1
|
Schwartz AL, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Radomski TR, Thorpe CT. Variation in Low-Value Service Use Across Veterans Affairs Facilities. J Gen Intern Med 2023; 38:2245-2253. [PMID: 36964425 PMCID: PMC10406760 DOI: 10.1007/s11606-023-08157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/10/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA). OBJECTIVE To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use. DESIGN In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics. PARTICIPANTS 5,242,301 patients across 139 VA facilities. MAIN MEASURES Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery. KEY RESULTS The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics. CONCLUSIONS Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.
Collapse
Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Charlotte, NC, USA
| |
Collapse
|
2
|
Appaneal HJ, Caffrey AR, Lopes VV, Mor V, Dosa DM, LaPlante KL, Shireman TI. Predictors of potentially suboptimal treatment of urinary tract infections in long-term care facilities. J Hosp Infect 2021; 110:114-121. [PMID: 33549769 DOI: 10.1016/j.jhin.2021.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted. AIM To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation across facilities. METHODS This was a retrospective cohort study of 21,938 residents in 120 VA LTCFs (2013-2018) known as Community Living Centers (CLCs). Potentially suboptimal treatment was assessed from drug choice, dose frequency, and/or treatment duration. To identify facility characteristics predictive of suboptimal UTI treatment, LTCFs with higher and lower rates of suboptimal treatment (≥median, < median) were compared using unconditional logistic regression models. Joinpoint regression models were used to quantify average percentage difference across facilities. Multilevel logistic regression models were used to quantify variation across facilities. FINDINGS The rate of potentially suboptimal antibiotic treatment varied from 1.7 to 34.2 per 10,000 bed-days across LTCFs. The average percentage difference in rates across facilities was 2.5% (95% confidence interval (CI): 2.4-2.7). The only facility characteristic predictive of suboptimal treatment was the incident rate of UTI per 10,000 bed-days (odds ratio: 4.9; 95% CI: 2.3-10.3). Multilevel models demonstrated that 94% of the variation between facilities was unexplained after controlling for resident and CLC characteristics. The median odds ratio for the full multilevel model was 1.37. CONCLUSION Potentially suboptimal UTI treatment was variable across VA LTCFs. However, most of the variation across LTCFs was unexplained. Future research should continue to investigate factors that are driving suboptimal antibiotic treatment in LTCFs.
Collapse
Affiliation(s)
- H J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - A R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - V V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - V Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - D M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - K L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI, USA
| | - T I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
3
|
Appaneal HJ, Caffrey AR, Lopes VV, Dosa DM, Shireman TI, LaPlante KL. Frequency and Predictors of Suboptimal Prescribing Among a Cohort of Older Male Residents with Urinary Tract Infection. Clin Infect Dis 2020; 73:e2763-e2772. [PMID: 32590839 DOI: 10.1093/cid/ciaa874] [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] [Received: 03/10/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Unnecessary antibiotic treatment of suspected urinary tract infection (UTI) is common in long-term care facilities (LTCFs). However, less is known about the extent of suboptimal treatment, in terms of antibiotic choice, dose, and duration, after the decision to use antibiotics has been made. METHODS We described the frequency of potentially suboptimal treatment among residents with an incident UTI (first during the study with none in the year prior) in Veterans Affairs' (VA) Community Living Centers (CLCs, 2013-2018). Time trends were analyzed using Joinpoint regression. Residents with UTIs receiving potentially suboptimal treatment were compared to those receiving optimal treatment to identify resident characteristics predictive of suboptimal antibiotic treatment, using multivariable unconditional logistic regression models. RESULTS We identified 21,938 residents with an incident UTI treated in 120 VA CLCs, of which 96.0% were male. Potentially suboptimal antibiotic treatment was identified in 65.0% of residents and decreased 1.8% annually (p<0.05). Potentially suboptimal initial drug choice was identified in 45.6% of residents, suboptimal dose frequency in 28.6%, and longer than recommended duration in 12.7%. Predictors of suboptimal antibiotic treatment included: prior fluoroquinolone exposure (adjusted odds ratio [aOR] 1.38), chronic renal disease (aOR 1.19), age >85 years (aOR 1.17), prior skin infection (aOR 1.14), recent high white blood cell count (aOR 1.08), and genitourinary disorder (aOR 1.08). CONCLUSION Similar to findings in non-VA facilities, potentially suboptimal treatment was common but improving in CLC residents with an incident UTI. Predictors of suboptimal antibiotic treatment should be targeted with antibiotic stewardship interventions to improve UTI treatment.
Collapse
Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI
| |
Collapse
|
4
|
Patel A, Pfoh ER, Misra Hebert AD, Chaitoff A, Shapiro A, Gupta N, Rothberg MB. Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study. J Gen Intern Med 2020; 35:1182-1188. [PMID: 31630364 PMCID: PMC7174444 DOI: 10.1007/s11606-019-05433-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/23/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
IMPORTANCE Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors. OBJECTIVE To identify factors associated with high and low prescriber status for management of URTIs in primary care practice. DESIGN AND PARTICIPANTS Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated. MAIN MEASURES Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted. RESULTS Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status. CONCLUSIONS AND RELEVANCE Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.
Collapse
Affiliation(s)
- Aditi Patel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth R Pfoh
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Anita D Misra Hebert
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.,Quantitative Health Services, Cleveland, OH, USA
| | - Alexander Chaitoff
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Aryeh Shapiro
- University Hospitals Portage Medical Center, Ravenna, OH, USA
| | - Niyati Gupta
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Michael B Rothberg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA. .,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
5
|
National trends in the treatment of urinary tract infections among Veterans' Affairs Community Living Center residents. Infect Control Hosp Epidemiol 2019; 40:1087-1093. [PMID: 31354115 DOI: 10.1017/ice.2019.204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe urinary tract infection (UTI) treatment among Veterans' Affairs (VA) Community Living Centers (CLCs) nationally and to assess related trends in antibiotic use. DESIGN Descriptive study. SETTING AND PARTICIPANTS All UTI episodes treated from 2013 through 2017 among residents in 110 VA CLCs. UTI episodes required collection of a urine culture, antibiotic treatment, and a UTI diagnosis code. UTI episodes were stratified into culture-positive and culture-negative episodes. METHODS Frequency and rate of antibiotic use were assessed for all UTI episodes overall and were stratified by culture-positive and culture-negative episodes. Joinpoint software was used for regression analyses of trends over time. RESULTS We identified 28,247 UTI episodes in 14,983 Veterans. The average age of Veterans was 75.7 years, and 95.9% were male. Approximately half of UTI episodes (45.7%) were culture positive and 25.7% were culture negative. Escherichia coli was recovered in 34.1% of culture-positive UTI episodes, followed by Proteus mirabilis and Klebsiella spp, which were recovered in 24.5% and 17.4% of culture-positive UTI episodes, respectively. The rate of total antibiotic use in days of therapy (DOT) per 1,000 bed days decreased by 10.1% per year (95% CI, -13.6% to -6.5%) and fluoroquinolone use (ciprofloxacin or levofloxacin) decreased by 14.5% per year (95% CI, -20.6% to -7.8%) among UTI episodes overall. Similar reductions in rates of total antibiotic use and fluoroquinolone use were observed among culture-positive UTI episodes and among culture-negative UTI episodes. CONCLUSION Over a 5-year period, antibiotic use for UTIs significantly decreased among VA CLCs, as did use of fluoroquinolones. Antibiotic stewardship efforts across VA CLCs should be applauded, and these efforts should continue.
Collapse
|
6
|
Jung S, Sexton ME, Owens S, Spell N, Fridkin S. Variability of Antibiotic Prescribing in a Large Healthcare Network Despite Adjusting for Patient-Mix: Reconsidering Targets for Improved Prescribing. Open Forum Infect Dis 2019; 6:ofz018. [PMID: 30815500 PMCID: PMC6386112 DOI: 10.1093/ofid/ofz018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/11/2018] [Accepted: 01/10/2019] [Indexed: 12/20/2022] Open
Abstract
Background In the outpatient setting, the majority of antibiotic prescriptions are for acute respiratory infections (ARIs), but most of these infections are viral and antibiotics are unnecessary. We analyzed provider-specific antibiotic prescribing in a group of outpatient clinics affiliated with an academic medical center to inform future interventions to minimize unnecessary antibiotic use. Methods We conducted a cross-sectional study of patients who presented with an ARI to any of 15 The Emory Clinic (TEC) primary care clinic sites between October 2015 and September 2017. We performed multivariable logistic regression analysis to examine the impact of patient, provider, and clinic characteristics on antibiotic prescribing. We also compared provider-specific prescribing rates within and between clinic sites. Results A total of 53.4% of the 9600 patient encounters with a diagnosis of ARI resulted in an antibiotic prescription. The odds of an encounter resulting in an antibiotic prescription were independently associated with patient characteristics of white race (adjusted odds ratio [aOR] = 1.59; 95% confidence interval [CI], 1.47–1.73), older age (aOR = 1.32, 95% CI = 1.20–1.46 for patients 51 to 64 years; aOR = 1.32, 95% CI = 1.20–1.46 for patients ≥65 years), and comorbid condition presence (aOR = 1.19; 95% CI, 1.09–1.30). Of the 109 providers, 13 (12%) had a rate significantly higher than predicted by modeling. Conclusions Antibiotic prescribing for ARIs within TEC outpatient settings is higher than expected based on prescribing guidelines, with substantial variation in prescribing rates by site and provider. These data lay the foundation for quality improvement interventions to reduce unnecessary antibiotic prescribing.
Collapse
Affiliation(s)
- Sophia Jung
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Correspondence: S. Jung, MPH, Emory University, 1075 Trail Rd., Moscow, ID 83843 ()
| | - Mary Elizabeth Sexton
- Division of Infectious Diseases, Department of Medicine, Atlanta, Georgia
- Emory Antibiotic Resistance Center, Atlanta, Georgia
| | - Sallie Owens
- Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - Nathan Spell
- Emory University School of Medicine, Emory University, Atlanta, Georgia
| | - Scott Fridkin
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Infectious Diseases, Department of Medicine, Atlanta, Georgia
- Emory Antibiotic Resistance Center, Atlanta, Georgia
| |
Collapse
|
7
|
Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Wiener RS, Gifford AL, Berlowitz DR. Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System. J Clin Endocrinol Metab 2017; 102:3226-3233. [PMID: 28911150 PMCID: PMC5587071 DOI: 10.1210/jc.2017-00468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023]
Abstract
CONTEXT Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur. OBJECTIVE We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing. DESIGN This study was cross-sectional in design. SETTING This study was conducted at the Veterans Health Administration (VA). PARTICIPANTS Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients. MAIN OUTCOME MEASURE This study measured receipt of testosterone and guideline-concordant testosterone prescribing. RESULTS Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97). CONCLUSIONS Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.
Collapse
Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School Boston, Boston, Massachusetts 02115
| | - Adam J. Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Joseph T. Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15213
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Anthony P. Morreale
- Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, San Diego, California 92161
| | - Leonard M. Pogach
- Department of Veterans Affairs, New Jersey Healthcare System, East Orange, New Jersey 07018
| | | | - Angela Park
- New England Veterans Engineering Resource Center, Boston, Massachusetts 02130
| | - Renda S. Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Medicine, The Pulmonary Center, Boston University, Boston, Massachusetts 02118
| | - Allen L. Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
| |
Collapse
|
8
|
Jones BE, Sauer B, Jones MM, Campo J, Damal K, He T, Ying J, Greene T, Goetz MB, Neuhauser MM, Hicks LA, Samore MH. Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study. Ann Intern Med 2015; 163:73-80. [PMID: 26192562 DOI: 10.7326/m14-1933] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite efforts to reduce antibiotic prescribing for acute respiratory infections (ARIs), information on factors that drive prescribing is limited. OBJECTIVE To examine trends in antibiotic prescribing in the Veterans Affairs population over an 8-year period and to identify patient, provider, and setting sources of variation. DESIGN Retrospective, cross-sectional study. SETTING All emergency departments and primary and urgent care clinics in the Veterans Affairs health system. PARTICIPANTS All patient visits between 2005 and 2012 with primary diagnoses of ARIs that typically had low proportions of bacterial infection. Patients with infections or comorbid conditions that indicated antibiotic use were excluded. MEASUREMENTS Overall antibiotic prescription; macrolide prescription; and patient, provider, and setting characteristics extracted from the electronic health record. RESULTS The proportion of 1 million visits with ARI diagnoses that resulted in antibiotic prescriptions increased from 67.5% in 2005 to 69.2% in 2012 (P < 0.001). The proportion of macrolide antibiotics prescribed increased from 36.8% to 47.0% (P < 0.001). Antibiotic prescribing was highest for sinusitis (adjusted proportion, 86%) and bronchitis (85%) and varied little according to fever, age, setting, or comorbid conditions. Substantial variation was identified in prescribing at the provider level: The 10% of providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, and the 10% who prescribed the least did so during 40% or fewer of their ARI visits. LIMITATION Some clinical data that may have influenced the prescribing decision were missing. CONCLUSION Veterans with ARIs commonly receive antibiotics, regardless of patient, provider, or setting characteristics. Macrolide use has increased, and substantial variation was identified in antibiotic prescribing at the provider level. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention.
Collapse
Affiliation(s)
- Barbara Ellen Jones
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brian Sauer
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Makoto M. Jones
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jose Campo
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kavitha Damal
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tao He
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jian Ying
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tom Greene
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Bidwell Goetz
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Melinda M. Neuhauser
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A. Hicks
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew H. Samore
- From Veterans Affairs Salt Lake City Health Care System and University of Utah, and Salt Lake City, Utah; Veterans Affairs Kansas City Health Care System, Kansas City, Missouri; Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; U.S. Department of Veterans Affairs, Hines, Illinois; and Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
9
|
McWilliams JM, Dalton JB, Landrum MB, Frakt AB, Pizer SD, Keating NL. Geographic variation in cancer-related imaging: Veterans Affairs health care system versus Medicare. Ann Intern Med 2014; 161:794-802. [PMID: 25437407 PMCID: PMC4251705 DOI: 10.7326/m14-0650] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Geographic variations in use of medical services have been interpreted as indirect evidence of wasteful care. Less overuse of services, however, may not be reliably associated with less geographic variation. OBJECTIVE To compare average use and geographic variation in use of cancer-related imaging between fee-for-service Medicare and the Department of Veterans Affairs (VA) health care system. DESIGN Observational analysis of cancer-related imaging from 2003 to 2005 using Medicare and VA utilization data linked to cancer registry data. Multilevel models, adjusted for sociodemographic and tumor characteristics, were used to estimate mean differences in annual imaging use between cohorts of Medicare and VA patients within geographic areas and variation in use across areas for each cohort. SETTING 40 hospital referral regions. PATIENTS Older men with lung, colorectal, or prostate cancer, including 34,475 traditional Medicare beneficiaries (Medicare cohort) and 6835 VA patients (VA cohort). MEASUREMENTS Per-patient count of imaging studies for which lung, colorectal, or prostate cancer was the primary diagnosis (each study weighted by a standardized price), and a direct measure of overuse-advanced imaging for prostate cancer at low risk for metastasis. RESULTS Adjusted annual use of cancer-related imaging was lower in the VA cohort than in the Medicare cohort (price-weighted count, $197 vs. $379 per patient; P < 0.001), as was annual use of advanced imaging for prostate cancer at low risk for metastasis ($41 vs. $117 per patient; P < 0.001). Geographic variation in cancer-related imaging use was similar in magnitude in the VA and Medicare cohorts. LIMITATION Observational study design. CONCLUSION Use of cancer-related imaging was lower in the VA health care system than in fee-for-service Medicare, but lower use was not associated with less geographic variation. Geographic variation in service use may not be a reliable indicator of the extent of overuse. PRIMARY FUNDING SOURCE Doris Duke Charitable Foundation and Department of Veterans Affairs Office of Policy and Planning.
Collapse
|
10
|
Aspinall SL, Good CB, Metlay JP, Mor MK, Fine MJ. Antibiotic prescribing for presumed nonbacterial acute respiratory tract infections. Am J Emerg Med 2009; 27:544-51. [DOI: 10.1016/j.ajem.2008.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 03/31/2008] [Accepted: 04/10/2008] [Indexed: 10/20/2022] Open
|