Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

Relationship Between Insurance Status and Receipt of Cardiac Tests and Procedures During Hospitalization: A Cross-Sectional Study

BACKGROUND

Prior analyses of the relationship between insurance status and receipt of tests and procedures have yielded conflicting findings and have focused on outpatient care. We sought to characterize the relationship between primary payer and diagnostic and procedural intensity, comparing rates of cardiac tests and procedures in matched hospitalized Medicaid and commercially insured patients.

METHODS AND RESULTS

We created a propensity score-matched sample of Medicaid and commercially insured adults hospitalized at all acute care hospitals in Kentucky, Maryland, New Jersey, and North Carolina from 2016 to 2018. The main outcome was receipt of a cardiac test or procedure: echocardiogram, stress test, cardiac catheterization (elective, in acute coronary syndrome, in ST-segment-elevation myocardial infarction), and pacemaker and subcutaneous cardiac rhythm monitor implantation. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds of a commercially insured patient receiving a given test or procedure relative to a Medicaid patient. Models controlled for race, ethnicity, and zip code income quartile. Commercially insured patients were more likely to receive each cardiac test or procedure, with adjusted odds ratios ranging from 1.16 (95% CI, 1.00-1.34) for cardiac catheterization in ST-segment-elevation myocardial infarction to 1.40 (95% CI, 1.27-1.54) for pacemaker implantation.

CONCLUSIONS

Hospitalized commercially insured patients were more likely to undergo a range of cardiac tests and procedures, some of which may represent low-value care. This may be driven by a combination of physician and patient preference, financial incentives, and social determinants of health. Our findings support the need for hospital payment models focused on increasing value and reducing inequities.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Routine preoperative assessment for cataract surgery is a source of frustration for primary care providers

BACKGROUND

Cataract surgery is one of the most common surgical procedures performed in older adults in the United States and is generally considered to be extremely low-risk. As of 2019, routine preoperative evaluation within 30 days of surgery is no longer mandated by the United States of America (USA) Centers for Medicare & Medicaid Services (CMS) for ambulatory surgery centers, but it is unclear how primary care providers perceive this change.

METHODS

We performed a qualitative analysis of semi-structured interviews with six primary care providers to explore primary care providers' perspectives on routine preoperative assessment for cataract surgery.

RESULTS

Primary care providers commented on the large number of referrals they receive for preoperative assessment before cataract procedures. The analysis revealed an overarching sentiment of resentment over the time, effort, and resources expended on these assessments. Themes included the lack of awareness of the updated regulations that no longer require a history and physical to be completed within 30 days and the perception of a universal lack of medical necessity to perform preoperative assessment for cataract surgery. Providers also commented on the strain on limited resources and the burden on patients. The relationship between specialties and professional roles emerged as another important theme.

CONCLUSIONS

Referrals for preoperative clearance for cataract surgery continue to burden providers, patients, and the health system, and represent an opportunity to streamline care in this patient population.

Pretransplant cardiac stress testing and transplant wait time in kidney transplantation candidates

OBJECTIVE

Routine screening for cardiovascular disease before kidney transplantation remains controversial. This study aims to compare cardiac testing rates in patients with end-stage renal disease, referred and not referred for transplantation, and assess the impact of testing on transplant wait times.

METHODS

This is a retrospective cohort study of 22 687 end-stage renal disease patients from 2011 to 2022, within an integrated health system. Cardiac testing patterns, and the association between cardiac testing and transplant wait times and post-transplant mortality were evaluated.

RESULTS

Of 22 687 patients (median age 66 years, 41.1% female), 6.9% received kidney transplants, and 21.0% underwent evaluation. Compared with dialysis patients, transplant patients had a 5.6 times higher rate of stress nuclear myocardial perfusion imaging with single-photon emission (rate ratio (RR) 5.64, 95% CI 5.37 to 5.92), a 6.5 times higher rate of stress echocardiogram (RR 6.51, 95% CI 5.65 to 7.51) and 16% higher cardiac catheterisation (RR 1.16, 95% CI 1.06 to 1.27). In contrast, revascularisation rates were significantly lower in transplant patients (RR 0.46, 95% CI 0.36 to 0.58). Transplant wait times were longer for patients who underwent stress testing (median 474 days with no testing vs 1053 days with testing) and revascularisation (1796 days for percutaneous intervention and 2164 days for coronary artery bypass surgery). No significant association was observed with 1-year post-transplant mortality (adjusted OR 1.99, 95% CI 0.46 to 8.56).

CONCLUSIONS

This study found a higher rate of cardiac testing in dialysis patients evaluated for kidney transplants. Cardiac testing was associated with longer transplant wait time, but no association was observed between testing and post-transplant mortality.

Medicaid Insurance is Associated With Decreased MRI Use for Ankle Sprains Compared With Private Insurance: A Retrospective Large-database Analysis

BACKGROUND

Advanced imaging modalities are expensive, and access to advanced imaging services may vary by socioeconomic factors, creating the potential for unwarranted variations in care. Ankle sprains are a common injury for which variations in MRI use can occur, both via underuse of indicated MRIs (appropriate use) and overuse of nonindicated MRIs (inappropriate use). High-value, equitable healthcare would decrease inappropriate use and increase appropriate use of MRI for this common injury. It is unknown whether socioeconomic factors are associated with underuse of indicated MRIs and overuse of nonindicated MRIs for ankle sprains.

QUESTIONS/PURPOSES

Using ankle sprains as a paradigm injury, given their high population incidence, we asked: (1) Does MRI use for ankle sprains vary by insurance type? (2) After controlling for relevant confounding variables, did patients who received an MRI have higher odds of undergoing ankle surgery?

METHODS

Between 2011 and 2019, a total of 6,710,223 patients were entered into the PearlDiver Mariner Patient Records Database with a diagnosis of ankle sprain. We considered patients with continuous enrollment in the database for at least 1 year before and 2 years after the diagnosis as potentially eligible. Based on that, 68% (4,567,106) were eligible; a further 20% (1,372,478) were excluded because of age younger than 18 years, age at least 65 years with Medicaid insurance, or age < 65 years with Medicare insurance. Another 0.1% (9169) had incomplete data, leaving 47% (3,185,459) for analysis here. Patients with Medicaid insurance differed from patients with Medicare Advantage or private insurance with respect to age, gender, region, and comorbidity burden. The primary outcome was ankle MRI occurring within 12 months after diagnosis. The use of ankle surgery after MRI in each cohort was measured as a secondary outcome. We used multivariable logistic regression models to evaluate the association between insurance type and MRI use while adjusting for age, gender, region, and comorbidity burden. Separate multivariable regression models were created to evaluate the association between receiving an MRI and subsequent ankle surgery for each insurance type, adjusting for age, gender, region, and comorbidity burden. Within 12 months of an ankle sprain diagnosis, 1% (3522 of 339,457) of patients with Medicaid, 2% (44,793 of 2,627,288) of patients with private insurance, and 1% (1660 of 218,714) of patients with Medicare Advantage received an MRI.

RESULTS

After controlling for age, gender, region, and comorbidity burden, patients with Medicaid had lower odds of receiving an MRI within 12 months after ankle sprain diagnosis than patients with private insurance (odds ratio 0.60 [95% confidence interval 0.57 to 0.62]; p < 0.001). Patients with Medicaid who received an MRI had higher adjusted odds of undergoing subsequent ankle surgery (OR 23 [95% CI 21 to 26]; p < 0.001) than patients with private insurance (OR 12.7 [95% CI 12 to 13]; p < 0.001).

CONCLUSION

Although absolute MRI use was generally low, there was substantial relative variation by insurance type. Given the high incidence of ankle sprains in the general population, these relative differences can translate to tens of thousands of MRIs. Further studies are needed to evaluate the reasons for decreased appropriate MRI use in patients with Medicaid and overuse of MRI in patients with private insurance. The establishment of clinical practice guidelines by orthopaedic professional societies and more stringent gatekeeping for MRI use by health insurers could reduce unwarranted variations in MRI use.

LEVEL OF EVIDENCE

Level III, prognostic study.

Development of a disease-based hospital-level diagnostic intensity index

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.

Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization

BACKGROUND

Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada.

METHODS

We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes.

DISCUSSION

The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work.

TRIAL REGISTRATION

This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic.

CLINICALTRIALS

gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.

Care cascades following low-value cervical cancer screening in dually enrolled Veterans

BACKGROUND

Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low-value service. Our objective was to characterize the frequency and cost of low-value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare.

METHODS

This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low-value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient- and facility-level covariates using inverse probability of treatment weighting.

RESULTS

Among 20,972 cohort-eligible Veterans, 494 (2.4%) underwent low-value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4-37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, -265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare.

CONCLUSIONS

Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low-value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low-value care, it is important to examine downstream care stemming from initial low-value services across all systems from which individuals receive care.

Prevalence and Cost of Routine Preoperative Care for Low-Risk Cataract Surgery a Decade after Choosing Wisely

PURPOSE

Examine the frequency and cost of procedural clearance tests and examinations in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the United States. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts postsurgical adverse events.

DESIGN

Retrospective healthcare claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania.

PARTICIPANTS

Members aged ≥ 65 years who were continuously enrolled 6 months before and after undergoing cataract surgery from 2018 to 2021 and had approved surgery claims.

METHODS

Preoperative exams or tests occurring in the 30 days before surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., Current Procedural Terminology codes for blood panels and preprocedural International Classification of Diseases, 10th Revision, Clinical Modification codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling.

MAIN OUTCOME MEASURES

Total costs, prevalence, and strength of association as indicated by odds ratios.

RESULTS

Up to 42% of members undergoing cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed in isolation or along with clearance visits. The combined costs for the preoperative visits and tests were $4.3 million (approximately $107-$114 per impacted member). There was little difference in member characteristics between those receiving and not receiving preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member's care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two.

CONCLUSIONS

Rates of routine preoperative testing before cataract surgery appear similar to those prior to the implementation of the Choosing Wisely campaign, which was meant to reduce this use. Additionally, preoperative evaluations, many likely unnecessary, were common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study

INTRODUCTION

Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts.

METHODS

We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD).

RESULTS

Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (TICD Social, Political, and Legal Factors), (2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and (3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers.

CONCLUSIONS

Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.

De-Implementation of Low-Value Care for Women 70 Years of Age or Older with Low-Risk Breast Cancer During the COVID-19 Pandemic

BACKGROUND

Older women with early-stage estrogen receptor-positive (ER+) invasive breast cancer (IBC) are at risk for overtreatment. Guidelines allow for sentinel lymph node biopsy (SLNB) and radiotherapy omission after breast-conserving surgery (BCS) for women 70 years of age or older with T1, clinical node negativity (cN0), and ER+ IBC. The study objective was to evaluate radiotherapy and SLNB de-implementation in older women with low-risk IBC after the resource limitations of the COVID-19 pandemic.

METHODS

An institutional database was analyzed to identify women 70 years of age or older who received BCS for IBC from 2012 to 2022. The patients were divided into two cohorts: (1) patients with low-risk IBC (pT1, cN0, and ER+/HER2-) who were eligible for radiotherapy and SLNB omission and (2) patients with high-risk IBC (pT2-T4, cN+, ER-, or HER2+) who were ineligible for therapy omission. Clinicopathologic variables in both cohorts were analyzed.

RESULTS

The study enrolled 881 patients. For the patients with low-risk IBC, the annual rates of radiotherapy were stable from 2012 to 2019. However, radiotherapy utilization decreased significantly from 2020 to 2022 (58% in 2012 vs 36% in 2022; p = 0.04). In contrast, radiotherapy usage among the patients with high-risk IBC was stable from 2012 to 2022 (79% in 2012 vs 79% in 2022; p = 0.95). Among the patients with low-risk IBC, SLNB rates decreased from 86% in 2012 to 56% in 2022, but this trend predated those in 2020. The factors significantly associated with SLNB and receipt of radiotherapy among the patients with low-risk IBC were younger age, larger tumors, grade 3 disease, and involved nodal status (p < 0.01).

CONCLUSION

This study demonstrated appropriate and sustained de-escalation of radiotherapy in older women with low-risk IBC after the COVID-19 pandemic.

Utility of Routine Preoperative Urinalysis in the Prevention of Surgical Site Infections

OBJECTIVE

Preoperative assessment is important for neurosurgical risk stratification, but the level of evidence for individual screening tests is low. In preoperative urinalysis (UA), testing may significantly increase costs and lead to inappropriate antibiotic treatment. We prospectively evaluated whether eliminating preoperative UA was noninferior to routine preoperative UA as measured by 30-day readmission for surgical site infection in adult elective neurosurgical procedures.

METHODS

A single-institution prospective, pragmatic study of patients receiving elective neurosurgical procedures from 2018 to 2020 was conducted. Patients were allocated based on same-day versus preoperative admission status. Rates of preoperative UA and subsequent wound infection were measured along with detailed demographic, surgical, and laboratory data.

RESULTS

The study included 879 patients. The most common types of surgery were cranial (54.7%), spine (17.4%), and stereotactic/functional (19.5%). No preoperative UA was performed in 315 patients, while 564 underwent UA. Of tested patients, 103 (18.3%) met criteria for suspected urinary tract infection, and 69 (12.2%) received subsequent antibiotic treatment. There were 14 patients readmitted within 30 days (7 without UA [2.2%] vs. 7 with UA [1.2%]) for subsequent wound infection with a risk difference of 0.98% (95% confidence interval -0.89% to 2.85%). The upper limit of the confidence interval exceeded the preselected noninferiority margin of 1%.

CONCLUSIONS

In this prospective study of preoperative UA for elective neurosurgical procedures using a pragmatic, real-world design, risk of readmission due to surgical site infection was very low across the study cohort, suggesting a limited role of preoperative UA for elective neurosurgical procedures.

Cardiac coronary tomography angiography (CCTA) use across geographical regions in the USA and the UK: a cross-sectional study

Objective

Increased use of CT imaging has been identified as a key component of unsustainable rising healthcare costs in the USA and globally. Understanding evidence and its relation to imaging coverage policies can help identify patterns of variation to better inform high value care initiatives. This cross-sectional study evaluates regional differences in US utilisation of cardiac coronary tomography angiography (CCTA) and compares use in the USA and England.

Design

We determined differences in CCTA order rates by US Medicare region and compared order rates in the US and England, compared CT scanner prevalence in the USA and UK, and reviewed the CCTA coverage policies for each region.

Setting

The US and the UK.

Participants

Medicare Coverage Database; Medicare 2018 Part B data; National Health Services 2018 data.

Interventions

CCTA orders, CT scanner prevalence.

Main outcome measures

CCTA orders per beneficiary, CT scanner prevalence, CCTA policy variation.

Results

We found that CCTA coverage policies are more permissive in the UK compared with the USA. However, CT scanner prevalence per beneficiary is four times greater in the USA than the UK. There was significant variation in number of CCTA ordered per 100 000 beneficiaries between regions in England and the USA, ranging from 74 to 313 in the US and 57-317 in England.

Conclusions

There is significant geographical variation in use of CCTA in both the USA and England, although overall use does not differ significantly between both countries. Similarities in order rates, despite a much higher CT scanner density in the USA, may be related to more permissive guidelines around use of CCTA in the UK. Variation in both countries may also reflect the lack of high-quality clinical outcomes data for use of CCTA, underscoring opportunities for more evidence and evidence-based policy to promote appropriate use of CCTA imaging.

Consequences of preoperative cardiac stress testing-A cohort study

OBJECTIVE

To understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery.

DESIGN

A retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018.

SETTING

A large integrated health system.

PATIENTS

Patients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery.

MEASUREMENTS

To assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality.

MAIN RESULTS

In causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1-12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8-9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9-9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75-0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1-33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses.

CONCLUSIONS

Preoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced.

Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality: A Randomized Clinical Trial

Importance

Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations.

Objective

To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits.

Design, Setting, and Participants

Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023.

Interventions

In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips.

Main outcomes and measures

The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted.

Results

There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials.

Conclusions and Relevance

In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships.

Trial Registration

ClinicalTrials.gov Identifier: NCT04902664.

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing

BACKGROUND

Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described.

OBJECTIVE

We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice.

DESIGN

Qualitative study of semi-structured telephone interviews.

PARTICIPANTS

We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate.

APPROACH

Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations.

KEY RESULTS

Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures).

CONCLUSIONS

We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

Patient, provider, and system-level factors associated with preoperative cardiac testing: A systematic review

BACKGROUND

Overuse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system-level factors associated with variation in testing have not been systematically studied.

OBJECTIVE

To conduct a systematic review to better delineate the patient, provider, and system-level factors associated with variation in preoperative cardiac testing.

METHODS

We included studies of an adult US population evaluating a patient, provider, or system-level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle-Ottawa Scale and Evidence Project Risk of Bias tool.

RESULTS

Twenty-eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher-intensity testing. The evidence for provider and system-level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low-value testing can be successful.

CONCLUSIONS

There is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well-defined. Further work should aim to better understand these factors.

Repurposing the Ordering of Routine Laboratory Tests in Hospitalised Medical Patients (RePORT): results of a cluster randomised stepped-wedge quality improvement study

BACKGROUND

Low-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients.

METHODS

We used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020-June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat.

RESULTS

We included a total of 125 854 patient-days. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=-0.14, 95% CI -0.07 to -0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention.

CONCLUSIONS

A multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results.

Who's Accountable? Low-Value Care Received By Medicare Beneficiaries Outside Of Their Attributed Health Systems

Policy makers and payers increasingly hold health systems accountable for spending and quality for their attributed beneficiaries. Low-value care-medical services that offer little or no benefit and have the potential for harm in specific clinical scenarios-received outside of these systems could threaten success on both fronts. Using national Medicare data for fee-for-service beneficiaries ages sixty-five and older and attributed to 595 US health systems, we describe where and from whom they received forty low-value services during 2017-18 and identify factors associated with out-of-system receipt. Forty-three percent of low-value services received by attributed beneficiaries originated from out-of-system clinicians: 38 percent from specialists, 4 percent from primary care physicians, and 1 percent from advanced practice clinicians. Recipients of low-value care were more likely to obtain that care out of system if age 75 or older (versus ages 65-74), male (versus female), non-Hispanic White (versus other races or ethnicities), rural dwelling (versus metropolitan dwelling), more medically complex, or experiencing lower continuity of care. However, out-of-system service receipt was not associated with recipients' health systems' accountable care organization status. Health systems might improve quality and reduce spending for their attributed beneficiaries by addressing out-of-system receipt of low-value care-for example, by improving continuity.

Low-value preoperative cardiac testing before low-risk surgical procedures: a population-based cohort study

BACKGROUND

Choosing Wisely Canada (CWC) recommends avoiding noninvasive advanced cardiac testing (e.g., exercise stress testing [EST], echocardiography and myocardial perfusion imaging [MPI]) for preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery. In this study, we assessed the temporal trends in testing, overlapping with the introduction of the CWC recommendations in 2014, and patient and provider factors associated with low-value testing.

METHODS

In this population-based retrospective cohort study, we used linked health administrative data in Alberta, Canada, to identify adult patients who underwent elective noncardiac surgery between Apr. 1, 2011, and Mar. 31, 2019, who had preoperative noninvasive advanced cardiac tests (EST, echocardiography or MPI) within 6 months before surgery. We included electrocardiography as an exploratory outcome. We excluded patients at high risk using the Revised Cardiac Risk Index (score ≥ 1 considered to indicate high risk), and modelled patient and temporal factors associated with the number of tests.

RESULTS

We identified 1 045 896 elective noncardiac operations performed in 798 599 patients and 25 599 advanced preoperative cardiac tests; 2.1% of operations were preceded by advanced cardiac testing. The incidence of testing increased over the study period, and, by 2018/19, patients were 1.3 times (95% confidence interval 1.2-1.4) more likely to receive a preoperative advanced test compared to 2011/12. Urban patients were more likely to receive a preoperative advanced cardiac test than their rural counterparts. Electrocardiography was the most common preoperative cardiac test, preceding 182 128 procedures (17.4%).

INTERPRETATION

Preoperative advanced cardiac testing was infrequent in adult Albertans who underwent low-risk elective noncardiac operations. Despite CWC recommendations, the use of some tests appears to be increasing, and there was substantial variation across geographic areas.

Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse

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.

Comparison of Low-Value Care Among Commercial and Medicaid Enrollees

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.

The role of preoperative toxicology screening in patients undergoing bariatric surgery

BACKGROUND

Some programs and insurers may require patients to undergo toxicology screening despite lack of evidence that this practice affects postoperative outcomes.

OBJECTIVES

To understand the prevalence of screening positive on toxicology testing in the bariatric surgical population and to examine the association between testing positive and important surgical outcomes.

METHODS

We performed a retrospective review of patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from an academic health system from 2017-2020. We described the rate of preoperative toxicology positivity as determined by serum and urine testing. We examined the association between toxicology positivity and outcomes of preoperative length, 30-day complications (bleeding, venous thromboembolism, leak, wound infection, pneumonia, urinary tract infection, and myocardial infarction), readmissions, and 1-year weight loss using chi-square and t-test analysis.

RESULTS

Of 1057 patients, there were 134 patients (12.7%) who had positive toxicology testing. Of these, 37 (28%) were positive for opiates and 21 (16%) were positive for cotinine. Mean preoperative length was 381.8 days (standard deviation [SD], 222.5) for patients with positive testing versus 287.8 days (SD, 151.5; P = 1.00) for negative testing. Toxicology positivity was not associated with readmissions (5.2% versus 4.3%, X² = 0.22; P = .64). The loss to follow-up at 1 year was 32.5%. There was no association with 1-year mean change in body mass index (mean of loss 12.23kg/m² [SD, 5.61]) versus mean of loss 12.74 (SD, 6.44; P = .20)].

CONCLUSIONS

Our study is the first to describe preoperative toxicology positivity rates. We found no association between toxicology positivity and preoperative length, readmissions, or weight loss. Given its lack of impact on outcomes, toxicology testing prior to bariatric surgery may be an unnecessary burden on patients and healthcare, with regard to cost and wait times.

Prevalence and Cost of Care Cascades Following Low-Value Preoperative Electrocardiogram and Chest Radiograph Within the Veterans Health Administration

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.

Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline?

PURPOSE

A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG.

METHODS

Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release.

RESULTS

Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to -0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by -23.57 per 1,000 patients (95% CI, -37.72 to -9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG.

CONCLUSIONS

The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS.

CLINICAL RELEVANCE

Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.

Alternative Payments and Physician Organizations

There are longstanding concerns about the sustainability of the US health care system. Payment reform has been seen over the last decade as a key strategy to reorienting the US health care system around value. Alternative payment models (APMs) that seek to accomplish this goal have become increasingly prevalent in the US, yet there is a perception that physicians are resistant to their use and that organizations have been slow to adopt such models. The reasons for the limited effectiveness of APM programs are multifactorial and include aspects related to the design and implementation of these programs and lack of alignment and coordination across different payers and health care sectors. Most importantly, however, is that the current organizational structures in US health care serve to dampen the direct impact of these incentives, often because health care delivery organizations face conflicting incentives themselves. Organizations filter and refine the incentives from multiple external payment contracts and develop internal incentive systems that best reflect the amalgamation of the incentives embedded across their contracts, and thus the fragmented nature of the US health care system serves to undermine efforts to transform care under value-based contracts. In addition to organizations having conflicting incentives, there also are fundamental problems with the design and implementation of APMs that hinder their acceptance among physicians and the organizations in which they work. Moreover, much remains to be learned about how organizations can best adapt to succeed under these models, and how organizational culture can be leveraged to transform care.

Extension of patient safety initiatives to perioperative care

PURPOSE OF REVIEW

Patient safety has significantly improved during the intraoperative period thanks to the anesthesiologists, surgeons, and nurses. Nowadays, it is within the perioperative period where most of the preventable harm happened to the surgical patient. We aim to highlight the main issues and efforts to improve perioperative patient safety focusing and the relation to intraoperative safety strategies.

RECENT FINDINGS

There is ongoing research on perioperative safety strategies aiming to initiate multidisciplinary interventions on early stages of the perioperative period as well as an increasing focus on preventing harm from postoperative complications.

SUMMARY

Any patient safety strategy to be implemented needs to be framed beyond the operating room and include in the intervention the whole perioperative period.

Assessment of Care Cascades Following Low-Value Prostate-Specific Antigen Testing Among Veterans Dually Enrolled in the US Veterans Health Administration and Medicare Systems

Importance

Older US veterans commonly receive health care outside of the US Veterans Health Administration (VHA) through Medicare, which may increase receipt of low-value care and subsequent care cascades.

Objective

To characterize the frequency, cost, and source of low-value prostate-specific antigen (PSA) testing and subsequent care cascades among veterans dually enrolled in the VHA and Medicare and to determine whether receiving a PSA test through the VHA vs Medicare is associated with more downstream services.

Design, Setting, and Participants

This retrospective cohort study used VHA and Medicare administrative data from fiscal years (FYs) 2017 to 2018. The study cohort consisted of male US veterans dually enrolled in the VHA and Medicare who were aged 75 years or older without a history of prostate cancer, elevated PSA, prostatectomy, radiation therapy, androgen deprivation therapy, or a urology visit. Data were analyzed from December 15, 2020, to October 20, 2022.

Exposures

Receipt of low-value PSA testing.

Main Outcomes and Measures

Differences in the use and cost of cascade services occurring 6 months after receipt of a low-value PSA test were assessed for veterans who underwent low-value PSA testing in the VHA and Medicare compared with those who did not, adjusted for patient- and facility-level covariates.

Results

This study included 300 393 male US veterans at risk of undergoing low-value PSA testing. They had a mean (SD) age of 82.6 (5.6) years, and the majority (264 411 [88.0%]) were non-Hispanic White. Of these veterans, 36 459 (12.1%) received a low-value PSA test through the VHA, which was associated with 31.2 (95% CI, 29.2 to 33.2) additional cascade services per 100 veterans and an additional $24.5 (95% CI, $20.8 to $28.1) per veteran compared with the control group. In the same cohort, 17 981 veterans (5.9%) received a PSA test through Medicare, which was associated with 39.3 (95% CI, 37.2 to 41.3) additional cascade services per 100 veterans and an additional $35.9 (95% CI, $31.7 to $40.1) per veteran compared with the control group. When compared directly, veterans who received a PSA test through Medicare experienced 9.9 (95% CI, 9.7 to 10.1) additional cascade services per 100 veterans compared with those who underwent testing within the VHA.

Conclusions and Relevance

The findings of this cohort study suggest that US veterans dually enrolled in the VHA and Medicare commonly experienced low-value PSA testing and subsequent care cascades through both systems in FYs 2017 and 2018. Care cascades occurred more frequently through Medicare compared with the VHA. These findings suggest that low-value PSA testing has substantial downstream implications for patients and may be especially challenging to measure when care occurs in multiple health care systems.

Assessing patient, physician, and practice characteristics predicting the use of low-value services

OBJECTIVE

To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices.

DATA SOURCES

This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018.

STUDY DESIGN

We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level.

DATA COLLECTION/EXTRACTION METHODS

The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites.

PRINCIPAL FINDINGS

Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level.

CONCLUSIONS

Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.

Low-Value Prostate-Specific Antigen Test for Prostate Cancer Screening and Subsequent Health Care Utilization and Spending

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.

A “Do No Harm” Novel Safety Checklist and Research Approach to Determine Whether to Launch an Artificial Intelligence Based Medical Technology – Introducing the Biological-Psychological, Economic, and Social Framework (Preprint)

Given the impact artificial intelligence (AI)-based medical technologies (hardware devices, software programs, and mobile apps) can have on society, debates regarding the principles behind their development and deployment are emerging. Using the biopsychosocial model applied in psychiatry and other fields of medicine as our foundation, we propose a novel 3-step framework to guide industry developers of AI-based medical tools as well as health care regulatory agencies on how to decide if a product should be launched-a "Go or No-Go" approach. More specifically, our novel framework places stakeholders' (patients, health care professionals, industry, and government institutions) safety at its core by asking developers to demonstrate the biological-psychological (impact on physical and mental health), economic, and social value of their AI tool before it is launched. We also introduce a novel cost-effective, time-sensitive, and safety-oriented mixed quantitative and qualitative clinical phased trial approach to help industry and government health care regulatory agencies test and deliberate on whether to launch these AI-based medical technologies. To our knowledge, our biological-psychological, economic, and social (BPES) framework and mixed method phased trial approach are the first to place the Hippocratic Oath of "Do No Harm" at the center of developers', implementers', regulators', and users' mindsets when determining whether an AI-based medical technology is safe to launch. Moreover, as the welfare of AI users and developers becomes a greater concern, our framework's novel safety feature will allow it to complement existing and future AI reporting guidelines.

Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis

BACKGROUND

Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.

QUESTIONS/PURPOSES

(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?

METHODS

In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.

RESULTS

When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.

CONCLUSION

Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing

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.

Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis

INTRODUCTION

Overuse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system inefficiencies and costs. We seek to systematically review the evidence for overuse of different cardiovascular healthcare services in high-income countries.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2010 onwards. Two investigators will independently review titles and abstracts and full-text studies. We will include published English-language studies conducted in high-income countries that enrolled adults (mean/median age ≥18 years) and reported the incidence or prevalence of overuse of cardiovascular tests, medications or procedures; adjusted risk factors for overuse; or adjusted associations between overuse and outcomes (reported estimates of morbidity, mortality, costs or lengths of hospital stay). Acceptable methods of defining low-value care will include literature review and multidisciplinary iterative panel processes, healthcare services with reproducible evidence of a lack of benefit or harm, or clinical practice guideline or Choosing Wisely recommendations. Two investigators will independently extract data and evaluate study risk of bias in duplicate. We will calculate summary estimates of the incidence and prevalence of overuse of different cardiovascular healthcare services across studies unstratified and stratified by country; method of defining low-value care; the percentage of included females, different races, and those with low and high socioeconomic status or cardiovascular risk; and study risks of bias using random-effects models. We will also calculate pooled estimates of adjusted risk factors for overuse and adjusted associations between overuse and outcomes overall and stratified by country using random-effects models. We will use the Grading of Recommendations, Assessment, Development and Evaluation to determine certainty in estimates.

ETHICS AND DISSEMINATION

No ethics approval is required for this study as it deals with published data. Results will be presented at meetings and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021257490.

Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care

In recent years, the Choosing Wisely and Less is More campaigns have gained growing attention in the medical scientific community. Several projects have been launched to facilitate confrontation among patients and physicians, to achieve better and harmless patient-centered care. Such initiatives have paved the way to a new "way of thinking." Embracing such a philosophy goes through a cognitive process that takes into account several issues. Medicine is a highly inaccurate science and physicians should deal with uncertainty. Evidence from the literature should not be accepted as it is but rather be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics. A wise choice requires active effort into minimizing the chance that potential biases may affect our clinical decisions. Potential harms and all consequences (both direct and indirect) of prescribing tests, procedures, or medications should be carefully evaluated, as well as patients' needs and preferences. Through such a cognitive process, a patient management shift is needed, moving from being centered on establishing a diagnosis towards finding the best management strategy for the right patient at the right time. Finally, while "thinking wisely," physicians should also "act wisely," being among the leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.

Downstream Mammary and Extramammary Cascade Services and Spending Following Screening Breast Magnetic Resonance Imaging vs Mammography Among Commercially Insured Women

Importance

Increasing use of screening breast magnetic resonance imaging (MRI), including among women at low or average risk of breast cancer, raises concerns about resulting mammary and extramammary cascades (downstream services and new diagnoses) of uncertain value.

Objective

To estimate rates of cascade events (ie, laboratory tests, imaging tests, procedures, visits, hospitalizations, and new diagnoses) and associated spending following screening breast MRI vs mammography among commercially insured US women.

Design, Setting, and Participants

This cohort study used 2016 to 2018 data from the MarketScan research database (IBM Corporation), which includes claims and administrative data from large US employers and commercial payers. Participants included commercially insured women aged 40 to 64 years without prior breast cancer who received an index bilateral screening breast MRI or mammogram between January 1, 2017, and June 30, 2018. We used propensity scores based on sociodemographic, clinical, and utilization variables to match MRI recipients to mammogram recipients in each month of index service use. Data were analyzed from October 8, 2020, to October 28, 2021.

Exposures

Breast MRI vs mammography.

Main Outcomes and Measures

Mammary and extramammary cascade event rates and associated total and patient out-of-pocket spending in the 6 months following the index test.

Results

In this study, 9208 women receiving breast MRI were matched with 9208 women receiving mammography (mean [SD] age, 51.4 [6.7] years). Compared with mammogram recipients, breast MRI recipients had 39.0 additional mammary cascade events per 100 women (95% CI, 33.7-44.2), including 5.0 additional imaging tests (95% CI, 3.8-6.2), 17.3 additional procedures (95% CI, 15.5-19.0), 13.0 additional visits (95% CI, 9.4-17.2), 0.34 additional hospitalizations (95% CI, 0.18-0.50), and 3.0 additional new diagnoses (95% CI, 2.5-3.6). For extramammary cascades, breast MRI recipients had 19.6 additional events per 100 women (95% CI, 8.6-30.7) including 15.8 additional visits (95% CI, 10.2-21.4) and no statistically significant differences in other events. Breast MRI recipients had higher total spending for mammary events ($564 more per woman; 95% CI, $532-$596), extramammary events ($42 more per woman; 95% CI, $16-$69), and overall ($1404 more per woman; 95% CI, $1172-$1636). They also had higher overall out-of-pocket spending ($31 more per woman; 95% CI, $6-$55).

Conclusions and Relevance

In this cohort study of commercially insured women, breast MRI was associated with more mammary and extramammary cascade events and spending relative to mammography. These findings can inform cost-benefit assessments and coverage policies to ensure breast MRI is reserved for patients for whom benefits outweigh harms.

Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication

BACKGROUND

Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise.

METHODS

Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention.

RESULTS

Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse.

CONCLUSION

Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.

Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association

Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.

Longitudinal Content Analysis of the Characteristics and Expected Impact of Low-Value Services Identified in US Choosing Wisely Recommendations

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.

Evaluation of choosing wisely recommendations on preprocedural cardiovascular testing

Study objective

The Choosing Wisely (CW) initiative currently has multiple recommendations focused on avoiding preprocedural testing in asymptomatic patients prior to low-risk surgery. The purpose of this study was to measure the potential impact of the CW recommendations as they relate to preprocedural testing prior to cataract surgery.

Design

Retrospective cohort study.

Setting

Single academic medical center.

Participants

Patients undergoing cataract surgery from 01/02/2018 to 12/31/2018.

Interventions

N/A.

Main outcome measures

Prevalence of preprocedural testing in elevated versus low cardiac risk patients as defined by the Revised Cardiac Risk Index (RCRI).

Results

Of a total 909 patients, 90 (9.9%) had some form of preprocedural testing ordered; testing was more common among elevated risk (n = 50/315, 15.9%) compared to low-risk patients (n = 40/594, 6.7%; p < 0.0001). Of the tests ordered, 9 were abnormal (4 in the low-risk cohort, 5 in the elevated risk cohort). ECGs were the vast majority of tests ordered (n = 88/90). No stress test orders or periprocedural adverse cardiovascular (CV) events were observed. Anesthesiology clinicians ordered 95.6% of preprocedural testing. "Routine" was the justification given for the substantial majority of tests ordered in both cohorts (90% low-risk, 86% elevated risk).

Conclusion

Our investigation confirms that cataract surgery has exceptionally low rates of postprocedural CV events. In contemporary practice, preprocedural CV testing for cataract surgery is not highly prevalent, rarely abnormal, and also not well justified by ordering clinicians. Our results may be considered as justification for revisions of some CW recommendations to potentially target higher prevalence areas of low-value care.

[Diagnostic error and overdiagnosis in Primary Care. Proposals for the improvement of clinical practice family medicine]

Family doctors see a wide range of patients, with a wide range of complexity, in a short time and with few diagnostic resources. This situation makes primary care professionals more vulnerable to diagnostic errors. For this reason, an adequate clinical reasoning process is the most powerful tool family doctors have to safely guide the patient care process. Considering these errors as missed opportunities for a correct diagnosis, which may cause harm to the patient, leads us as professionals to review how to improve this process. The review includes, among other aspects, identifying cognitive biases, analysing the ways in which work is organised in primary care teams, and situations in the care context that may contribute to such errors. In this article we describe the most frequent diagnostic errors and their causal factors in primary care, the impact of cognitive process failures, situations of overdiagnosis and the diagnostic and therapeutic cascades associated with them. Finally, we propose a set of tools to improve decision-making in the diagnostic process in primary care.

Changing patterns of use of implantable cardiac monitors from 2011 to 2018 for a large commercially-insured U.S. population

Implantable cardiac monitors (ICMs) provide long-term electrocardiographic monitoring for a number of indications. However, frequencies of use by indication and temporal changes have not been characterized on a national scale. We sought to characterize overall use and changes between 2011 and 2018. We used generalized linear models to characterize the incidence rate per 1,000,000 patient-quarters at risk and an autoregressive integrated moving average model to account for autocorrelation in this time series data. We studied commercially-insured patients and their insured dependents in the IBM MarketScan Commercial Database who had an ICM placed. We described the characteristics of individuals who received ICMs and the frequency of placements into 3 guideline concordance groups. We estimated the mean change per quarter in ICM placements (mean quarterly change in incidence rate per 1,000,000 patient-quarters at risk) for quarter (Q)1 2011 through Q1 2014, Q1 2014 to Q2 2014, and Q2 2014 through Q4 2018 for each guideline concordance group. The most common indications for categorizable ICM placement were syncope (24%), atrial fibrillation (11%), and stroke (11%). For each of the 3 guideline concordance groups except guideline unaddressed inpatient ICM placements, there was a significant increase in use either during the Q1 2014 to Q2 2014 or the Q2 2014 through Q4 2018 periods. A significant portion of ICM placements were for indications that lack strong evidence, such as established atrial fibrillation. The incidence of ICM placement for most of the indications and settings increased after miniaturization and technical improvements.

The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016

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.

Low-Value Care at the Actionable Level of Individual Health Systems

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.