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Matsuo M, Takemura Y, Yamazaki M. Limited Utility of Routine Tests Prior to Ophthalmologic Surgery: An Observational Study in a Japanese Hospital. JMA J 2021; 4:270-276. [PMID: 34414322 PMCID: PMC8355728 DOI: 10.31662/jmaj.2020-0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/17/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Routine preoperative testing for low-risk surgeries without a clinical indication should be avoided; however, such tests are still frequently performed in Japan. This study was performed to assess the impact of routine preoperative tests in low-risk surgery in a Japanese medical setting. Methods: We performed a retrospective chart review to examine the utility of routine tests with respect to anesthetic management and postoperative complications in all patients aged ≥ 18 years whom ophthalmologists consulted with anesthesiologists before ophthalmologic surgery under general anesthesia. Results: During the 10-year study period, 1,234 anesthetic consultations and 1,211 routine preoperative tests (laboratory tests, chest X-rays, and electrocardiograms) were performed in Toyama University Hospital. In total, 59 patients (4.8% of the study population) canceled surgery after a battery of preoperative evaluation. Among them, 10 patients had incidental abnormalities that necessitated additional tests, and only three patients (0.2%) canceled surgery. In-hospital postoperative complications developed in nine patients (0.7%) whose routine test results made it difficult to predict development of these adverse events. No severe life-threatening events were noted in this survey. Conclusions: Routine tests prior to eye surgery for adults were of low value for perioperative management and prediction of development of in-hospital complications in this Japanese medical setting. Anesthesiologists and ophthalmologists should selectively order preoperative tests based on the medical interview and physical examination.
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Affiliation(s)
- Mitsuhiro Matsuo
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yoshinori Takemura
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Mitsuaki Yamazaki
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, Toyama, Japan
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Schwartz AL, Brennan TA, Verbrugge DJ, Newhouse JP. Measuring the Scope of Prior Authorization Policies. JAMA HEALTH FORUM 2021; 2:e210859. [PMID: 35977311 PMCID: PMC8796979 DOI: 10.1001/jamahealthforum.2021.0859] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/09/2021] [Indexed: 12/01/2022] Open
Abstract
Question How common and expensive are medical services that can require prior authorization? Findings This cross-sectional study examined medical services paid for by government-administered Medicare Part B, which lacks prior authorization requirements, for approximately 6.5 million beneficiaries; 2.2 services per beneficiary per year would have been subject to prior authorization under the coverage rules of a large Medicare Advantage insurer, and these services accounted for 25% of annual Part B spending. Meaning In Medicare, the scope of prior authorization policies differs considerably between government-administered insurance and privately administered insurance. Importance Health insurers use prior authorization to evaluate the medical necessity of planned medical services. Data challenges have precluded measuring the frequency with which medical services can require prior authorization, the spending on these services, the types of services and clinician specialties affected, and differences in the scope of prior authorization policies between government-administered and privately administered insurance. Objectives To measure the extent of prior authorization requirements for medical services and to describe the services and clinician specialties affected by them using novel data on private insurer coverage policies. Design, Setting, and Participants Fee-for-service Medicare claims from 2017 were analyzed for beneficiaries in Medicare Part B, which lacks prior authorization. We measured the use of services that would have been subject to prior authorization according to the coverage rules of a large Medicare Advantage insurer and calculated the associated spending. We report the rates of these services for 14 clinical categories and 27 clinician specialties. Main Outcomes and Measures Annual count per beneficiary and associated spending for 1151 services requiring prior authorization by the Medicare Advantage insurer; likelihood of providing 1 or more such service per year, by clinician specialty. Results Of 6 497 534 beneficiaries (mean [SD] age, 72.1 [12.1] years), 41% received at least 1 service per year that would have been subject to prior authorization under Medicare Advantage prior authorization requirements. The mean (SD) number of services per beneficiary per year was 2.2 (8.9) (95% CI, 2.17-2.18), corresponding to a mean (SD) of $1661 ($8900) in spending per beneficiary per year (95% CI, $1654-$1668), or 25% of total annual Part B spending. Part B drugs constituted 58% of the associated spending, mostly accounted for by hematology or oncology drugs. Radiology was the largest source of nondrug spending (16%), followed by musculoskeletal services (9%). Physician specialties varied widely in rates of services that required prior authorization, with highest rates among radiation oncologists (97%), cardiologists (93%), and radiologists (91%) and lowest rates among pathologists (2%) and psychiatrists (4%). Conclusions and Relevance In this cross-sectional study, a large portion of fee-for-service Medicare Part B spending would have been subject to prior authorization under private insurance coverage policies. Prior authorization requirements for Part B drugs have been an important source of difference in coverage policy between government-administered and privately administered Medicare.
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Affiliation(s)
- Aaron L. Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | | | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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Mudumbai SC, Pershing S, Bowe T, Kamal RN, Sears ED, Hawn MT, Eisenberg D, Finlay AK, Hagedorn H, Harris AHS. Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration. JAMA Netw Open 2021; 4:e217470. [PMID: 33956131 PMCID: PMC8103225 DOI: 10.1001/jamanetworkopen.2021.7470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. OBJECTIVE To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. EXPOSURES A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. MAIN OUTCOMES AND MEASURES Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). RESULTS A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. CONCLUSIONS AND RELEVANCE Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.
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Affiliation(s)
- Seshadri C. Mudumbai
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California
| | - Suzann Pershing
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Department of Ophthalmology, Byers Eye Institute at Stanford, Stanford University School of Medicine, Stanford, California
| | - Tom Bowe
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
| | - Robin N. Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Erika D. Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Surgery, Michigan Medicine, Ann Arbor
| | - Mary T. Hawn
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Stanford–Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Dan Eisenberg
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Stanford–Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Andrea K. Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
| | - Hildi Hagedorn
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Alex H. S. Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
- Stanford–Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Ganguli I, Cui J, Thakore N, Orav EJ, Januzzi JL, Baugh CW, Sequist TD, Wasfy JH. Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation. J Am Coll Cardiol 2021; 77:3171-3179. [PMID: 34167642 DOI: 10.1016/j.jacc.2021.04.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value. OBJECTIVES This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events. METHODS Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services. RESULTS Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending. CONCLUSIONS Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Jinghan Cui
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - James L Januzzi
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher W Baugh
- Harvard Medical School, Boston, Massachusetts, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. https://twitter.com/DrChrisBaugh
| | - Thomas D Sequist
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Mass General Brigham, Boston, Massachusetts, USA. https://twitter.com/TomSequist
| | - Jason H Wasfy
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Park S, Jung J, Burke RE, Larson EB. Trends in Use of Low-Value Care in Traditional Fee-for-Service Medicare and Medicare Advantage. JAMA Netw Open 2021; 4:e211762. [PMID: 33729504 PMCID: PMC7970337 DOI: 10.1001/jamanetworkopen.2021.1762] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Decreasing use of low-value care is a major goal for Medicare given the potential to decrease costs and harms. Compared with traditional fee-for-service Medicare (TM), Medicare Advantage (MA) is more strongly financially incentivized to decrease use of low-value care. OBJECTIVES To compare use of low-value care among individuals enrolled in TM and those enrolled in MA overall and to examine trends in use of low-value care in both programs from 2006 to 2015. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed individuals enrolled in TM and MA using data from the 2006 to 2015 Medical Expenditure Panel Survey. To account for differences in characteristics between individuals enrolled in TM and those enrolled in MA, a propensity score-based approach was used. Data were analyzed from August 2020 through January 2021. EXPOSURES Being enrolled in MA or TM. MAIN OUTCOMES AND MEASURES Binary measures of use were collected for 13 low-value services in 4 categories (ie, [1] cancer screening: cervical, colorectal, and prostate cancer screening in older adults; [2] antibiotic use: antibiotic for acute upper respiratory infection and antibiotic for influenza; [3] medication: anxiolytic, sedative, or hypnotic in an adult older than 65 years; benzodiazepine for depression; opioid for headache; opioid for back pain; and nonsteroidal anti-inflammatory drug [NSAID] for hypertension, heart failure, or chronic kidney disease; and [4] imaging: magnetic resonance imaging [MRI] or computed tomography [CT] for back pain, radiograph for back pain, and MRI or CT for headache) and 4 low-value composites corresponding to the categories (ie, cancer screening composite, antibiotic use composite, medication composite, and imaging composite). RESULTS Among 11 677 individuals enrolled in TM and 5164 individuals enrolled in MA, 9429 (56.0%) were women and the mean (SD) age was 74.5 (6.3) years. Of 13 low-value services and 4 low-value composites, statistically significant differences were found in 2 measures. For the low-value medication composite, 2054 of 11 636 eligible individuals enrolled in TM (adjusted mean, 17.6%; 95% CI, 16.8%-18.3%) received the care, and 981 of 5141 eligible individuals enrolled in MA (adjusted mean, 19.7%; 95% CI, 18.3%-21.2%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.2 percentage points (95% CI, 0.5-3.8 percentage points; P = .02). For the NSAID use for hypertension, heart failure, or kidney disease metric, 807 of 7832 individuals enrolled in TM (adjusted mean, 10.0%; 95% CI, 9.2%-10.8%) received the care, and 447 of 3566 individuals enrolled in MA (adjusted mean, 12.9%; 95% CI, 19.7%-27.1%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.9 percentage points (95% CI, 1.3-4.6 percentage points; P = .001). Overall, there were no decreases in use of low-value care in TM or MA over time. CONCLUSIONS AND RELEVANCE This cross-sectional study found that use of low-value care was similarly prevalent in MA and TM, suggesting that MA enrollment was not associated with decreased provision of low-value care compared with TM.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, Pennsylvania State University, University Park
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle
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King BC, Richardson T, Patel RM, Lee HC, Bamat NA, Hall M, Slaughter JL. Prioritization framework for improving the value of care for very low birth weight and very preterm infants. J Perinatol 2021; 41:2463-2473. [PMID: 34075201 PMCID: PMC8514333 DOI: 10.1038/s41372-021-01114-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Create a prioritization framework for value-based improvement in neonatal care. STUDY DESIGN A retrospective cohort study of very low birth weight (<1500 g) and/or very preterm (<32 weeks) infants discharged between 2012 and 2019 using the Pediatric Health Information System Database. Resource use was compared across hospitals and adjusted for patient-level differences. A prioritization score was created combining cost, patient exposure, and inter-hospital variability to rank resource categories. RESULTS Resource categories with the greatest cost, patient exposure, and inter-hospital variability were parenteral nutrition, hematology (lab testing), and anticoagulation (for central venous access and therapy), respectively. Based on our prioritization score, parenteral nutrition was identified as the highest priority overall. CONCLUSIONS We report the development of a prioritization score for potential value-based improvement in neonatal care. Our findings suggest that parenteral nutrition, central venous access, and high-volume laboratory and imaging modalities should be priorities for future comparative effectiveness and quality improvement efforts.
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Affiliation(s)
- Brian C. King
- grid.416975.80000 0001 2200 2638Department of Pediatrics, Section of Neonatology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Troy Richardson
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Ravi M. Patel
- grid.189967.80000 0001 0941 6502Division of Neonatology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Henry C. Lee
- grid.168010.e0000000419368956Division of Neonatology, Stanford University, Stanford, CA USA
| | - Nicolas A. Bamat
- grid.239552.a0000 0001 0680 8770Division of Neonatology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Matthew Hall
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Jonathan L. Slaughter
- grid.240344.50000 0004 0392 3476Division of Neonatology, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH USA
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Ganguli I, Lupo C, Mainor AJ, Wang Q, Orav EJ, Rosenthal MB, Sequist TD, Colla CH. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit. JAMA Netw Open 2020; 3:e2029891. [PMID: 33306120 PMCID: PMC7733154 DOI: 10.1001/jamanetworkopen.2020.29891] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. OBJECTIVE To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. EXPOSURE Receipt of a given test within 1 week before or after the AWV. MAIN OUTCOMES AND MEASURES Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. RESULTS Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. CONCLUSIONS AND RELEVANCE In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Chou SC, Hong AS, Weiner SG, Wharam JF. High-deductible health plans and low-value imaging in the emergency department. Health Serv Res 2020; 56:709-720. [PMID: 33025604 DOI: 10.1111/1475-6773.13569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine the effect of an employer-mandated switch to high-deductible health plans (HDHP) on emergency department (ED) low-value imaging. DATA SOURCES Claims data of a large national insurer between 2003 and 2014. STUDY DESIGN Difference-in-differences analysis with matched control groups. DATA COLLECTION/EXTRACTION METHODS The primary outcome is low-value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19-63 years whose employers offered only low-deductible (≤$500) plans for one (baseline) year and, in the next (follow-up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low-deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit-level probability of low-value imaging using multivariable logistic regression with member-clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation. PRINCIPAL FINDINGS After matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit-level analyses, there were no significant differential changes in the probability of low-value imaging use in the HDHP and control groups. In population-level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI - 10.3, -1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI -9.6, -0.6) in the subset of ED visits with low-value imaging. CONCLUSION Though HDHP switches decreased ED utilization, they had no significant effect on low-value imaging use after patients have decided to seek ED care.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Arthur S Hong
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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Anderson TS, Leonard S, Zhang AJ, Madden E, Mowery D, Chapman WW, Keyhani S. Trends in Low-Value Carotid Imaging in the Veterans Health Administration From 2007 to 2016. JAMA Netw Open 2020; 3:e2015250. [PMID: 32886120 PMCID: PMC7489844 DOI: 10.1001/jamanetworkopen.2020.15250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE As part of the Choosing Wisely campaign, primary care, surgery, and neurology societies have identified carotid imaging ordered for screening, preoperative evaluation, and syncope as frequently low value. OBJECTIVE To determine the changes in overall and indication-specific rates of carotid imaging following Choosing Wisely recommendations. DESIGN, SETTING, AND PARTICIPANTS This serial cross-sectional study compared annual rates of carotid imaging before Choosing Wisely recommendations (ie, 2007 to 2012) and after (ie, 2013 to 2016) among adults receiving care in the Veterans Health Administration (VHA) national health system. Data analysis was performed from April 10, 2019, to November 27, 2019. EXPOSURES Release of the Choosing Wisely recommendations. MAIN OUTCOMES AND MEASURES Annual rates of overall imaging, imaging ordered for stroke workup, imaging ordered for low-value indications (ie, screening owing to carotid bruit, preoperative evaluation, and syncope). Indications were identified using a text lexicon algorithm based on electronic health record review of a stratified random sample of 1000 free-text imaging orders. The subsequent performance of carotid procedures within 6 months after carotid imaging was assessed. RESULTS Between 2007 and 2016, 809 071 carotid imaging examinations were identified (mean [SD] age of patients undergoing imaging, 69 [10] years; 776 632 [96%] men), of which 201 467 images (24.9%) were ordered for low-value indications (67 064 [8.2%] for carotid bruit, 25 032 [3.1%] for preoperative evaluation, and 109 400 [13.5%] for syncope), 257 369 (31.8%) for stroke workup, and 350 235 (43.3%) for other indications. Imaging for carotid bruits declined across the study period while there was no significant change in imaging for syncope or preoperative evaluation. Compared with the 6 years before, during the 4 years following Choosing Wisely recommendations, there was no change in the trend for syncope, a small decline in preoperative imaging (post-Choosing Wisely trend, -0.1 [95% CI, -0.1 to <-0.1] images per 10 000 veterans), and a continued but less steep decline in imaging for carotid bruits (post-Choosing Wisely trend, -0.3 [95% CI, -0.3 to -0.2] images per 10 000 veterans). During the study period, 17 689 carotid procedures were identified, of which 3232 (18.3%) were preceded by carotid imaging ordered for low-value indications. CONCLUSIONS AND RELEVANCE These findings suggest that Choosing Wisely recommendations were not associated with a meaningful change in low-value carotid imaging in a national integrated health system. To reduce low-value testing and utilization cascades, interventions targeting ordering clinicians are needed to augment the impact of public awareness campaigns.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samuel Leonard
- Northern California Institute of Research and Education, San Francisco
| | - Alysandra J. Zhang
- Northern California Institute of Research and Education, San Francisco
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, New York
| | - Erin Madden
- Northern California Institute of Research and Education, San Francisco
| | - Danielle Mowery
- Department of Bioinformatics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | | | - Salomeh Keyhani
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Bouck Z, Calzavara AJ, Ivers NM, Kerr EA, Chu C, Ferguson J, Martin D, Tepper J, Austin PC, Cram P, Levinson W, Bhatia RS. Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA Intern Med 2020; 180:973-983. [PMID: 32511668 PMCID: PMC7281357 DOI: 10.1001/jamainternmed.2020.1611] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE The association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date. OBJECTIVE To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE). DESIGN, SETTING, AND PARTICIPANTS This population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019. EXPOSURES Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE. MAIN OUTCOMES AND MEASURES Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested). RESULTS Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score-matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age, 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively. CONCLUSIONS AND RELEVANCE Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.
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Affiliation(s)
- Zachary Bouck
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Noah M Ivers
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eve A Kerr
- VA Center for Clinical Management Research, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor.,Michigan Program on Value Enhancement, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - Cherry Chu
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Jacob Ferguson
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Joshua Tepper
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine and Geriatrics at Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Anderson TS, Lin GA. Testing Cascades-A Call to Move From Descriptive Research to Deimplementation Science. JAMA Intern Med 2020; 180:984-985. [PMID: 32511685 DOI: 10.1001/jamainternmed.2020.1588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Grace A Lin
- Division of General Internal Medicine, University of California, San Francisco.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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Choosing Daily Labs Wisely in the Hospital: A Novel Tool for Assessing Laboratory Testing Appropriateness. Qual Manag Health Care 2020; 29:169-172. [PMID: 32590493 DOI: 10.1097/qmh.0000000000000258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Minnesota Lab Appropriateness (MLAB) criteria were developed for assessing appropriateness of complete blood counts (CBCs) and serum electrolyte panels (SEPs) ordered for adult inpatients. METHODS Two independent raters used the MLAB criteria to rate appropriateness of labs ordered during 50 hospitalizations through retrospective medical record review. RESULTS Evaluation of 208 CBCs and 253 SEPs on a 2-category scale (appropriate/inappropriate) resulted in an inappropriate lab rate of 24% and 25% for CBCs and SEPs, respectively. Using a 3-category Likert scale that included an "equivocal" rating to allow for clinical uncertainty, 17% of CBCs and 20% of SEPs were considered inappropriate. Interrater reliability was "substantial" using the dichotomous scale for both CBCs and SEPs. Using the 3-category Likert scale, reliability was "substantial" for CBCs and "moderate" for SEPs. CONCLUSION The MLAB criteria identified inappropriate labs at a rate consistent with published figures, with good interrater reliability.
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63
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The prevalence of preoperative medical testing and consultation in cataract surgery patients at a teaching hospital. J Cataract Refract Surg 2020; 46:827-830. [PMID: 32347690 DOI: 10.1097/j.jcrs.0000000000000153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the prevalence of preoperative cataract surgery testing and consultation at a single United States teaching hospital. SETTING Academic-affiliated Veterans Affairs Medical Center. DESIGN Retrospective chart review. METHODS This study included patients who received cataract surgery from 2014 to 2018. For patients with bilateral cataracts, the second surgery was excluded to ensure independent selection. Charlson Comorbidity Index (CCI) scores and heart disease status were recorded. The outcomes of interest were preoperative testing, such as complete blood count, chemistry panel, and echocardiography, and consultation (office visits to non-ophthalmologists) during the period between the date the decision was made to proceed with surgery and the cataract surgery date. RESULTS For this study 1320 charts were reviewed; 1257 (95.2%) patients met the study criteria. The mean CCI score was 1.7; 42.0% (528/1257) had heart disease. The prevalence of preoperative testing was 0.08% (1/1257). The prevalence of preoperative consultation was 4.2% (53/1257); 86.8% (46/53) of patients received cardiology consultation; 17.0% (9/53) pulmonology; and 15.1% (8/53) primary care. Of the patients who received cardiac consultation, 63.0% (29/46) had heart disease; the remaining had an electrocardiogram abnormality. CONCLUSIONS There was a low prevalence of preoperative testing and consultation for cataract surgery at this teaching hospital. Further studies using medical record data are needed to assess the current rates and the role of preoperative testing and consultation for cataract surgery patients.
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Gérvas J, Oliver LL, Pérez-Fernandez M. Family and Community Medicine and its role in preventing health overuse (preventive, diagnostic, therapeutic and rehabilitative). CIENCIA & SAUDE COLETIVA 2019; 25:1233-1240. [PMID: 32267426 DOI: 10.1590/1413-81232020254.30082019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/23/2019] [Indexed: 11/22/2022] Open
Abstract
In Medicine, it is critical "to offer 100% of what is needed and avoid 100% of what is not needed." Unfortunately, this primary issue is challenging, and generally, more than required is offered, and everything that is unnecessary is not avoided. This is a nonsystematic review with a teaching objective that reviews the general issue in primary care and suggests ways to avoid overuse and shortcomings concerning preventive, diagnostic, therapeutic, and rehabilitative interventions. Knowing not to do is science and art that is hardly taught and practiced less. The overuse that harm are an almost daily part of clinical practice in prevention, diagnosis, treatment, and rehabilitation. It is essential to promote "the art and science of not doing".
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Affiliation(s)
- Juan Gérvas
- Equipo CESCA. Pradillo 68.28002 Madrid España.
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65
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Segal JB, Varadhan R. If we recognize heterogeneity of treatment effect can we lessen waste? J Comp Eff Res 2019; 8:1143-1145. [PMID: 31571494 DOI: 10.2217/cer-2019-0118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Jodi B Segal
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, MD, USA
| | - Ravi Varadhan
- Department of Oncology, Division of Oncology Biostatistics, Johns Hopkins University School of Medicine, MD, USA
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Ganguli I, Simpkin AL, Lupo C, Weissman A, Mainor AJ, Orav EJ, Rosenthal MB, Colla CH, Sequist TD. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open 2019; 2:e1913325. [PMID: 31617925 PMCID: PMC6806665 DOI: 10.1001/jamanetworkopen.2019.13325] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. OBJECTIVE To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. DESIGN, SETTING, AND PARTICIPANTS Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. MAIN OUTCOMES AND MEASURES Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. RESULTS This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. CONCLUSIONS AND RELEVANCE The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Arabella L. Simpkin
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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