliation(s)
- Robert Roscioli
- Department of Surgery, University of Melbourne, Epping, Victoria, Australia
| | - Tracey Wyllie
- Division of Surgery, Northern Health, Epping, Victoria, Australia
| | | | - Lana Dent
- Division of Surgery, Northern Health, Epping, Victoria, Australia
| | - Darren Lowen
- Department of Anaesthesia & Perioperative Medicine, Northern Health, Epping, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - David Tan
- Department of Anaesthesia & Perioperative Medicine, Northern Health, Epping, Victoria, Australia
| | - Ben Dunne
- Department of Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, Peter Macallum Cancer Centre, Parkville, Victoria, Australia
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Russell Hodgson
- Department of Surgery, University of Melbourne, Epping, Victoria, Australia
- Division of Surgery, Northern Health, Epping, Victoria, Australia
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Tamblyn R, Moraga T, Girard N, Boulet J, Chan FKI, Habib B. Do clinical and communication skills scores on credentialing exams predict potentially inappropriate antibiotic prescribing? BMC Med Educ 2023; 23:821. [PMID: 37915014 PMCID: PMC10621187 DOI: 10.1186/s12909-023-04817-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/29/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND There is considerable variation among physicians in inappropriate antibiotic prescribing, which is hypothesized to be attributable to diagnostic uncertainty and ineffective communication. The objective of this study was to evaluate whether clinical and communication skills are associated with antibiotic prescribing for upper respiratory infections and sinusitis. METHODS A cohort study of 2,526 international medical graduates and 48,394 U.S. Medicare patients diagnosed by study physicians with an upper respiratory infection or sinusitis between July 2014 and November 2015 was conducted. Clinical and communication skills were measured by scores achieved on the Clinical Skills Assessment examination administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as a requirement for entry into U.S residency programs. Medicare Part D data were used to determine whether patients were dispensed an antibiotic following an outpatient evaluation and management visit with the study physician. Physician age, sex, specialty and practice region were retrieved from the ECFMG databased and American Medical Association (AMA) Masterfile. Multivariate GEE logistic regression was used to evaluate the association between clinical and communication skills and antibiotic prescribing, adjusting for other physician and patient characteristics. RESULTS Physicians prescribed an antibiotic in 71.1% of encounters in which a patient was diagnosed with sinusitis, and 50.5% of encounters for upper respiratory infections. Better interpersonal skills scores were associated with a significant reduction in the odds of antibiotic prescribing (OR per score decile 0.93, 95% CI 0.87-0.99), while greater proficiency in clinical skills and English proficiency were not. Female physicians, those practicing internal medicine compared to family medicine, those with citizenship from the US compared to all other countries, and those practicing in southern of the US were also more likely to prescribe potentially unnecessary antibiotics. CONCLUSIONS Based on this study, physicians with better interpersonal skills are less likely to prescribe antibiotics for acute sinusitis and upper respiratory infections. Future research should examine whether tailored interpersonal skills training to help physicians manage patient expectations for antibiotics could reduce unnecessary antibiotic prescribing.
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Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue, H3A 1G1, Montreal, QC, Canada.
- Department of Medicine, McGill University Health Center, Montreal, QC, Canada.
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada.
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - John Boulet
- Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, PA, USA
| | - Fiona K I Chan
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 2001 McGill College Avenue, H3A 1G1, Montreal, QC, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
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Lan T, Chen L, Hu Y, Wang J, Tan K, Pan J. Measuring low-value care in hospital discharge records: evidence from China. Lancet Reg Health West Pac 2023; 38:100887. [PMID: 37790076 PMCID: PMC10544294 DOI: 10.1016/j.lanwpc.2023.100887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 10/05/2023]
Abstract
Background Plenty of efforts have been made to reduce the use of low-value care (the care that is not expected to provide net benefits for patients) across the world, but measures of low-value care have not been developed in China. This study aims to develop hospital discharge records-based measures of low-value surgical procedures, evaluate their annual use and associated expenditure, and analyze the practice patterns by characterizing its temporal trends and correlations across rates of different low-value procedures within hospitals. Methods Informed by evidence-based lists including Choosing Wisely, we developed 11 measures of low-value surgical procedures. We evaluated the count and proportion of low-value episodes, as well as the proportion of expenditure and medical insurance payouts for these episodes, using hospital discharge records in Sichuan Province, China during a period of 2016-2022. We compared the count and expenditure detected by different versions of these measures, which varied in sensitivity and specificity. We characterized the temporal trends in the rate of low-value surgical procedures and estimated the annual percent change using joint-point regression. Additionally, we calculated the Spearman correlation coefficients between the risk-standardized rates of low-value procedures which were estimated by multilevel models adjusting for case mix across hospitals. Findings Low-value episodes detected by more specific versions of measures accounted for 3.25% (range, 0.11%-71.66%), and constituted 6.03% (range, 0.32%-84.63%) and 5.90% (range, 0.33%-82.86%) of overall expenditure and medical insurance payouts, respectively. The three figures accounted for 5.90%, 8.41%, and 8.38% in terms of more sensitive versions of measures. Almost half of the low-value procedures (five out of eleven) experienced an increase in rates during the period of 2016-2022, with four of them increasing over 20% per year. There was no significant correlation across risk-standardized rates of different low-value procedures within hospitals (mean r for pairwise, 0.03; CI, -0.02, 0.07). Interpretation Despite overall low-value practices detected by the 11 developed measures was modest, certain clinical specialties were plagued by widespread low-value practices which imposed heavy economic burdens for the healthcare system. Given the pervasive and significant upward trends in rates of low-value practices, it has become increasingly urgent to reduce such practices. Interventions in reducing low-value practices in China would be procedure-specific as practice patterns of low-value care varied by procedures and common drivers of low-value practices may not exist. Funding The National Science Foundation of China (72074163), Taikang Yicai Public Health and Epidemic Control Fund, Sichuan Science and Technology Program (2022YFS0052 and 2021YFQ0060), and Sichuan University (2018hhf-27 and SKSYL201811).
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Affiliation(s)
- Tianjiao Lan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Lingwei Chen
- Ningbo Municipal Center for Disease Control and Prevention, Ningbo, China
| | - Yifan Hu
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jianjian Wang
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Kun Tan
- Health Information Center of Sichuan Province, Chengdu, China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- School of Public Administration, Sichuan University, Chengdu, China
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Schwartz AL, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Radomski TR, Thorpe CT. Variation in Low-Value Service Use Across Veterans Affairs Facilities. J Gen Intern Med 2023; 38:2245-2253. [PMID: 36964425 PMCID: PMC10406760 DOI: 10.1007/s11606-023-08157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/10/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA). OBJECTIVE To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use. DESIGN In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics. PARTICIPANTS 5,242,301 patients across 139 VA facilities. MAIN MEASURES Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery. KEY RESULTS The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics. CONCLUSIONS Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.
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Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Charlotte, NC, USA
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Ellenbogen MI, Wiegand AA, Austin JM, Schoenborn NL, Kodavarti N, Segal JB. Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis. J Gen Intern Med 2023; 38:2519-2526. [PMID: 36781578 PMCID: PMC10465435 DOI: 10.1007/s11606-023-08060-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Healthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA. OBJECTIVE To learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse. PARTICIPANTS Leaders at select healthcare systems in the USA. INTERVENTIONS None APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework. KEY RESULTS We interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse. CONCLUSIONS Our qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.
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Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA.
| | - Aaron A Wiegand
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Matthew Austin
- Department of Anesthesia and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA
| | - Nihal Kodavarti
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Brotzman LE, Zikmund-Fisher BJ. Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison. Med Care Res Rev 2023; 80:372-385. [PMID: 36800914 DOI: 10.1177/10775587231153269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.
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Lai Y, Zeng W, Liao J, Yu Y, Liu X, Wu K. Retrospective analyses of routine preoperative blood testing in a tertiary eye hospital: could Choosing Wisely work in China? Br J Ophthalmol 2023:bjo-2022-322431. [PMID: 37468212 DOI: 10.1136/bjo-2022-322431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/21/2023]
Abstract
AIMS To explore the possibility of implementing Choosing Wisely on ocular patients in China by investigating the prevalence of abnormalities in routine preoperative blood tests (RPBTs) and its turnaround time (TAT). METHODS Data from 102 542 ocular patients between January 2016 and December 2018, at Zhongshan Ophthalmic Center, were pooled from the laboratory information system. The test results were divided into normal and abnormal, including critical values. Ocular diseases were stratified into 11 subtypes based on the primary diagnosis. The TAT of 243 350 blood tests from January 2017 to December 2018 was categorised into transportation time and intralaboratory time. RESULTS RPBT was grouped into complete blood count (CBC), blood biochemistry (BBC), blood coagulation (BCG) and blood-borne pathogens (BBP), completed for 97.22%, 87.66%, 94.41% and 95.35% of the recruited patients (male, 52 549 (51.25%); median(IQR) age, 54 (29-67) years), respectively. Stratified by the test items, 9.19% (95% CI 9.07% to 9.31%) were abnormal results, and 0.020% (95% CI 0.019% to 0.022%) were critical; most abnormalities were on the CBC, while glucose was the most common critical item. Classified by the patients' primary diagnosis, 76.97% (95% CI 76.71% to 77.23%) had at least one abnormal result, and 0.28% (95% CI 0.25% to 0.32%) were critical; abnormal findings were reported in 45.29% (95% CI 44.98% to 45.60%), 54.97% (95% CI 54.65% to 55.30%), 30.29% (95% CI 30.00% to 30.58%) and 11.32% (95% CI 11.12% to 11.52%) for the CBC, BBC, BCG and BBP tests, respectively. The median transportation time and intralaboratory TAT of the samples were 12 min and 78 min respectively. CONCLUSION Blood abnormalities are common in ocular patients. With acceptable timelines, RPBT is still indispensable in China for patient safety.
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Affiliation(s)
- Yunxi Lai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Weiting Zeng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Jingyu Liao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Yubin Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Xiuping Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Kaili Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University; Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
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Weinerman AS, Guo Y, Saha S, Yip PM, Lapointe-Shaw L, Fralick M, Kwan JL, MacMillan TE, Liu J, Rawal S, Sheehan KA, Simons J, Tang T, Bhatia S, Razak F, Verma AA. Data-driven approach to identifying potential laboratory overuse in general internal medicine (GIM) inpatients. BMJ Open Qual 2023; 12:e002261. [PMID: 37495257 PMCID: PMC10373691 DOI: 10.1136/bmjoq-2023-002261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge. OBJECTIVE To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests. DESIGN, SETTING AND PARTICIPANTS A multicentre, retrospective study at three academic hospitals in Toronto, Canada. All general internal medicine (GIM) hospitalisations between 1 April 2010 and 31 October 2017. RESULTS There were 106 813 GIM hospitalisations during the study period, with median hospital length-of-stay of 4.6 days (IQR: 2.33-9.19). There were 21 tests which had a cumulative cost >US$15 400 at all three sites. The costliest test was plasma electrolytes (US$4 907 775), the test with the lowest proportion of abnormal results was red cell folate (0.2%) and the test with the greatest physician-level variation in use was antiphospholipid antibodies (coefficient of variation 3.08). The five tests with the highest cumulative rank based on greatest cost, lowest proportion of abnormal results and highest physician-level variation were: (1) lactate, (2) antiphospholipid antibodies, (3) magnesium, (4) troponin and (5) partial thromboplastin time. In addition, this method identified unique tests that may be a potential source of laboratory overuse at each hospital. CONCLUSIONS A simple multidimensional, data-driven approach combining cost, proportion of abnormal results and physician-level variation can inform interventions to reduce laboratory test overuse. Reducing low value laboratory testing is important to promote high value, patient-centred care.
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Affiliation(s)
- Adina S Weinerman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yishan Guo
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sudipta Saha
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Paul M Yip
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
| | - Michael Fralick
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Janice L Kwan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Thomas E MacMillan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jessica Liu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Shail Rawal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kathleen A Sheehan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Janet Simons
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, Ontario, Canada
| | - Terence Tang
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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16
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Gurakar M, Faghih M, Akshintala VS, Bhullar FA, Kanthasamy K, Khashab MA, Kamal A, Zaheer A, He J, Afghani E, Singh VK. Factors Associated With Serial Lipase Measurement in Hospitalized Patients With Acute Pancreatitis. Pancreas 2023; 52:e293-e297. [PMID: 37816173 DOI: 10.1097/mpa.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVES To determine the factors associated with serial lipase measurement in patients with acute pancreatitis (AP). METHODS Patients admitted to Johns Hopkins Health System between September 2019 and August 2020 with lipase ≥3 times upper limit normal were prospectively identified. Acute pancreatitis was defined using revised Atlanta criteria. Serial lipase measurement was defined as >2 lipase measurements on consecutive days within 7 days of presentation. RESULTS There were 294 patients with AP with mean age 52.4 ± 16 years (SD), and 155 (52.7%) were male. A total of 227 (77.2%) were admitted to a medical service. There were 111 (37.7%) who underwent serial lipase measurements. There were 89 (30.8%), 36 (12.2%), 6 (1%), and 40 (13.6%) patients with systemic inflammatory response syndrome at time of initial lipase measurement, persistent organ failure, necrosis on admission, and intensive care unit admission. Serial lipase measurements were more likely to be obtained in patients admitted to surgical services (odds ratio, 4.3; 95% confidence interval, 1.4-13.2; P = 0.01) and nontertiary hospitals (odds ratio, 1.8; 95% confidence interval, 1.0-2.9; P = 0.04). CONCLUSION More than one-third of AP patients undergo serial lipase measurements. This practice is more likely to occur on surgical services and in nontertiary hospitals.
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Affiliation(s)
| | - Mahya Faghih
- Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Furqan A Bhullar
- Division of Internal Medicine, St Joseph's University Medical Center, Paterson, NJ
| | | | | | | | | | - Jin He
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
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Metz AK, Berlin NL, Yost ML, Cheng B, Kerr E, Nathan H, Cuttitta A, Henderson J, Dossett LA. Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse. J Surg Res 2023; 283:93-101. [PMID: 36399802 DOI: 10.1016/j.jss.2022.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/21/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.
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Affiliation(s)
- Allan K Metz
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Monica L Yost
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Bonnie Cheng
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Eve Kerr
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Anthony Cuttitta
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - James Henderson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Ellison JE, Kumar S, Steingrimsson JA, Adhikari D, Charlesworth CJ, McConnell KJ, Trivedi AN, Trikalinos TA, Forbes SP, Panagiotou OA. Comparison of Low-Value Care Among Commercial and Medicaid Enrollees. J Gen Intern Med 2023; 38:954-960. [PMID: 36175761 PMCID: PMC10039208 DOI: 10.1007/s11606-022-07823-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low-value healthcare is costly and inefficient and may adversely affect patient outcomes. Despite increases in low-value service use, little is known about how the receipt of low-value care differs across payers. OBJECTIVE To evaluate differences in the use of low-value care between patients with commercial versus Medicaid coverage. DESIGN Retrospective observational analysis of the 2017 Rhode Island All-payer Claims Database, estimating the probability of receiving each of 14 low-value services between commercial and Medicaid enrollees, adjusting for patient sociodemographic and clinical characteristics. Ensemble machine learning minimized the possibility of model misspecification. PARTICIPANTS Medicaid and commercial enrollees aged 18-64 with continuous coverage and an encounter at which they were at risk of receiving a low-value service. INTERVENTION Enrollment in Medicaid or Commercial insurance. MAIN MEASURES Use of one of 14 validated measures of low-value care. KEY RESULTS Among 110,609 patients, Medicaid enrollees were younger, had more comorbidities, and were more likely to be female than commercial enrollees. Medicaid enrollees had higher rates of use for 7 low-value care measures, and those with commercial coverage had higher rates for 5 measures. Across all measures of low-value care, commercial enrollees received more (risk difference [RD] 6.8 percentage points; CI: 6.6 to 7.0) low-value services than their counterparts with Medicaid. Commercial enrollees were also more likely to receive low-value services typically performed in the emergency room (RD 11.4 percentage points; CI: 10.7 to 12.2) and services that were less expensive (RD 15.3 percentage points; CI 14.6 to 16.0). CONCLUSION Differences in the provision of low-value care varied across measures, though average use was slightly higher among commercial than Medicaid enrollees. This difference was more pronounced for less expensive services indicating that financial incentives may not be the sole driver of low-value care.
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Affiliation(s)
- Jacqueline E Ellison
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Soryan Kumar
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jon A Steingrimsson
- Center for Statistical Sciences, Brown University School of Public Health, Providence, RI, USA
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | | | | | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, USA
- Department of Emergency Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amal N Trivedi
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Thomas A Trikalinos
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Shaun P Forbes
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Orestis A Panagiotou
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA.
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Khullar D, Zhang Y, Zang C, Xu Z, Wang F, Weiner MG, Carton TW, Rothman RL, Block JP, Kaushal R. Racial/Ethnic Disparities in Post-acute Sequelae of SARS-CoV-2 Infection in New York: an EHR-Based Cohort Study from the RECOVER Program. J Gen Intern Med 2023; 38:1127-1136. [PMID: 36795327 PMCID: PMC9933823 DOI: 10.1007/s11606-022-07997-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 12/23/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Compared to white individuals, Black and Hispanic individuals have higher rates of COVID-19 hospitalization and death. Less is known about racial/ethnic differences in post-acute sequelae of SARS-CoV-2 infection (PASC). OBJECTIVE Examine racial/ethnic differences in potential PASC symptoms and conditions among hospitalized and non-hospitalized COVID-19 patients. DESIGN Retrospective cohort study using data from electronic health records. PARTICIPANTS 62,339 patients with COVID-19 and 247,881 patients without COVID-19 in New York City between March 2020 and October 2021. MAIN MEASURES New symptoms and conditions 31-180 days after COVID-19 diagnosis. KEY RESULTS The final study population included 29,331 white patients (47.1%), 12,638 Black patients (20.3%), and 20,370 Hispanic patients (32.7%) diagnosed with COVID-19. After adjusting for confounders, significant racial/ethnic differences in incident symptoms and conditions existed among both hospitalized and non-hospitalized patients. For example, 31-180 days after a positive SARS-CoV-2 test, hospitalized Black patients had higher odds of being diagnosed with diabetes (adjusted odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.50-2.56, q<0.001) and headaches (OR: 1.52, 95% CI: 1.11-2.08, q=0.02), compared to hospitalized white patients. Hospitalized Hispanic patients had higher odds of headaches (OR: 1.62, 95% CI: 1.21-2.17, q=0.003) and dyspnea (OR: 1.22, 95% CI: 1.05-1.42, q=0.02), compared to hospitalized white patients. Among non-hospitalized patients, Black patients had higher odds of being diagnosed with pulmonary embolism (OR: 1.68, 95% CI: 1.20-2.36, q=0.009) and diabetes (OR: 2.13, 95% CI: 1.75-2.58, q<0.001), but lower odds of encephalopathy (OR: 0.58, 95% CI: 0.45-0.75, q<0.001), compared to white patients. Hispanic patients had higher odds of being diagnosed with headaches (OR: 1.41, 95% CI: 1.24-1.60, q<0.001) and chest pain (OR: 1.50, 95% CI: 1.35-1.67, q < 0.001), but lower odds of encephalopathy (OR: 0.64, 95% CI: 0.51-0.80, q<0.001). CONCLUSIONS Compared to white patients, patients from racial/ethnic minority groups had significantly different odds of developing potential PASC symptoms and conditions. Future research should examine the reasons for these differences.
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Affiliation(s)
- Dhruv Khullar
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA. .,Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Yongkang Zhang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Chengxi Zang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Zhenxing Xu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Fei Wang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Mark G Weiner
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | | | - Russell L Rothman
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason P Block
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, MA, USA
| | - Rainu Kaushal
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Mafi JN, Walling AM, Villaflores C, Vangala S, Sorensen A, Cheng E, Turner A, Trutner Z, Cheng G, Arbanas JC, Waterman B, Shu S, Goldstein N, Sarkisian C. A pragmatic parallel arm randomized-controlled trial of a multi-pronged electronic health record-based clinical decision support tool protocol to reduce low-value antipsychotic prescriptions among older adults with Alzheimer's and related dementias. PLoS One 2022; 17:e0277409. [PMID: 36538552 PMCID: PMC9767350 DOI: 10.1371/journal.pone.0277409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/02/2022] [Indexed: 12/24/2022] Open
Abstract
Among patients with Alzheimer's disease and its related dementias (ADRD) with behavioral disturbances, antipsychotic prescriptions have limited efficacy and increase the risk of death. Yet, physicians continue to routinely prescribe low-value antipsychotic medications for behavioral disturbances among patients with ADRD. We designed a pragmatic randomized-controlled trial to measure the impact of a behavioral economic electronic health record (EHR) clinical decision support (CDS) intervention to reduce physician prescriptions of new antipsychotic medications among patients with ADRD. Utilizing a pragmatic parallel arm randomized-controlled trial design, the study will randomize eligible physicians from a large academic health system to either receive a EHR CDS intervention or not (control) when they prescribe a new antipsychotic medication during visits with patients with ADRD. The intervention will include three components: 1) alerts prescribers that antipsychotic prescriptions increase mortality risk (motivating physicians' intrinsic desire for non-malfeasance); 2) offers non-pharmacological behavioral resources for caregivers; 3) auto-defaults the prescription to contain the lowest dose and number of pill-days (n = 30) without refills if the prescriber does not cancel the order (appealing to default bias). Over 1 year, we will compare the cumulative total of new antipsychotic pill-days prescribed (primary outcome) by physicians in the intervention group versus in the control group. The study protocol meets international SPIRIT guidelines. Behavioral economics, or the study of human behavior as a function of more than rational incentives, considering a whole host of cognitive and social psychological preferences, tendencies, and biases, is increasingly recognized as an important conceptual framework to improve physician behavior. This pragmatic trial is among the first to combine two distinct behavioral economic principles, a desire for non-malfeasance and default bias, to improve physician prescribing patterns for patients with ADRD. We anticipate this trial will substantially advance understanding of how behavioral-economic informed EHR CDS tools can potentially reduce harmful, low-value care among patients with ADRD.
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Affiliation(s)
- John N. Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- RAND Corporation, Santa Monica, California, United States of America
- * E-mail:
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- RAND Corporation, Santa Monica, California, United States of America
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
| | - Chad Villaflores
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Andrea Sorensen
- Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Eric Cheng
- Division of Medical Informatics, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Ashley Turner
- Division of Medical Informatics, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Zoe Trutner
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Grace Cheng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Julia Cave Arbanas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Benjamin Waterman
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Suzanne Shu
- Division of Marketing, Charles H. Dyson School of Applied Economics and Management at Cornell University, Ithaca, New York, United States of America
| | - Noah Goldstein
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Division of Management and Organizations, Anderson School of Management at UCLA, Los Angeles, California, United States of America
| | - Catherine Sarkisian
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
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22
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Haratian A, Maleki Z, Shayegh F, Safaeian A. Detection of factors affecting kidney function using machine learning methods. Sci Rep 2022; 12:21740. [PMID: 36526702 DOI: 10.1038/s41598-022-26160-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Due to the increasing prevalence of chronic kidney disease and its high mortality rate, study of risk factors affecting the progression of the disease is of great importance. Here in this work, we aim to develop a framework for using machine learning methods to identify factors affecting kidney function. To this end classification methods are trained to predict the serum creatinine level based on numerical values of other blood test parameters in one of the three classes representing different ranges of the variable values. Models are trained using the data from blood test results of healthy and patient subjects including 46 different blood test parameters. The best developed models are random forest and LightGBM. Interpretation of the resulting model reveals a direct relationship between vitamin D and blood creatinine level. The detected analogy between these two parameters is reliable, regarding the relatively high predictive accuracy of the random forest model reaching the AUC of 0.90 and the accuracy of 0.74. Moreover, in this paper we develop a Bayesian network to infer the direct relationships between blood test parameters which have consistent results with the classification models. The proposed framework uses an inclusive set of advanced imputation methods to deal with the main challenge of working with electronic health data, missing values. Hence it can be applied to similar clinical studies to investigate and discover the relationships between the factors under study.
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23
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Hall A, Pike A, Patey A, Mortazhejri S, Inwood S, Ruzycki S, Kirkham K, Mahoney K, Grimshaw J. Barriers to reducing preoperative testing for low-risk surgical procedures: A qualitative assessment guided by the Theoretical Domains Framework. PLoS One 2022; 17:e0278549. [PMID: 36480568 DOI: 10.1371/journal.pone.0278549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/02/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. AIM Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. METHOD We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. RESULTS We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years' experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. CONCLUSION These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.
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24
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Zouch J, Comachio J, Bussières A, Ashton-James CE, dos Reis AHS, Chen Y, Ferreira M, Ferreira P. Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review. Phys Ther 2022; 102:pzac150. [PMID: 36317766 PMCID: PMC10071499 DOI: 10.1093/ptj/pzac150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/05/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP). METHODS Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure. RESULTS A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent. CONCLUSIONS Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings. IMPACT This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems. LAY SUMMARY This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- James Zouch
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Josielli Comachio
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - André Bussières
- Department de Chiropractique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Claire E Ashton-James
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Yanyu Chen
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela Ferreira
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Paulo Ferreira
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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25
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Lang G, Ingvarsson S, Hasson H, Nilsen P, Augustsson H. Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden. Scand J Prim Health Care 2022; 40:426-437. [PMID: 36325746 PMCID: PMC9848255 DOI: 10.1080/02813432.2022.2139467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC. DESIGN Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis. SETTING Six publicly owned primary health care centers in Stockholm. SUBJECTS The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7. MAIN OUTCOME MEASURES Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC. RESULTS Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. . CONCLUSION The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.
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Affiliation(s)
- Gabriella Lang
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- CONTACT Gabriella Lang Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, SE 171 77, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
| | - Per Nilsen
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hanna Augustsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
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26
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Skinner L, Wong S, Colla C. Rethinking rurality: using hospital referral regions to investigate rural-urban health outcomes. BMC Health Serv Res 2022; 22:1312. [PMID: 36329451 PMCID: PMC9635085 DOI: 10.1186/s12913-022-08649-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Rural residents in the United States face disproportionately poorer health outcomes compared to urban residents. This study aims to establish a continuous rural-urban measure for the 306 hospital referral regions (HRRs) in the U.S. and to investigate the relationship between the proportion of rural population served in each HRR and health outcomes, healthcare spending and utilization, and access to and quality of primary care. METHODS Cross-sectional analysis using data from The Dartmouth Atlas and the U.S. Census. The sample is limited to fee-for-service Medicare beneficiaries aged 65-99 years and living during 2015. The primary outcomes were measured at the HRR-level: mortality rates, Medicare reimbursements, percent Medicare enrollees who have at least one visit to a primary care physician, diabetic hemoglobin A1c testing rates, and mammography rates. We calculate a population-weighted rural proportion and population-weighted area deprivation index (ADI) for each HRR by aggregating zip-code level data. RESULTS The most rural quartile of HRRs had significantly greater mean mortality rate of 4.50%, compared to 3.95% in most urban quartile of HRRs (p < 0.001). Increasing rural proportion was associated with decreasing price-adjusted Medicare reimbursements. In the multivariate, linear regression model, increasing area deprivation (ADI) was associated with increasing rates of mortality and greater utilization. CONCLUSION Disparities in rural mortality are driven by sociodemographic disadvantage, rather than the quality of care provided at hospitals serving rural areas. After accounting for sociodemographic disadvantage, rural areas achieve similar quality of primary care in measured domains at an overall lower cost.
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Affiliation(s)
- Lucy Skinner
- grid.254880.30000 0001 2179 2404Geisel School of Medicine at Dartmouth, Hanover, NH US
| | - Sandra Wong
- grid.254880.30000 0001 2179 2404Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, Dartmouth-Hitchcock, NH US
| | - Carrie Colla
- grid.431721.20000 0001 2342 2087The Congressional Budget Office, Washington, DC US ,grid.254880.30000 0001 2179 2404The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH USA
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27
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Ellenbogen MI, Prichett L, Brotman DJ. Characterizing the Relationship Between Payer Mix and Diagnostic Intensity at the Hospital Level. J Gen Intern Med 2022; 37:3783-3788. [PMID: 35266125 PMCID: PMC9640504 DOI: 10.1007/s11606-022-07453-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/03/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Overuse of diagnostic testing in the hospital setting contributes to high healthcare costs, yet the drivers of diagnostic overuse in this setting are not well-understood. If financial incentives play an important role in perpetuating hospital-level diagnostic overuse, then hospitals with favorable payer mixes might be more likely to exhibit high levels of diagnostic intensity. OBJECTIVES To apply a previously developed hospital-level diagnostic intensity index to characterize the relationship between payer mix and diagnostic intensity. DESIGN Cross-sectional analysis SUBJECTS: Acute care hospitals in seven states MAIN MEASURES: We utilized a diagnostic intensity index to characterize the level of diagnostic intensity at a given hospital (with higher index values and tertiles signifying higher levels of diagnostic intensity). We used two measures of payer mix: (1) a hospital's ratio of discharges with Medicare and Medicaid as the primary payer to those with a commercial insurer as the primary payer, (2) a hospital's disproportionate share hospital ratio. KEY RESULTS A 5-fold increase in the Medicare or Medicaid to commercial insurance ratio was associated with an adjusted odds ratio of 0.24 (95% CI 0.16-0.36) of being in a higher tertile of the intensity index. A ten percentage point increase in the disproportionate share hospital ratio was associated with an adjusted odds ratio of 0.56 (95% CI 0.42-0.74) of being in a higher intensity index tertile. CONCLUSIONS At the hospital level, a favorable payer mix is associated with higher diagnostic intensity. This suggests that financial incentives may be a driver of diagnostic overuse.
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Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.
- Hopkins Business of Health Initiative, Johns Hopkins University, Baltimore, MD, USA.
| | - Laura Prichett
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel J Brotman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anthony L Edelman
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shannon M Ruzycki
- Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Boudreau E, Schwartz R, Schwartz AL, Navathe AS, Caplan A, Li Y, Blink A, Racsa P, Antol DD, Erwin CJ, Shrank WH, Powers BW. Comparison of Low-Value Services Among Medicare Advantage and Traditional Medicare Beneficiaries. JAMA Health Forum 2022; 3:e222935. [PMID: 36218933 PMCID: PMC9463603 DOI: 10.1001/jamahealthforum.2022.2935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Question Do rates of low-value care differ between traditional Medicare (TM) and Medicare Advantage (MA), and, if so, what elements of insurance design are associated with the differences? Findings In this cross-sectional study of 2 470 199 Medicare beneficiaries, those enrolled in MA received 9.2% fewer low-value services than those in TM (23.1 vs 25.4 total low-value services per 100 beneficiaries). The MA beneficiaries in health maintenance organizations and those in primary care organizations reimbursed within advanced value-based payment models had the lowest rates of low-value care. Meaning The study results suggest that low-value care is less common in MA than TM, with elements of insurance design present in MA associated with fewer low-value services. Importance Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care. Objectives To compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care. Design, Setting, and Participants This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022. Exposures Enrollment in MA vs TM. Main Outcomes and Measures Low-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries. Results Among a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.
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Affiliation(s)
| | | | - Aaron L. Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amol S. Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Yong Li
- Humana Inc, Louisville, Kentucky
| | | | | | | | | | | | - Brian W. Powers
- Humana Inc, Louisville, Kentucky
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
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Do LA, Koethe BC, Daly AT, Chambers JD, Ollendorf DA, Wong JB, Fendrick AM, Neumann PJ, Kim DD. State-Level Variation In Low-Value Care For Commercially Insured And Medicare Advantage Populations. Health Aff (Millwood) 2022; 41:1281-1290. [PMID: 36067429 DOI: 10.1377/hlthaff.2022.00325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Low-value care is a major source of health care inefficiency in the US. Our analysis of 2009-19 administrative claims data from OptumLabs Data Warehouse found that low-value care and associated spending remain prevalent among commercially insured and Medicare Advantage enrollees. The aggregated prevalence of twenty-three low-value services was 1,920 per 100,000 eligible enrollees, which amounted to $3.7 billion in wasteful expenditures during the study period. State-level variation in spending was greater than variation in utilization, and much of the variation in spending was driven by differences in average procedure prices. If the average price for twenty-three low-value services among the top ten states in spending were set to the national average, their spending would decrease by 19.8 percent (from $735,000 to $590,000 per 100,000 eligible enrollees). State-level actions to improve the routine measurement and reporting of low-value care could identify sources of variation and help design state-specific policies that lead to better patient-centered outcomes, enhanced equity, and more efficient spending.
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Affiliation(s)
- Lauren A Do
- Lauren A. Do, Tufts Medical Center, Boston, Massachusetts
| | | | | | - James D Chambers
- James D. Chambers, Tufts Medical Center and Tufts University, Boston, Massachusetts
| | | | - John B Wong
- John B. Wong, Tufts Medical Center and Tufts University
| | - A Mark Fendrick
- A. Mark Fendrick, University of Michigan, Ann Arbor, Michigan
| | | | - David D Kim
- David D. Kim , Tufts Medical Center and Tufts University
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Beck da Silva Etges AP, Marcolino MAZ, Ogliari LA, de Souza AC, Zanotto BS, Ruschel R, Safanelli J, Magalhães P, Diegoli H, Weber KT, Araki AP, Nunes A, Ponte Neto OM, Nabi J, Martins SO, Polanczyk CA. Moving the Brazilian Ischemic Stroke Pathway to a Value-Based Care: Introduction of a Risk-Adjusted Cost Estimate Model for Stroke Treatment. Health Policy Plan 2022; 37:1098-1106. [PMID: 35866723 DOI: 10.1093/heapol/czac058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
The unsustainable increases in healthcare expenses and waste have motivated the migration of reimbursement strategies from volume to value. Value-based health care requires detailed comprehension of cost information at the patient level. This study introduces a clinical risk- and outcome-adjusted cost estimate model for stroke care sustained on time-driven activity-based costing (TDABC). In a cohort and multicenter study, a TDABC tool was developed to evaluate the costs per stroke patient, allowing us to identify and describe differences in cost by clinical risk at hospital arrival, treatment strategies, and modified Rankin Score (mRS) at discharge. The clinical risk was confirmed by multivariate analysis and considered patients' National Institute for Health Stroke Scale and age. Descriptive cost analyses were conducted, followed by univariate and multivariate models to evaluate the risk levels, therapies, and mRS stratification effect in costs. Then, the risk-adjusted cost estimate model for ischemic stroke treatment was introduced. All the hospitals collected routine prospective data from consecutive patients admitted with ischemic stroke diagnosis confirmed. A total of 822 patients were included. The median cost was I$2,210 (IQR: I$1,163-4,504). Fifty percent of the patients registered a favorable outcome mRS (0-2), costing less at all risk levels, while patients with the worst mRS (5-6) registered higher costs. Those undergoing mechanical thrombectomy had an incremental cost for all three risk levels, but this difference was lower for high-risk patients. Estimated costs were compared to observed costs per risk group, and there were no significant differences in most groups, validating the risk and outcome adjusted cost estimate model. By introducing a risk-adjusted cost estimate model, this study elucidates how healthcare delivery systems can generate local cost information to support value-based reimbursement strategies employing the data collection instruments and analysis developed in this study.
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Affiliation(s)
- Ana Paula Beck da Silva Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,School of Technology, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Miriam Allein Zago Marcolino
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Leonardo Alves Ogliari
- Programa de Pós-graduação em Engenharia de Produção da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Bruna Stella Zanotto
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Renata Ruschel
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil
| | | | | | | | - Karina Tavares Weber
- Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Paula Araki
- Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Altacílio Nunes
- Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Octávio Marques Ponte Neto
- Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Sheila Ouriques Martins
- Hospital Moinhos de Vento, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Faculdade de Medicina Universidade Federal do Rio Grande do Sul
| | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Hospital Moinhos de Vento, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Faculdade de Medicina Universidade Federal do Rio Grande do Sul
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Juang WC, Chiou SMJ, Yang HL, Li YC. Exploring emergency physicians’ knowledge, attitudes, and behaviour towards Choosing Wisely in Taiwan. PLoS One 2022; 17:e0271346. [PMID: 35819965 PMCID: PMC9275691 DOI: 10.1371/journal.pone.0271346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/28/2022] [Indexed: 11/27/2022] Open
Abstract
Background In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to reduce unnecessary care. However, it is unclear how much emergency physicians in Taiwan understand about Choosing Wisely. The purpose of this study was to explore the knowledge, attitude, and behaviour of emergency physicians in Taiwan regarding Choosing Wisely and its related factors; the intention was to identify the baseline knowledge on the basis of which to promote Choosing Wisely in Taiwan. Methods This was a cross-sectional study including emergency physicians in Taiwan as research subjects who answered online questionnaires. A 42-item questionnaire was designed according to the Knowledge, Attitude, and Behaviour model (KAB). The questionnaire linkages were delivered to emergency physicians through social media (eg., Line, Facebook) and received assistance from different hospital directors. A total of 162 valid questionnaires were collected. Data analyses include t-test, analysis of variance, chi-square test, Pearson’s correlation, and multivariate linear regression model. Results The study determined that although only 38.9% of emergency physicians had heard of Choosing Wisely, the mean correct rate of knowledge score among emergency physicians was 70.1%. Attitude and the behaviour related to Choosing Wisely were positively associated, which means that the more positive the attitude towards Choosing Wisely is, the more positive the behaviour towards Choosing Wisely is. In multiple linear regression analyses, having served as a supervisor, belonging to divisions of health insurance service, and having heard of Choosing Wisely (P < 0.05) positively affect the knowledge of Choosing Wisely, but age presented a negative association. Conclusion This study found that physicians’ knowledge does not influence their attitudes and behaviours, which may be related to barriers of practicing Choosing Wisely activities. To effectively promote Choosing Wisely campaign, it is recommended to focus on the significant factors associated with emergency physicians’ perceptions regarding knowledge, attitude, and behavior of Choosing Wisely. Based on these factors, appropriate practice guidelines for Choosing Wisely can be formulated and promoted.
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Affiliation(s)
- Wang-Chuan Juang
- Department of Quality Management Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Sonia Ming-Jiu Chiou
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Hui-Ling Yang
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Department of Planning, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung, Taiwan
| | - Ying-Chun Li
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- * E-mail:
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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: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Landon SN, Padikkala J, Horwitz LI. Identifying drivers of health care value: a scoping review of the literature. BMC Health Serv Res 2022; 22:845. [PMID: 35773663 PMCID: PMC9248090 DOI: 10.1186/s12913-022-08225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/31/2022] [Indexed: 12/03/2022] Open
Abstract
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. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08225-6.
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Affiliation(s)
- Susan N Landon
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, 227 E 30th St, Room 633, New York, NY, 10016, USA
| | - Jane Padikkala
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, 227 E 30th St, Room 633, New York, NY, 10016, USA
| | - Leora I Horwitz
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, 227 E 30th St, Room 633, New York, NY, 10016, USA. .,Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, NY, USA. .,Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
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Müskens JL, van Dulmen SA, Wiersma T, Burgers JS, Hek K, Westert GP, Kool RB. Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study. Br J Gen Pract 2022; 72:e369-e377. [PMID: 35314429 PMCID: PMC8966784 DOI: 10.3399/bjgp.2021.0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/31/2022] [Indexed: 10/31/2022] Open
Abstract
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.
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Affiliation(s)
- Joris Ljm Müskens
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen
| | | | - Jako S Burgers
- Department of General Practice, School CAPHRI, Maastricht University, Maastricht; senior consultant, Dutch College of General Practitioners, Utrecht
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht
| | - Gert P Westert
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
| | - Rudolf B Kool
- 'Doen of laten?', IQ Healthcare, Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen
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Gourevitch RA, Natwick T, Chaisson CE, Weiseth A, Shah NT. Variation in guideline-based prenatal care in a commercially insured population. Am J Obstet Gynecol 2022; 226:413.e1-413.e19. [PMID: 34614398 DOI: 10.1016/j.ajog.2021.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether attending more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients' clinical and sociodemographic characteristics has also not been studied. OBJECTIVE This study aimed to measure the receipt of guideline-based prenatal care among pregnant patients and to describe the association between guideline-based prenatal care and the number of prenatal visits and other patient characteristics. STUDY DESIGN This was a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016 and 2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs Data Warehouse. We identified the following 8 components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists and other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory test panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, tetanus, diphtheria, and pertussis vaccine, and group B Streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care according to patient age, comorbidities, high deductible health plan enrollment, and their county's rurality, health professional shortage area status, racial composition, median income, and educational attainment. RESULTS The 176,092 pregnancy episodes were mostly among patients aged 25 to 34 years (63%) with few pregnancy comorbidities (81%) and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least 4 prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of tetanus, diphtheria, and pertussis vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income. CONCLUSION In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient- and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.
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Affiliation(s)
- Rebecca A Gourevitch
- Department of Health Care Policy, Harvard Medical School, Boston, MA; Delivery Decisions Initiative, Ariadne Labs, Boston, MA.
| | | | | | - Amber Weiseth
- Delivery Decisions Initiative, Ariadne Labs, Boston, MA
| | - Neel T Shah
- Delivery Decisions Initiative, Ariadne Labs, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; OptumLabs Visiting Fellow, Cambridge, MA; Maven Clinic, New York, NY
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Al-Hihi E, Gibson C, Lee J, Mount RR, Irani N, McGowan C. Improving appropriate imaging for non-specific low back pain. BMJ Open Qual 2022; 11:bmjoq-2021-001539. [PMID: 35190485 PMCID: PMC8862455 DOI: 10.1136/bmjoq-2021-001539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 01/15/2022] [Indexed: 12/03/2022] Open
Abstract
Non-specific low back pain (LBP) is a common condition in the USA, with approximately 80% of adults who will have LBP at some point during their life and roughly 30% of the adult population suffering from LBP at any given time. Although LBP is the most common cause of disability in the USA, it often has no identifiable anatomic or physiologic cause. Many patients seeking care for non-specific LBP receive X-rays and other imaging studies. However, for most acute LBP patients, symptoms resolve within 4 weeks and the use of routine imaging may result in unnecessary radiation exposure and add unnecessary costs and wasted time for patients without contributing to patient outcomes. The specific aim of the quality improvement (QI) project was to determine the effect of a multicomponent intervention to enhance the appropriate imaging utilisation for acute LBP to ≥90%. During the first 6 months of the QI project, 191 patients with LBP were seen. Of those patients, 156 (81.7%) received appropriate imaging over the 6-month intervention period, missing our targeted goal. Furthermore, this rate declined to baseline values after termination of the intervention, suggesting the need for additional prompts to sustain the initial intervention effect. Following a health system-wide deployment of practice-based alerts and quality score cards, the appropriate utilisation rate increased again and quickly to the target rate of 90%. To reduce variability in our clinical practice and to sustain an appropriate utilisation rate will require continued work. Health systems must find efficient methods to reduce LBP imaging and increase appropriate management of non-specific LBP in primary care. Increasing concordance with imaging guidelines can lessen harm associated with unnecessary radiation exposure and result in significant cost savings.
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Affiliation(s)
- Eyad Al-Hihi
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Cheryl Gibson
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Jaehoon Lee
- Educational Psychology, Leadership, and Counseling, Texas Tech University, Lubbock, Texas, USA
| | - Rebecca R Mount
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Neville Irani
- Radiology, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Caylin McGowan
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ha NT, Abdullah L, Bulsara M, Celenza A, Doust J, Fatovich D, McRobbie D, Mountain D, O’Leary P, Slavotinek J, Wright C, Youens D, Moorin R. The use of computed tomography in the management of injury in tertiary emergency departments in Western Australia: Evidence of overtesting? Acad Emerg Med 2022; 29:193-205. [PMID: 34480498 DOI: 10.1111/acem.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. METHODS A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. RESULTS While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. CONCLUSIONS The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.
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Affiliation(s)
- Ninh T. Ha
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Lana Abdullah
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Max Bulsara
- Institute for Health Research University of Notre Dame Fremantle Western Australia Australia
- Centre for Health Services Research School of Population and Global Health The University of Western Australia Perth Western Australia Australia
| | - Antonio Celenza
- Department of Emergency Medicine Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Daniel Fatovich
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
- Emergency Department Royal Perth Hospital Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Western Australia Australia
| | - Donald McRobbie
- School of Physical Sciences University of Adelaide Adelaide South Australia Australia
| | - David Mountain
- Department of Emergency Medicine Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
- Curtin University Medical School Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Peter O’Leary
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Obstetrics and Gynaecology Medical School Faculty of Health and Medical Sciences The University of Western Australia Perth Western Australia Australia
- PathWest Laboratory Medicine QE2 Medical Centre Nedlands Western Australia Australia
| | - John Slavotinek
- SA Medical Imaging SA Health and College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Cameron Wright
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Fiona Stanley Hospital Murdoch Western Australia Australia
- Division of Internal Medicine Medical School Faculty of Health and Medical Sciences University of Western Australia Perth Western Australia Australia
- School of Medicine College of Health and Medicine University of Tasmania Hobart Tasmania Australia
| | - David Youens
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Rachael Moorin
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Centre for Health Services Research School of Population and Global Health The University of Western Australia Perth Western Australia Australia
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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: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Rockwell MS, Michaels KC, Epling JW. Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study. BMC Health Serv Res 2022; 22:37. [PMID: 34991573 PMCID: PMC8733793 DOI: 10.1186/s12913-021-07345-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods
Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). Conclusions In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07345-9.
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Affiliation(s)
- Michelle S Rockwell
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA.
| | - Kenan C Michaels
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, VA, 24016, Roanoke, USA
| | - John W Epling
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA
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Schwartz AL, Chen Y, Jagmin CL, Verbrugge DJ, Brennan TA, Groeneveld PW, Newhouse JP. Coverage Denials: Government And Private Insurer Policies For Medical Necessity In Medicare. Health Aff (Millwood) 2022; 41:120-128. [PMID: 34982629 DOI: 10.1377/hlthaff.2021.01054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their key features, using Medicare Advantage claims for a large insurer from the period 2014-19. In this setting, claims could be denied because of traditional Medicare's coverage rules or additional Medicare Advantage private insurer rules. We observed $416 million in denied spending, with 0.81 denials and $60 of denied spending per beneficiary annually. We found that 1.40 percent of services were denied and 0.68 percent of total spending was denied, with rates rising over time. Traditional Medicare's coverage rules accounted for 85 percent of denied services and 64 percent of denied spending; the remaining denials were due to additional Medicare Advantage insurer rules. Denial rates varied greatly across service type and provider type, with the most denials being for laboratory services and hospital outpatient providers. Traditional Medicare and Medicare Advantage insurer coverage policies each addressed different sources of medical spending; together they contributed to the denial of a modest but nontrivial portion of payments.
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Affiliation(s)
- Aaron L Schwartz
- Aaron L. Schwartz , University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Yujun Chen
- Yujun Chen, CVS Health, New York, New York
| | | | | | | | - Peter W Groeneveld
- Peter W. Groeneveld, University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center
| | - Joseph P Newhouse
- Joseph P. Newhouse, Harvard University and National Bureau of Economic Research, Cambridge, Massachusetts
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Oronce CIA, Fendrick AM, Ladapo JA, Sarkisian C, Mafi JN. The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016. J Gen Intern Med 2021; 36:3711-8. [PMID: 33852141 DOI: 10.1007/s11606-021-06784-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/31/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed. OBJECTIVE To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries. DESIGN We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services. SETTING/PARTICIPANTS NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees. MAIN MEASURES We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources. KEY RESULTS During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study. CONCLUSIONS US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.
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Iloabuchi C, Dwibedi N, LeMasters T, Shen C, Ladani A, Sambamoorthi U. Low-value care and excess out-of-pocket expenditure among older adults with incident cancer - A machine learning approach. J Cancer Policy 2021; 30:100312. [PMID: 35559807 PMCID: PMC8916690 DOI: 10.1016/j.jcpo.2021.100312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/05/2021] [Accepted: 10/27/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the association of low-value care with excess out-of-pocket expenditure among older adults diagnosed with incident breast, prostate, colorectal cancers, and Non-Hodgkin's Lymphoma. METHODS We used a retrospective cohort study design with 12-month baseline and follow-up periods. We identified a cohort of older adults (age ≥ 66 years) diagnosed with breast, prostate, colorectal cancers, or Non-Hodgkin's lymphoma between January 2014 and December 2014. We assessed low-value care and patient out-of-pocket expenditure in the follow-up period. We identified relevant low-value services using ICD9/ICD10 and CPT/HCPCS codes from the linked health claims and patient out-of-pocket expenditure from Medicare claim files and expressed expenditure in 2016 USD. RESULTS About 29 % of older adults received at least one low-value care procedure during the follow-up period. Low-value care differed by gender, and rates were higher in women with colorectal cancer (32.7 %) vs. (28.8 %) and NHL (40 %) vs. (39 %) compared to men. Individuals who received one or more low-value care procedures had significantly higher mean out-of-pocket expenditure ($8,726 ± $7,214) vs. ($6,802 ± $6,102). XGBOOST, a machine learning algorithm revealed that low-value care was among the five leading predictors of OOP expenditure. CONCLUSION One in four older adults with incident cancer received low-value care in 12-months after a cancer diagnosis. Across all cancer populations, individuals who received low-value care had significantly higher out-of-pocket expenditure. Excess out-of-pocket expenditure was driven by low-value care, fragmentation of care, and an increasing number of pre-existing chronic conditions. POLICY STATEMENT This study focuses on health policy issues, specifically value-based care and its findings have important clinical and policy implications for Centers for Medicare and Medicaid Services (CMS) which has issued a roadmap for states to accelerate the adoption of value-based care, with the Department of Health and Human Services (HHS) setting a goal of converting 50 % of traditional Medicare payment systems to alternative payment models tied to value-based care by 2022.
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Affiliation(s)
- Chibuzo Iloabuchi
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Robert C. Byrd Health Sciences Center [North], P.O. Box 9510, Morgantown, WV, 26506-9510, USA.
| | - Nilanjana Dwibedi
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Robert C. Byrd Health Sciences Center [North], P.O. Box 9510, Morgantown, WV, 26506-9510, USA.
| | - Traci LeMasters
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Robert C. Byrd Health Sciences Center [North], P.O. Box 9510, Morgantown, WV, 26506-9510, USA.
| | - Chan Shen
- Division of Outcomes Research and Quality, Department of Surgery, College of Medicine, Pennsylvania State University, Hershey, PA, USA.
| | - Amit Ladani
- Department of Medicine, Division of Rheumatology, West Virginia University Medicine, Morgantown, WV, USA.
| | - Usha Sambamoorthi
- Department of Pharmacotherapy, College of Pharmacy, "Vashisht" Professor of Disparities, Health Education, Awareness & Research in Disparities (HEARD) Scholar, Texas Center for Health Disparities, University of North Texas Health Sciences Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA.
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Soltana K, Moore L, Bouderba S, Lauzier F, Clément J, Mercier É, Krouchev R, Tardif PA, Belcaid A, Stelfox T, Lamontagne F, Archambault P, Turgeon A. Adherence to Clinical Practice Guideline Recommendations on Low-Value Injury Care: A Multicenter Retrospective Cohort Study. Value Health 2021; 24:1728-1736. [PMID: 34838270 DOI: 10.1016/j.jval.2021.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Kahina Soltana
- Canada Research Chair in Critical Care Neurology and Trauma, CHU de Québec - Laval University, Québec City, QC, Canada; Cochrane Canada Francophone, CHU de Québec - Laval University, Québec City, QC, Canada; CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Population Health and Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Center, Laval University, Québec City, QC, Canada
| | - Lynne Moore
- CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Population Health and Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Center, Laval University, Québec City, QC, Canada; Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Québec City, QC, Canada.
| | - Samy Bouderba
- CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Population Health and Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Center, Laval University, Québec City, QC, Canada
| | - François Lauzier
- Canada Research Chair in Critical Care Neurology and Trauma, CHU de Québec - Laval University, Québec City, QC, Canada; CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Division of Critical Care, Department of Medicine and Anesthesiology and Research Center, CHU de Québec - Laval University, Québec City, QC, Canada
| | - Julien Clément
- Institut national d'excellence en santé et en services sociaux (INESSS), Québec, QC, Canada; Department of Surgery, Université Laval, Québec, QC, Canada
| | - Éric Mercier
- CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Population Health and Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Center, Laval University, Québec City, QC, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Laval University, Québec City, QC, Canada
| | | | - Pier-Alexandre Tardif
- CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Population Health and Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Center, Laval University, Québec City, QC, Canada
| | - Amina Belcaid
- CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Population Health and Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Center, Laval University, Québec City, QC, Canada; Institut national d'excellence en santé et en services sociaux (INESSS), Québec, QC, Canada
| | - Thomas Stelfox
- Department of Critical Care Medicine - Calgary Zone, University of Calgary and Alberta Health Services, University of Calgary, Calgary, AB, Canada
| | - François Lamontagne
- Internal Medicine Department, Department of Medicine, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Division of Critical Care, Department of Anesthesia, CISSS Chaudière-Appalaches (Secteur Alphonse-Desjardins), Sainte-Marie, QC, Canada
| | - Alexis Turgeon
- Canada Research Chair in Critical Care Neurology and Trauma, CHU de Québec - Laval University, Québec City, QC, Canada; Cochrane Canada Francophone, CHU de Québec - Laval University, Québec City, QC, Canada; CHU de Québec Research Center, Hôpital de l'Enfant-Jésus, CHU de Québec - Laval University, Québec City, QC, Canada; Population Health and Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Center, Laval University, Québec City, QC, Canada; Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, on behalf of the Canadian Traumatic Brain Research Consortium
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Ha NT, Maxwell S, Bulsara MK, Doust J, Mcrobbie D, O'Leary P, Slavotinek J, Moorin R. Factors driving CT utilisation in tertiary hospitals: a decomposition analysis using linked administrative data in Western Australia. BMJ Open 2021; 11:e052954. [PMID: 34764174 PMCID: PMC8587703 DOI: 10.1136/bmjopen-2021-052954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES While CT scanning plays a significant role in healthcare, its increasing use has raised concerns about inappropriate use. This study investigated factors driving the changing use of CT among people admitted to tertiary hospitals in Western Australia (WA). DESIGN AND SETTING A repeated cross-sectional study of CT use in WA in 2003-2005 and 2013-2015 using linked administrative heath data at the individual patient level. PARTICIPANTS A total of 2 375 787 tertiary hospital admissions of people aged 18 years or older. MAIN OUTCOME MEASURE Rate of CT scanning per 1000 hospital admissions. METHODS A multivariable decomposition model was used to quantify the contribution of changes in patient characteristics and changes in the probability of having a CT over the study period. RESULTS The rate of CT scanning increased by 112 CT scans per 1000 admissions over the study period. Changes in the distribution of the observed patient characteristics were accounted for 62.7% of the growth in CT use. However, among unplanned admissions, changes in the distribution of patient characteristics only explained 17% of the growth in CT use, the remainder being explained by changes in the probability of having a CT scan. While the relative probability of having a CT scan generally increased over time across most observed characteristics, it reduced in young adults (-2.8%), people living in the rural/remote areas (-0.8%) and people transferred from secondary hospitals (-0.8%). CONCLUSIONS Our study highlights potential improvements in practice towards reducing medical radiation exposure in certain high risk population. Since changes in the relative probability of having a CT scan (representing changes in scope) rather than changes in the distribution of the patient characteristics (representing changes in need) explained a major proportion of the growth in CT use, this warrants more in-depth investigations in clinical practices to better inform health policies promoting appropriate use of diagnostic imaging tests.
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Affiliation(s)
- Ninh Thi Ha
- Health Economics & Data Analytics, Curtin School of Population Health, Faculty of Health Sciences, Curtin University - Bentley Campus, Perth, Western Australia, Australia
- Department of Community Health, Institute of Public Health Vietnam, Ho Chi Minh City, Viet Nam
| | - Susannah Maxwell
- Health Economics & Data Analytics, Curtin School of Population Health, Faculty of Health Sciences, Curtin University - Bentley Campus, Perth, Western Australia, Australia
| | - Max K Bulsara
- Institute for Health and Rehabilitation Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Jenny Doust
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Donald Mcrobbie
- School of Physical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Peter O'Leary
- Faculty of Health Sciences, Curtin University, Perth, Australian Capital Territory, Australia
- Obstetrics and Gynaecology Medical School, The University of Western Australia Faculty of Health and Medical Sciences, Perth, Western Australia, Australia
| | - John Slavotinek
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rachael Moorin
- Health Economics & Data Analytics, Curtin School of Population Health, Faculty of Health Sciences, Curtin University - Bentley Campus, Perth, Western Australia, Australia
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
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Abstract
IMPORTANCE Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability. OBJECTIVES To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of health system-attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. MAIN OUTCOMES AND MEASURES Use of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions. RESULTS Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs -0.16 [95% CI, -0.27 to -0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, -0.01 to 0.20] without a teaching hospital vs -0.18 [95% CI, -0.34 to -0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, -0.02 to 0.32] for systems with >20% of non-White beneficiaries vs -0.06 [95% CI, -0.16 to 0.03] for systems with ≤20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with -0.09 [95% CI, -0.26 to 0.08] for the Northeast and -0.44 [95% CI, -0.60 to -0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs -0.24 [95% CI, -0.36 to -0.12] for areas below the median level of spending; P < .001). CONCLUSIONS AND RELEVANCE The findings of this large cohort study suggest that system-level measurement and reporting of specific low-value services is feasible, enables cross-system comparisons, and reveals a broad range of low-value care use.
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Affiliation(s)
- Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Ching-Wen Wendy Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Maia Crawford
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
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Hofmann B, Andersen ER, Kjelle E. What can we learn from the SARS-COV-2 pandemic about the value of specific radiological examinations? BMC Health Serv Res 2021; 21:1158. [PMID: 34702243 PMCID: PMC8546787 DOI: 10.1186/s12913-021-07190-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 191, N-2802, Gjøvik, Norway.
- Centre of Medical Ethics at the University of Oslo, Oslo, Norway.
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 191, N-2802, Gjøvik, Norway
| | - Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 191, N-2802, Gjøvik, Norway
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Schuttner L, Haraldsson B, Maynard C, Helfrich CD, Reddy A, Parikh T, Nelson KM, Wong E. Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Netw Open 2021; 4:e2130581. [PMID: 34677595 PMCID: PMC8536952 DOI: 10.1001/jamanetworkopen.2021.30581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. OBJECTIVE To understand rates and factors associated with outpatient low-value cancer screenings. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. EXPOSURES Receipt of cancer screening test. MAIN OUTCOMES AND MEASURES Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. RESULTS Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. CONCLUSIONS AND RELEVANCE This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | | | - Charles Maynard
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Christian D. Helfrich
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Ashok Reddy
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Toral Parikh
- Department of Medicine, University of Washington, Seattle
- Geriatrics and Extended Care, VA Puget Sound Healthcare System
| | - Karin M. Nelson
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Edwin Wong
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
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