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Born KB, Levinson W, Pramesh CS, Kerr EA. Choosing Wisely in a time of resource constraints. BMJ 2024; 385:q166. [PMID: 38609103 DOI: 10.1136/bmj.q166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Affiliation(s)
- Karen B Born
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - C S Pramesh
- Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Eve A Kerr
- Department of Internal Medicine, University of Michigan, Ann Arbour, Michigan, United States
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Liu PH, Singal AG, Murphy CC. Colorectal Cancer Screening Receipt Does Not Differ by 10-Year Mortality Risk Among Older Adults. Am J Gastroenterol 2024; 119:353-363. [PMID: 37782288 PMCID: PMC10872814 DOI: 10.14309/ajg.0000000000002536] [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: 06/22/2023] [Accepted: 09/06/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Health status and life expectancy are important considerations for assessing potential benefits and harms of colorectal cancer (CRC) screening programs, particularly among older adults. METHODS We examined receipt of past-year CRC screening according to predicted 10-year mortality risk among 25,888 community-dwelling adults aged 65-84 years who were not up-to-date with screening in the nationwide National Health Interview Survey. Ten-year mortality risk was estimated using a validated index; from the lowest to highest quintiles of the index, risk was 12%, 24%, 39%, 58%, and 79%, respectively. We also examined the proportion of screening performed among adults with life expectancy <10 years. RESULTS The prevalence of past-year CRC screening was 39.5%, 40.6%, 38.7%, 36.4%, and 35.4%, from the lowest to highest quintile of 10-year mortality risk. Odds of CRC screening did not differ between adults in the lowest vs highest quintile (adjusted odds ratio 1.05, 95% confidence interval: 0.93-1.20). One-quarter (27.9%) of past-year CRC screening occurred in adults with life expectancy <10 years, and more than half (50.7%) of adults aged 75-84 years had 10-year mortality risk ≥50% at the time of screening. In an exploratory analysis, invasive but not noninvasive screening increased as 10-year mortality risk increased ( P < 0.05) among adults aged 70-79 years. DISCUSSION Past-year CRC screening does not differ by predicted 10-year mortality risk. An age-based approach to CRC screening results in underscreening of older, healthier adults and overscreening of younger adults with chronic conditions. Personalized screening with incorporation of individual life expectancy may increase the value of CRC screening programs.
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Affiliation(s)
- Po-Hong Liu
- Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX
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Saini SD, Lewis CL, Kerr EA, Zikmund-Fisher BJ, Hawley ST, Forman JH, Zauber AG, Lansdorp-Vogelaar I, van Hees F, Saffar D, Myers A, Gauntlett LE, Lipson R, Kim HM, Vijan S. Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1334-1342. [PMID: 37902744 PMCID: PMC10616770 DOI: 10.1001/jamainternmed.2023.5656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/01/2023] [Indexed: 10/31/2023]
Abstract
Importance Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. Objective To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Design, Setting, and Participants Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. Intervention The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. Main Outcomes and Measures The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. Results A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). Conclusions and Relevance In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. Trial Registration ClinicalTrials.gov Identifier: NCT02027545.
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Affiliation(s)
- Sameer D. Saini
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | | | - Eve A. Kerr
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Brian J. Zikmund-Fisher
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
| | - Sarah T. Hawley
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jane H. Forman
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Darcy Saffar
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Aimee Myers
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Lauren E. Gauntlett
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - Rachel Lipson
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
| | - H. Myra Kim
- Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan
- Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Deardorff WJ, Lu K, Jing B, Jeon SY, Boscardin WJ, Fung KZ, Lee SJ. Frequency of Screening for Colorectal Cancer by Predicted Life Expectancy Among Adults 76-85 Years. JAMA 2023; 330:1280-1282. [PMID: 37676665 PMCID: PMC10485741 DOI: 10.1001/jama.2023.15820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 09/08/2023]
Abstract
This study assesses whether colorectal cancer screening varied by predicted life expectancy in a national sample of Veterans Affairs patients aged 76 to 85 years.
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Affiliation(s)
- W. James Deardorff
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Kaiwei Lu
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Bocheng Jing
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sun Y. Jeon
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - W. John Boscardin
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Kathy Z. Fung
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sei J. Lee
- San Francisco Veterans Affairs Health Care System, San Francisco, California
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Spanos S, Singh N, Laginha BI, Arnolda G, Wilkinson D, Smith AL, Cust AE, Braithwaite J, Rapport F. Measuring the quality of skin cancer management in primary care: A scoping review. Australas J Dermatol 2023; 64:177-193. [PMID: 36960976 PMCID: PMC10952799 DOI: 10.1111/ajd.14023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/25/2023]
Abstract
Skin cancer is a growing global problem and a significant health and economic burden. Despite the practical necessity for skin cancer to be managed in primary care settings, little is known about how quality of care is or should be measured in this setting. This scoping review aimed to capture the breadth and range of contemporary evidence related to the measurement of quality in skin cancer management in primary care settings. Six databases were searched for relevant texts reporting on quality measurement in primary care skin cancer management. Data from 46 texts published since 2011 were extracted, and quality measures were catalogued according to the three domains of the Donabedian model of healthcare quality (structure, process and outcome). Quality measures within each domain were inductively analysed into 13 key emergent groups. These represented what were deemed to be the most relevant components of skin cancer management as related to structure, process or outcomes measurement. Four groups related to the structural elements of care provision (e.g. diagnostic tools and equipment), five related to the process of care delivery (e.g. diagnostic processes) and four related to the outcomes of care (e.g. poor treatment outcomes). A broad range of quality measures have been documented, based predominantly on articles using retrospective cohort designs; systematic reviews and randomised controlled trials were limited.
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Affiliation(s)
- Samantha Spanos
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
| | - Nehal Singh
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
| | - Bela I. Laginha
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
| | - Gaston Arnolda
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
| | - David Wilkinson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
- National Skin Cancer CentresSouth BrisbaneQueenslandAustralia
| | - Andrea L. Smith
- The Daffodil CentreUniversity of Sydney, a joint venture with Cancer Council NSWSydneyNew South WalesAustralia
| | - Anne E. Cust
- The Daffodil CentreUniversity of Sydney, a joint venture with Cancer Council NSWSydneyNew South WalesAustralia
- Melanoma Institute AustraliaThe University of SydneySydneyNew South WalesAustralia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
| | - Frances Rapport
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNew South WalesAustralia
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6
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Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA. J Gen Intern Med 2022; 37:2475-2481. [PMID: 34379279 PMCID: PMC9360208 DOI: 10.1007/s11606-021-07072-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources. OBJECTIVE To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening. DESIGN Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. PARTICIPANTS Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543). MAIN MEASURES Cancer screening procedures were coded as low value using USPSTF age thresholds. KEY RESULTS Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians. CONCLUSIONS Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.
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Lee AK, Jing B, Jeon SY, Boscardin WJ, Lee SJ. Predicting Life Expectancy to Target Cancer Screening Using Electronic Health Record Clinical Data. J Gen Intern Med 2022; 37:499-506. [PMID: 34327653 PMCID: PMC8858374 DOI: 10.1007/s11606-021-07018-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Guidelines recommend breast and colorectal cancer screening for older adults with a life expectancy >10 years. Most mortality indexes require clinician data entry, presenting a barrier for routine use in care. Electronic health records (EHR) are a rich clinical data source that could be used to create individualized life expectancy predictions to identify patients for cancer screening without data entry. OBJECTIVE To develop and internally validate a life expectancy calculator from structured EHR data. DESIGN Retrospective cohort study using national Veteran's Affairs (VA) EHR databases. PATIENTS Veterans aged 50+ with a primary care visit during 2005. MAIN MEASURES We assessed demographics, diseases, medications, laboratory results, healthcare utilization, and vital signs 1 year prior to the index visit. Mortality follow-up was complete through 2017. Using the development cohort (80% sample), we used LASSO Cox regression to select ~100 predictors from 913 EHR data elements. In the validation cohort (remaining 20% sample), we calculated the integrated area under the curve (iAUC) and evaluated calibration. KEY RESULTS In 3,705,122 patients, the mean age was 68 years and the majority were male (97%) and white (85%); nearly half (49%) died. The life expectancy calculator included 93 predictors; age and gender most strongly contributed to discrimination; diseases also contributed significantly while vital signs were negligible. The iAUC was 0.816 (95% confidence interval, 0.815, 0.817) with good calibration. CONCLUSIONS We developed a life expectancy calculator using VA EHR data with excellent discrimination and calibration. Automated life expectancy prediction using EHR data may improve guideline-concordant breast and colorectal cancer screening by identifying patients with a life expectancy >10 years.
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Affiliation(s)
- Alexandra K Lee
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA.
- San Francisco Veterans Affairs Medical Center, San Francisco, USA.
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
- Northern California Institute for Research and Education, San Francisco, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
- Division of Biostatistics, University of California, San Francisco, San Francisco, USA
| | - Sei J Lee
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
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Doria-Rose VP, Lansdorp-Vogelaar I, McCarthy S, Puricelli-Perin DM, Butera V, Segnan N, Taplin SH, Senore C. Measures of longitudinal adherence to fecal-based colorectal cancer screening: Literature review and recommended approaches. Int J Cancer 2021; 149:316-326. [PMID: 33811643 DOI: 10.1002/ijc.33589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/11/2021] [Accepted: 03/12/2021] [Indexed: 12/14/2022]
Abstract
The success of fecal occult blood-based colorectal cancer screening programs is dependent on repeating screening at short intervals (ie, every 1-2 years). We conducted a literature review to assess measures that have been used to assess longitudinal adherence to fecal-based screening. Among 46 citations identified and included in this review, six broad classifications of longitudinal adherence were identified: (a) stratified single-round attendance, (b) all possible adherence permutations, (c) consistent/inconsistent/never attendance, (d) number of times attended, (e) program adherence and (f) proportion of time covered. Advantages and disadvantages of these measures are described, and recommendations on which measures to use based on data availability and scientific question are also given. Stratified single round attendance is particularly useful for describing the yield of screening, while programmatic adherence measures are best suited to evaluating screening efficacy. We recommend that screening programs collect detailed longitudinal, individual-level data, not only for the screening tests themselves but additionally for diagnostic follow-up and surveillance exams, to allow for maximum flexibility in reporting adherence patterns using the measure of choice.
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Affiliation(s)
- V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Sharon McCarthy
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, USA
| | - Douglas M Puricelli-Perin
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Vicent Butera
- Center for Global Health, National Cancer Institute, Bethesda, Maryland, USA
| | - Nereo Segnan
- AOU Cittadella Salute e della Scienza, Centro di Prevenzione Oncologica Piemonte, Turin, Italy
| | - Stephen H Taplin
- Center for Global Health, National Cancer Institute, Bethesda, Maryland, USA
| | - Carlo Senore
- AOU Cittadella Salute e della Scienza, Centro di Prevenzione Oncologica Piemonte, Turin, Italy
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Aubert CE, Kerr EA, Klamerus ML, Hofer TP, Wei MY. Focus and features of prescribing indications spanning multiple chronic conditions in older adults: A narrative review. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2021; 11:26335565211012876. [PMID: 35620567 PMCID: PMC9128827 DOI: 10.1177/26335565211012876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/01/2020] [Accepted: 04/06/2021] [Indexed: 11/22/2022]
Abstract
Background: Inappropriate prescribing is frequent in older adults and associated with
adverse outcomes. Prescribing indications aim to optimize prescribing, but
little is known about the focus and features of prescribing indications for
the most common chronic conditions in older adults. Understanding the
conditions, medications, and issues addressed (e.g., patient perspective,
drug-disease interaction, adverse drug event) in current prescribing
indications may help to identify missing indications and develop
standardized measures to improve prescribing quality. Methods: We searched Ovid/MEDLINE and EMBASE for articles published between 2015 and
2020 reporting prescribing indications for older adults. Prescribing
indication included 1) prescribing “criteria,” or statements that guide
prescribing action, and 2) prescribing “measures,” or prescribing actions
observed in a population. We categorized their focus by conditions,
medications and issues addressed, as well as level of evidence provided. Results: Among 16 sets of prescribing indications, we identified 748 criteria and 47
measures. The most common addressed medications were antihypertensives,
analgesics/antirheumatics, and antiplatelets/anticoagulants. The most
frequently addressed issues were drug-disease interaction, adverse drug
event, administration, better therapeutic alternative, and (co-)prescription
omission (20.8–36.1%). Age/functioning, drug-drug interaction, monitoring,
and efficacy/safety ratio were found in only 9.9–16.5% of indications.
Indications rarely focused on the patient perspective or issues with
multiple providers. Conclusion: Most prescribing indications for chronic conditions in older patients are
criteria rather than measures. Indications accounting for patient
perspective and multiple providers are limited. The gaps identified in this
review may help improve the development of prescribing measures for older
adults and ultimately improve quality of care.
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Affiliation(s)
- Carole E Aubert
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Eve A Kerr
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mandi L Klamerus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Timothy P Hofer
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Melissa Y Wei
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
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Fritsch P, Wong C, Kolber MR. Is 45 the new 50 in colorectal cancer screening? CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:743. [PMID: 33077453 PMCID: PMC7571651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Paul Fritsch
- Family medicine resident at the University of Calgary in Alberta
| | - Clarence Wong
- Associate Professor in the Division of Gastroenterology at the University of Alberta in Edmonton
| | - Michael R Kolber
- Professor with the PEER Group in the Department of Family Medicine at the University of Alberta in Edmonton
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Tharmaratnam T, Bouck Z, Sivaswamy A, Wijeysundera HC, Chu C, Yin CX, Nesbitt GC, Edwards J, Yared K, Wong B, Weinerman A, Thavendiranathan P, Rakowski H, Dorian P, Anderson G, Austin PC, Dudzinski DM, Ko DT, Weiner RB, Bhatia RS. Association Between Physicians' Appropriate Use of Echocardiography and Subsequent Healthcare Use and Outcomes in Patients With Heart Failure. J Am Heart Assoc 2020; 9:e013360. [PMID: 31870231 PMCID: PMC6988149 DOI: 10.1161/jaha.119.013360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background There is little understanding of whether a physician's tendency to order an inappropriate cardiac service is associated with the use of other cardiac services and clinical outcomes in their patients with heart failure (HF). Methods and Results We conducted a secondary analysis of 35 Ontario‐based cardiologists who participated in the control arm of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial. Transthoracic echocardiograms, ordered during the trial, were classified as rarely appropriate (rA), appropriate, or maybe appropriate on the basis of the 2011 appropriate use criteria. Cardiologists were grouped into tertiles of rA transthoracic echocardiogram ordering frequency: low ordering (bottom tertile), n=11; moderate ordering, n=12; or high ordering (top tertile), n=12. The main outcomes were measures of cardiac service use, including cardiology‐related physician visits, tests, and medications. Among 1677 patients with heart failure and an outpatient visit to 1 of 35 cardiologists, we found no significant association between rA transthoracic echocardiogram ordering frequency (by tertile) and cardiac testing use, although patients of cardiologists in the high ordering group had fewer physician visits, on average, than patients seen by low ordering cardiologists. In addition, patients of cardiologists in the highest rA ordering tertile had significantly lower odds of receiving potentially effective interventions, such as β blockers (odds ratio, 0.62; 95% CI, 0.43–0.89), than the low ordering group. Conclusions Although patients of cardiologists who frequently order rA transthoracic echocardiograms do not appear more (or less) likely to have subsequent cardiac tests, these patients have fewer follow‐up visits and lower odds of receiving evidence‐based medications. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02038101.
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Affiliation(s)
- Tharmegan Tharmaratnam
- School of Medicine Royal College of Surgeons Ireland Dublin Ireland.,Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,Dalla Lana School of Public Health University of Toronto Ontario Canada
| | | | - Harindra C Wijeysundera
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Cherry Chu
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | - Cindy X Yin
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada
| | | | - Jeremy Edwards
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Kibar Yared
- The Scarborough Hospital Toronto Ontario Canada
| | - Brian Wong
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Adina Weinerman
- Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | | | - Harry Rakowski
- Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
| | - Paul Dorian
- Division of Cardiology St. Michael's Hospital Toronto Ontario Canada
| | - Geoff Anderson
- Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - Peter C Austin
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada
| | - David M Dudzinski
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - Dennis T Ko
- ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada.,Sunnybrook Research Institute Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Rory B Weiner
- Division of Cardiology Massachusetts General Hospital Harvard Medical School Boston MA
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care Women's College Hospital Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy, Management, and Evaluation University of Toronto Ontario Canada.,Peter Munk Cardiac Centre University Health Network Toronto Ontario Canada
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13
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Maratt JK, Calderwood AH. Colorectal Cancer Screening and Surveillance Colonoscopy in Older Adults. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:292-302. [PMID: 30969399 PMCID: PMC6584566 DOI: 10.1007/s11938-019-00230-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW The purpose of this chapter is to highlight current recommendations regarding colorectal cancer (CRC) screening and post-polypectomy surveillance colonoscopy in older adults and to review the available literature in order to help inform decision-making in this age group. RECENT FINDINGS Age is a risk factor for CRC; however, older adults with a history of prior screening are at lower risk for CRC compared to those who have never been screened. Decision-making for CRC screening and post-polypectomy surveillance colonoscopy in older adults is complex and several factors including age, screening history, comorbidities, functional status, bowel preparation, prior experiences, preferences, and barriers need to be considered when weighing risks and benefits. Recent guidelines have started to incorporate life expectancy and prior screening history into their recommendations; however, how to incorporate these factors into actual clinical practice is less clear. There are limited data on the relative benefits of screening and surveillance in older adults and therefore, at this time, decision-making should be individualized and incorporate patient preferences in addition to medical factors.
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Affiliation(s)
- Jennifer K Maratt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Audrey H Calderwood
- Section of Gastroenterology, Department of Medicine, Dartmouth Geisel School of Medicine and the Dartmouth Institute for Health Policy and Clinical Practice, One Medical Center Drive, Lebanon, NH, 03756, USA.
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14
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Gawron A, Bielefeldt K. Unrelated Death After Colorectal Cancer Screening: Implications for Improving Colonoscopy Referrals. Fed Pract 2019; 36:262-270. [PMID: 31258319 PMCID: PMC6590950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The observed mortality < 5 years after the index colonoscopy lowered the overall impact of screening, which should prompt health care providers to perform a more thorough assessment of the potential reduced benefit for individual veterans when incorporating cancer risk, comorbidity burden, and age-based criteria.
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Affiliation(s)
- Andrew Gawron
- is a Gastroenterologist at the Salt Lake City Specialty Care Center of Innovation, and is Chief of the Gastroenterology Section, both at the VA George E. Wahlen VA Medical Center in Salt Lake City, Utah. Andrew Gawron is an Associate Professor at the University of Utah
| | - Klaus Bielefeldt
- is a Gastroenterologist at the Salt Lake City Specialty Care Center of Innovation, and is Chief of the Gastroenterology Section, both at the VA George E. Wahlen VA Medical Center in Salt Lake City, Utah. Andrew Gawron is an Associate Professor at the University of Utah
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15
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Schoenborn NL, Huang J, Sheehan OC, Wolff JL, Roth DL, Boyd CM. Influence of Age, Health, and Function on Cancer Screening in Older Adults with Limited Life Expectancy. J Gen Intern Med 2019; 34:110-117. [PMID: 30402822 PMCID: PMC6318172 DOI: 10.1007/s11606-018-4717-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES We examined the relationship between cancer screening and life expectancy predictors, focusing on the influence of age versus health and function, in older adults with limited life expectancy. DESIGN Longitudinal cohort study SETTING: National Health and Aging Trends Study (NHATS) with linked Medicare claims. PARTICIPANTS Three cohorts of adults 65+ enrolled in fee-for-service Medicare were constructed: women eligible for breast cancer screening (n = 2043); men eligible for prostate cancer screening (n = 1287); men and women eligible for colorectal cancer screening (n = 3759). MEASUREMENTS We assessed 10-year mortality risk using 2011 NHATS data, then used claims data to assess 2-year prostate and breast cancer screening rates and 3-year colorectal cancer screening rates. Among those with limited life expectancy (10-year mortality risk > 50%), we stratified participants at each level of predicted mortality risk and split participants in each risk stratum by the median age. We assembled two sub-groups from these strata that were matched on predicted life expectancy: a "younger sub-group" with relatively poorer health/functional status and an "older sub-group" with relatively better health/functional status. We compared screening rates between sub-groups. RESULTS For all three cancer screenings, the younger sub-groups (average ages 73.4-76.1) had higher screening rates than the older sub-groups (average ages 83.6-86.9); screening rates were 42.9% versus 34.2% for prostate cancer screening (p = 0.02), 33.6% versus 20.6% for breast cancer screening (p < 0.001), 13.1% versus 6.7% for colorectal cancer screening in women (p = 0.006), and 20.5% versus 12.1% for colorectal cancer screening in men (p = 0.002). CONCLUSION Among older adults with limited life expectancy, those who are relatively younger with poorer health and functional status are over-screened for cancer at higher rates than those who are older with the same predicted life expectancy.
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Affiliation(s)
- Nancy L Schoenborn
- The Johns Hopkins School of Medicine, Baltimore, MD, USA. .,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA.
| | - Jin Huang
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Orla C Sheehan
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Jennifer L Wolff
- The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA.,The Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - David L Roth
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- The Johns Hopkins School of Medicine, Baltimore, MD, USA.,The Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
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16
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Piper MS, Maratt JK, Zikmund-Fisher BJ, Lewis C, Forman J, Vijan S, Metko V, Saini SD. Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening. JAMA Netw Open 2018; 1:e185461. [PMID: 30646275 PMCID: PMC6324357 DOI: 10.1001/jamanetworkopen.2018.5461] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations. OBJECTIVE To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators). DESIGN, SETTING, AND PARTICIPANTS This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017. MAIN OUTCOMES AND MEASURES Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?" RESULTS Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89). CONCLUSIONS AND RELEVANCE The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.
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Affiliation(s)
- Marc S. Piper
- Division of Gastroenterology, Department of Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jennifer K. Maratt
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian J. Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Carmen Lewis
- Division of General Internal Medicine, Department of Internal Medicine, University of Colorado, Aurora
| | - Jane Forman
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sandeep Vijan
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valbona Metko
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sameer D. Saini
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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17
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Gotanda H, Ganz DA, Wenger NS. Association Between Estimated Mortality Risk and Measured Quality of Care in Older Adults. J Am Geriatr Soc 2018; 66:1838-1844. [PMID: 30080251 DOI: 10.1111/jgs.15491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/14/2018] [Accepted: 05/20/2018] [Indexed: 11/30/2022]
Abstract
Quality measures based on processes of care (e.g., breast cancer screening) are frequently used to compare performance of providers and healthcare organizations in a value-based reimbursement system, but using these measures to make performance comparisons could penalize clinicians caring for older adults with multiple comorbidities. These clinicians may more frequently withhold recommended care based on limited prognosis, patient preference, or potential adverse effects and, as a result, may incur financial penalties because of poor measured performance. Alternatively, they may need to perform additional administrative work to exclude patients from quality measurement. To examine the potential performance handicap associated with caring for complex populations, we cross-sectionally examined the association between broad outpatient processes of care and 5-year mortality risk in a nationally representative older adult sample (≥ 65) from the 2002 to 2015 Medical Expenditure Panel Survey (n=26,006). In adjusted analyses, performance score based on process-of-care measures was significantly worse in the high-risk group (5-year mortality risk ≥50; adjusted performance score 67.4%; adjusted absolute difference 6.7%, 95% confidence interval (CI)=5.3-8.1%, p<.001) and in the intermediate-risk group (5-year mortality risk 25-49%; adjusted performance score 71.7%; adjusted absolute difference 2.4%, 95% CI=1.7-3.1%, p<.001) than in the low-risk group (5-year mortality risk <25%); adjusted performance score 74.1% following <25%. The trend was overall constant across types of care processes and was more prominent in the younger age brackets of our sample. These results suggest that use of process-of-care measures can lead to disproportionate burden for clinicians and organizations primarily taking care of complex populations.
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Affiliation(s)
- Hiroshi Gotanda
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - David A Ganz
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Division of Geriatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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18
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Rivera MP, Tanner NT, Silvestri GA, Detterbeck FC, Tammemägi MC, Young RP, Slatore CG, Caverly TJ, Boyd CM, Braithwaite D, Fathi JT, Gould MK, Iaccarino JM, Malkoski SP, Mazzone PJ, Tanoue LT, Schoenborn NL, Zulueta JJ, Wiener RS. Incorporating Coexisting Chronic Illness into Decisions about Patient Selection for Lung Cancer Screening. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2018; 198:e3-e13. [DOI: 10.1164/rccm.201805-0986st] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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19
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Egberg MD, Gulati AS, Gellad ZF, Melmed GY, Kappelman MD. Improving Quality in the Care of Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2018; 24:1660-1669. [PMID: 29718299 PMCID: PMC6231366 DOI: 10.1093/ibd/izy030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Indexed: 02/06/2023]
Abstract
Efforts to improve healthcare quality were firmly established before the Institute of Medicine (IOM) historic 2000 and 2001 reports, To Err is Human Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century Despite the long-standing healthcare quality improvement (QI) efforts that date back to the turn of the 20th century, the IOM reports significantly advanced the awareness of healthcare quality deficits and the resulting risk to patients from those gaps in care. Studies immediately following the IOM reports emphasized and verified the presence of detrimental care gaps and highlighted a myriad of contributing factors. Studies focused specifically on the inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis , demonstrated suboptimal patient outcomes stemming from, in part, system and provider variation. In the years that have followed, research studies have shown the persistence of suboptimal outcomes in IBD despite an awareness of key drivers for poor care quality and concerted efforts in advancing QI initiatives. In 2017, IBD advocacy groups and provider networks have demonstrated progress in furthering both pediatric and adult IBD outcomes through the use of QI methods and tools including collaborative learning networks. A significant amount of work lies ahead, however, to build upon these advances and improve IBD outcomes further. This article reviews the history of quality initiatives in healthcare, identifies ongoing gaps in IBD care with a review of current IBD improvement efforts taking place, and identifies several targets for improving IBD care quality moving forward into the 21st century.
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Affiliation(s)
- Matthew D Egberg
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
- Institute for Healthcare Improvement, Cambridge, MA
| | - Ajay S Gulati
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Departments of Pediatrics and Pathology and Laboratory Medicine. Chapel Hill, NC
| | - Ziad F Gellad
- Durham VA Medical Center, Durham, NC
- Division of Gastroenterology, Duke University Medical Center, Durham, NC
| | - Gil Y Melmed
- Inflammatory Bowel and Immunobiology Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael D Kappelman
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Division of Pediatric Gastroenterology, Chapel Hill, NC
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20
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Kondo KK, Wyse J, Mendelson A, Beard G, Freeman M, Low A, Kansagara D. Pay-for-Performance and Veteran Care in the VHA and the Community: a Systematic Review. J Gen Intern Med 2018; 33:1155-1166. [PMID: 29700789 PMCID: PMC6025676 DOI: 10.1007/s11606-018-4444-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Although pay-for-performance (P4P) strategies have been used by the Veterans Health Administration (VHA) for over a decade, the long-term benefits of P4P are unclear. The use of P4P is further complicated by the increased use of non-VHA healthcare providers as part of the Veterans Choice Program. We conducted a systematic review and key informant interviews to better understand the effectiveness and potential unintended consequences of P4P, as well as the implementation factors and design features important in both VHA and non-VHA/community settings. METHODS We searched PubMed, PsycINFO, and CINAHL through March 2017 and reviewed reference lists. We included trials and observational studies of P4P targeting Veteran health. Two investigators abstracted data and assessed study quality. We interviewed VHA stakeholders to gain further insight. RESULTS The literature search yielded 1031 titles and abstracts, of which 30 studies met pre-specified inclusion criteria. Twenty-five examined P4P in VHA settings and 5 in community settings. There was no strong evidence supporting the effectiveness of P4P in VHA settings. Interviews with 17 key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in the VHA. Key informants' views on P4P in community settings included the need to develop relationships with providers and health systems with records of strong performance, to improve coordination by targeting documentation and data sharing processes, and to troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. DISCUSSION The evidence to support the effectiveness of P4P on Veteran health is limited. Key informants recognize the potential for unintended consequences, such as overtreatment in VHA settings, and suggest that implementation of P4P in the community focus on relationship building and target areas such as documentation and coordination of care.
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Affiliation(s)
- Karli K Kondo
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA.
- Oregon Health and Science University, Portland, OR, USA.
| | - Jessica Wyse
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | | | - Gabriella Beard
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Michele Freeman
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Allison Low
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Devan Kansagara
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
- Oregon Health and Science University, Portland, OR, USA
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21
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Lewis CL, Kistler CE, Dalton AF, Morris C, Ferrari R, Barclay C, Brewer NT, Dolor R, Harris R, Vu M, Golin CE. A Decision Aid to Promote Appropriate Colorectal Cancer Screening among Older Adults: A Randomized Controlled Trial. Med Decis Making 2018; 38:614-624. [DOI: 10.1177/0272989x18773713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background. Concerns have been raised about both over- and underutilization of colorectal cancer (CRC) screening in older patients and the need to align screening behavior with likelihood of net benefit. Objective. The purpose of this study was to test a novel use of a patient decision aid (PtDA) to promote appropriate CRC screening in older adults. Methods. A total of 424 patients ages 70 to 84 y who were not up to date with CRC screening participated in a double-blinded randomized controlled trial of a PtDA targeted to older adults making decisions about whether to undergo CRC screening from March 2012 to February 2015. Intervention. Patients were randomized to a targeted PtDA or an attention control. The PtDA was designed to facilitate individualized decision making—helping patients understand the potential risks, benefits, and uncertainties of CRC screening given advanced age, health state, preferences, and values. Outcomes. Two composite outcomes, appropriate CRC screening behavior 6 mo after the index visit and appropriate screening intent immediately after the visit, were defined as completed screening or intent for patients in good health, discussion about screening with their provider for patients in intermediate health, and no screening or intent for patients in poor health. Health state was determined by age and Charlson Comorbidity Index. Results. Four hundred twelve (97%) and 421 (99%) patients were analyzed for the primary and secondary outcomes, respectively. Appropriate screening behavior at 6 mo was higher in the intervention group (55% v. 45%, P = 0.023) as was appropriate screening intent following the provider visit (61% v. 47%, P = 0.003). Limitations. The study took place in a single geographic region. The appropriate CRC screening classification system used in this study has not been formally validated. Conclusions. A PtDA for older adults promoted appropriate CRC screening behavior and intent. Trial Registration: Clinicaltrials.gov, registration number NCT01575990. https://clinicaltrials.gov/ct2/show/NCT01575990?term=epic-d&rank=1
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Affiliation(s)
- Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexandra F. Dalton
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carolyn Morris
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Renée Ferrari
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Colleen Barclay
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Noel T. Brewer
- Department of Health Behavior, Gillings School of Global Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rowena Dolor
- Division of General Internal Medicine, Department of Medicine, Duke School of Medicine, Durham, NC, USA
| | - Russell Harris
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maihan Vu
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carol E. Golin
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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22
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Predmore Z, Pannikottu J, Sharma R, Tung M, Nothelle S, Segal JB. Factors Associated With the Overuse of Colorectal Cancer Screening: A Systematic Review. Am J Med Qual 2018; 33:472-480. [PMID: 29546768 DOI: 10.1177/1062860618764302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This systematic review examined factors associated with overuse of colorectal cancer (CRC) screening. The authors searched MEDLINE and EMBASE from January 1998 to March 2017. Studies were included if they were written in English, contained original data, involved a US population, and examined factors potentially associated with overuse of CRC screening. Paired reviewers independently screened abstracts, assessed quality, and extracted data. In 8 studies, the associations between patient factors, including age, sex, race, and number of comorbidities, were tested and were inconsistently associated with CRC screening overuse. Overuse of screening was greater in the Northeast/Mid-Atlantic regions and in urban areas and was lower in academically affiliated centers. Although the literature supports important overuse of CRC screening, it remains unclear what drives these practices. Future research should thoroughly explore these factors and test the impact of interventions to reduce overuse of screening.
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Affiliation(s)
- Zachary Predmore
- 1 Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Jean Pannikottu
- 2 Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ritu Sharma
- 2 Johns Hopkins University School of Medicine, Baltimore, MD
| | - Monica Tung
- 1 Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Stephanie Nothelle
- 1 Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Jodi B Segal
- 1 Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.,2 Johns Hopkins University School of Medicine, Baltimore, MD.,3 Johns Hopkins University Center for Health Services and Outcomes Research, Baltimore, MD
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23
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Ethical Issues in the Design and Implementation of Population Health Programs. J Gen Intern Med 2018; 33:370-375. [PMID: 29256088 PMCID: PMC5834965 DOI: 10.1007/s11606-017-4234-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/27/2017] [Accepted: 11/08/2017] [Indexed: 01/17/2023]
Abstract
Spurred on by recent health care reforms and the Triple Aim's goals of improving population health outcomes, reducing health care costs, and improving the patient experience of care, emphasis on population health is increasing throughout medicine. Population health has the potential to improve patient care and health outcomes for individual patients. However, specific population health activities may not be in every patient's best interest in every circumstance, which can create ethical tensions for individual physicians and other health care professionals. Because individual medical professionals remain committed primarily to the best interests of individual patients, physicians have a unique role to play in ensuring population health supports this ethical obligation. Using widely recognized principles of medical ethics-nonmaleficence/beneficence, respect for persons, and justice-this article describes the ethical issues that may arise in contemporary population health programs and how to manage them. Attending to these principles will improve the design and implementation of population health programs and help maintain trust in the medical profession.
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24
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Overuse of Repeat Upper Endoscopy in the Veterans Health Administration: A Retrospective Analysis. Am J Gastroenterol 2017; 112:1678-1685. [PMID: 28695907 DOI: 10.1038/ajg.2017.192] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 05/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Americans undergo ∼7 million esophagogastroduodenoscopies (EGDs) annually, and one-third of Medicare beneficiaries undergo a repeat EGD within 3 years. As many as 43% of these repeat EGDs are inappropriate. We aimed to determine the rate of repeat inappropriate EGD within the Veterans Health Administration (VHA), and identify factors associated with repeat EGD. METHODS We conducted retrospective analyses of Veterans undergoing an index EGD at 159 VHA facilities between 1 January 2003 and 30 June 2007. We excluded Veterans without regular use of VHA for health care or 5 years of follow-up. Appropriateness of repeat EGDs was classified based on diagnostic and procedure codes into three categories: Likely Appropriate, Possible Overuse, and Probable Overuse. The proportion of repeat EGDs in each category was tabulated. Multilevel logistic regression was performed to estimate the impact of patient-level and site-level factors on the odds of repeat EGD. RESULTS Of the 235,855 included Veterans, 85,690 (36.3%) underwent a repeat EGD within 5 years. Of the repeat EGDs, 42,412 (49.5%) were Likely Appropriate, 35,503 (41.4%) represented Possible Overuse, and 7,756 (9.1%) represented Probable Overuse. Patients with more frequent encounters with primary care providers and access to facilities performing EGD and with greater complexity of services were more likely to receive repeat EGD, regardless of whether the repeat EGD was appropriate or overuse. Women were slightly more likely to undergo repeat EGD in Probable Overuse situations. CONCLUSIONS Overuse of repeat EGD is common in VHA despite the absence of financial incentives that promote overuse. Efforts are needed to better understand the motivations for overuse and barriers to appropriate use, and to promote appropriate use of repeat EGD.
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Kerr EA, Kullgren JT, Saini SD. Choosing Wisely: How To Fulfill The Promise In The Next 5 Years. Health Aff (Millwood) 2017; 36:2012-2018. [DOI: 10.1377/hlthaff.2017.0953] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Eve A. Kerr
- Eve A. Kerr is director of the Center for Clinical Management Research at the Veterans Affairs (VA) Ann Arbor Health System and a professor in the Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, in Ann Arbor
| | - Jeffrey T. Kullgren
- Jeffrey T. Kullgren is an investigator in the Center for Clinical Management Research at VA Ann Arbor and an assistant professor in the Department of Internal Medicine, the Institute for Healthcare Policy and Innovation, and the Center for Bioethics and Social Sciences in Medicine, University of Michigan
| | - Sameer D. Saini
- Sameer D. Saini is an investigator in the Center for Clinical Management Research at VA Ann Arbor and an associate professor in the Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan
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Abstract
The primary goal of cancer screening is early detection of cancer to reduce cancer-specific mortality and morbidity. The benefits of screening in older adults are uncertain due to paucity of evidence. Extrapolating data from younger populations, evidence suggests that the benefit occurs years later from the time of initial screening and therefore may not be applicable in those older adults with limited life expectancy. Contrast this with the harms of screening, which are more immediate and increase with age and comorbidities. An individualized approach to cancer screening takes these factors into consideration, allowing for thoughtful decision making for older adults.
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Affiliation(s)
- Kimberley T Lee
- Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F Lord Building Center Tower, Room 711, Baltimore, MD 21224, USA.
| | - Russell P Harris
- Division of General Medicine and Clinical Epidemiology, Sheps Center for Health Services Research, University of North Carolina, 101 Parkview Crescent, Chapel Hill, NC 27516, USA
| | - Nancy L Schoenborn
- Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F Lord Building Center Tower, Room 711, Baltimore, MD 21224, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the current state of endoscopic quality measurement and use of measures in enhancing the value of endoscopic services. RECENT FINDINGS Initially, quality measurement of endoscopic procedures was claims based or included small unit or practice-specific efforts. Now we have a mature national registry and large electronic medical or procedural records that are designed to yield valuable data relevant to quality measurement. SUMMARY With the advent of better measures, we are beginning to understand that initial process and surrogate outcome measures (adenoma detection rate) can be improved to provide a better reflection of endoscopic quality. Importantly, however, even measures currently in use relate to important patient outcomes such as missed colon cancers. At a federal level, older cumbersome pay-for-performance initiatives have been combined into a new overarching program named the quality payment program within the centers for medicare and medicaid services. This program is an additional step toward furthering the progress from volume-to-value-based reimbursement. The legislation mandating the movement toward outcomes-linked (value) reimbursement is the medicare access and children's health insurance program reauthorization act, which was passed with overwhelming bipartisan support and will not be walked back by alterations of the affordable care act. Increasing portions of medicare reimbursement (and likely commercial to follow) will be linked to quality metrics, so familiarity with the underlying process and rationale will be important for all proceduralists.
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Colorectal cancer screening: Systematic review of screen-related morbidity and mortality. Cancer Treat Rev 2017; 54:87-98. [DOI: 10.1016/j.ctrv.2017.02.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 12/12/2022]
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Goldvaser H, Katz Shroitman N, Ben-Aharon I, Purim O, Kundel Y, Shepshelovich D, Shochat T, Sulkes A, Brenner B. Octogenarian patients with colorectal cancer: Characterizing an emerging clinical entity. World J Gastroenterol 2017; 23:1387-1396. [PMID: 28293085 PMCID: PMC5330823 DOI: 10.3748/wjg.v23.i8.1387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/26/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To characterize colorectal cancer (CRC) in octogenarians as compared with younger patients.
METHODS A single-center, retrospective cohort study which included patients diagnosed with CRC at the age of 80 years or older between 2008-2013. A control group included consecutive patients younger than 80 years diagnosed with CRC during the same period. Clinicopathological characteristics, treatment and outcome were compared between the groups. Fisher’s exact test was used for dichotomous variables and χ2 was used for variables with more than two categories. Overall survival was assessed by Kaplan-Meier survival analysis, with the log-rank test. Cancer specific survival (CSS) and disease-free survival were assessed by the Cox proportional hazards model, with the Fine and Gray correction for non-cancer death as a competing risk.
RESULTS The study included 350 patients, 175 patients in each group. Median follow-up was 40.2 mo (range 1.8-97.5). Several significant differences were noted. Octogenarians had a higher proportion of Ashkenazi ethnicity (64.8% vs 47.9%, P < 0.001), a higher rate of personal history of other malignancies (22.4% vs 13.7%, P = 0.035) and lower rates of family history of any cancer (36.6% vs 64.6%, P < 0.001) and family history of CRC (14.4% vs 27.3%, P = 0.006). CRC diagnosis by screening was less frequent in octogenarians (5.7% vs 20%, P < 0.001) and presentation with performance status (PS) of 0-1 was less common in octogenarians (71% vs 93.9%, P < 0.001). Octogenarians were more likely to have tumors located in the right colon (45.7% vs 34.3%, P = 0.029) and had a lower prevalence of well differentiated histology (10.4% vs 19.3%, P = 0.025). They received less treatment and treatment was less aggressive, both in patients with metastatic and non-metastatic disease, regardless of PS. Their 5-year CSS was worse (63.4% vs 77.6%, P = 0.009), both for metastatic (21% vs 43%, P = 0.03) and for non-metastatic disease (76% vs 88%, P = 0.028).
CONCLUSION Octogenarians presented with several distinct characteristics and had worse outcome. Further research is warranted to better define this growing population.
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Salloum RG, O'Keeffe-Rosetti M, Ritzwoller DP, Hornbrook MC, Lafata JE, Nielsen ME. Use of Evidence-Based Prostate Cancer Imaging in a Nongovernmental Integrated Health Care System. J Oncol Pract 2017; 13:e441-e450. [PMID: 28221895 DOI: 10.1200/jop.2016.018333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The overuse of imaging, particularly for staging of low-risk prostate cancer, is well documented and widespread. The existing literature, which focuses on the elderly in fee-for-service settings, points to financial incentives as a driver of overuse and may not identify factors relevant to policy solutions within integrated health care systems, where physicians are salaried. METHODS Imaging rates were analyzed among men with incident prostate cancer diagnosed between 2004 and 2011 within the Colorado and Northwest regions of Kaiser Permanente. The sample was stratified according to indication for imaging, ie, high risk for whom imaging was necessary versus low risk for whom imaging was discouraged. Logistic regression was used to model the association between imaging receipt and clinical/demographic patient characteristics by risk strata. RESULTS Of the men with low-risk prostate cancer, 35% received nonindicated imaging at diagnosis, whereas 42% of men with high-risk prostate cancer did not receive indicated imaging. Compared with men diagnosed in 2004, those diagnosed in subsequent years were less likely to receive imaging across both risk groups. Men with high-risk cancer diagnosed at ≥ 65 years of age and those with clinical stage ≥ T2 were more likely to receive indicated imaging. Men with comorbidities were more likely to receive imaging across both risk groups. Men with low-risk prostate cancer who had higher median household incomes were less likely to receive nonindicated imaging. CONCLUSION Nonindicated imaging for diagnostic staging of patients with low-risk prostate cancer was common, but has decreased over the past decade. These findings suggest that factors other than financial incentives may be driving overuse of imaging.
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Affiliation(s)
- Ramzi G Salloum
- University of Florida College of Medicine, Gainesville, FL; Kaiser Permanente Center for Health Research, Portland, OR; Kaiser Permanente Colorado, Denver, CO; and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Maureen O'Keeffe-Rosetti
- University of Florida College of Medicine, Gainesville, FL; Kaiser Permanente Center for Health Research, Portland, OR; Kaiser Permanente Colorado, Denver, CO; and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Debra P Ritzwoller
- University of Florida College of Medicine, Gainesville, FL; Kaiser Permanente Center for Health Research, Portland, OR; Kaiser Permanente Colorado, Denver, CO; and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark C Hornbrook
- University of Florida College of Medicine, Gainesville, FL; Kaiser Permanente Center for Health Research, Portland, OR; Kaiser Permanente Colorado, Denver, CO; and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jennifer Elston Lafata
- University of Florida College of Medicine, Gainesville, FL; Kaiser Permanente Center for Health Research, Portland, OR; Kaiser Permanente Colorado, Denver, CO; and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew E Nielsen
- University of Florida College of Medicine, Gainesville, FL; Kaiser Permanente Center for Health Research, Portland, OR; Kaiser Permanente Colorado, Denver, CO; and University of North Carolina at Chapel Hill, Chapel Hill, NC
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Saini SD, Adams MA, Brill JV, Gupta N, Naveed M, Rosenberg JA, Gellad ZF. Colorectal Cancer Screening Quality Measures: Beyond Colonoscopy. Clin Gastroenterol Hepatol 2016; 14:644-7. [PMID: 26996882 DOI: 10.1016/j.cgh.2016.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Megan A Adams
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Joel V Brill
- Predictive Health, LLC, Paradise Valley, Arizona
| | - Neil Gupta
- Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, Illinois
| | - Mariam Naveed
- Division of Gastroenterology, University of Iowa, Iowa City, Iowa
| | | | - Ziad F Gellad
- Durham VA Medical Center, Durham, North Carolina; Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
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Developing and Testing an Electronic Measure of Screening Colonoscopy Overuse in a Large Integrated Healthcare System. J Gen Intern Med 2016; 31 Suppl 1:53-60. [PMID: 26951277 PMCID: PMC4803673 DOI: 10.1007/s11606-015-3569-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Most existing performance measures focus on underuse of care, but there is growing interest in identifying and reducing overuse. OBJECTIVE We aimed to develop a valid and reliable electronic performance measure of overuse of screening colonoscopy in the Veterans Affairs Health Care System (VA), and to quantify overuse in VA. DESIGN This was a cross-sectional study with multiple cross-sections. SUBJECTS U.S. Veterans who underwent screening colonoscopy between 2011 and 2013. MAIN MEASURES Overuse of screening colonoscopy, using a validated electronic measure developed by an expert workgroup. KEY RESULTS Compared to results obtained from manual record review, the electronic measure was highly specific (97 %) for overuse, but not sensitive (20 %). After exclusion of diagnostic and high-risk screening or surveillance procedures, the validated electronic measure identified 88,754 average-risk screening colonoscopies performed in VA during 2013. Of these, 20,530 (23 %) met the definition for probable (17 %) or possible (6 %) overuse. Substantial variation in colonoscopy overuse was noted between Veterans Integrated Care Networks (VISNs) and between facilities, with a nearly twofold difference between the maximum and minimum rates of overuse at the VISN level and a nearly eightfold difference at the facility level. Overuse at the VISN and facility level was relatively stable over time. CONCLUSIONS Overuse of screening colonoscopy can be measured reliably and with high specificity using electronic data, and is common in a large integrated healthcare system. Overuse measures, such as those we have specified through a consensus workgroup process, could be combined with underuse measures to improve the appropriateness of colorectal cancer screening.
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Asch SM, Kerr EA. Measuring What Matters in Health: Lessons from the Veterans Health Administration State of the Art Conference. J Gen Intern Med 2016; 31 Suppl 1:1-2. [PMID: 26951269 PMCID: PMC4803670 DOI: 10.1007/s11606-015-3576-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Steven M Asch
- Palo Alto Veterans Affairs Healthcare System and the Division of General Medical Disciplines, Stanford University, Stanford, CA, USA. .,Palo Alto Veterans Affairs Healthcare System, Center for Innovation to Implementation, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Eve A Kerr
- Department of Veterans Affairs Center for Clinical Management Research, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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Abstract
BACKGROUND Process measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators. OBJECTIVE In 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion. DESIGN Using 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes. PARTICIPANTS All veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009. MAIN MEASURES The two outcomes were 1) measured performance-patients retained/patients qualified and 2) denominator prevalence-patients qualified/patients with SUD program contact. KEY RESULTS Measured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001). CONCLUSIONS These results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of "shadow measures" to monitor and reduce undesirable denominator management.
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Abstract
Dhruv Khullar and Anupam Jena argue that we need to pay more attention to prognosis if we are to ensure that patients get appropriate and safe treatment
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Affiliation(s)
- Dhruv Khullar
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anupam B Jena
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA National Bureau of Economic Research, Cambridge, MA. USA
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36
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van Hees F, Zauber AG, van Veldhuizen H, Heijnen MLA, Penning C, de Koning HJ, van Ballegooijen M, Lansdorp-Vogelaar I. The value of models in informing resource allocation in colorectal cancer screening: the case of The Netherlands. Gut 2015; 64:1985-97. [PMID: 26063755 PMCID: PMC4672636 DOI: 10.1136/gutjnl-2015-309316] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/17/2015] [Indexed: 12/31/2022]
Abstract
In May 2011, the Dutch government decided to implement a national programme for colorectal cancer (CRC) screening using biennial faecal immunochemical test screening between ages 55 and 75. Decision modelling played an important role in informing this decision, as well as in the planning and implementation of the programme afterwards. In this overview, we illustrate the value of models in informing resource allocation in CRC screening using the role that decision modelling has played in the Dutch CRC screening programme as an example.
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Affiliation(s)
- Frank van Hees
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Harriët van Veldhuizen
- Department of Quality Improvement, Erasmus MC, Rotterdam, the Netherlands from August 2014, before National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | | | - Corine Penning
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
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van Hees F, Saini SD, Lansdorp-Vogelaar I, Vijan S, Meester RGS, de Koning HJ, Zauber AG, van Ballegooijen M. Personalizing colonoscopy screening for elderly individuals based on screening history, cancer risk, and comorbidity status could increase cost effectiveness. Gastroenterology 2015; 149:1425-37. [PMID: 26253304 PMCID: PMC4631390 DOI: 10.1053/j.gastro.2015.07.042] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) screening decisions for elderly individuals are often made primarily on the basis of age, whereas other factors that influence the effectiveness and cost effectiveness of screening are often not considered. We investigated the relative importance of factors that could be used to identify elderly individuals most likely to benefit from CRC screening and determined the maximum ages at which screening remains cost effective based on these factors. METHODS We used a microsimulation model (Microsimulation Screening Analysis-Colon) calibrated to the incidence of CRC in the United States and the prevalence of adenomas reported in autopsy studies to determine the appropriate age at which to stop colonoscopy screening in 19,200 cohorts (of 10 million individuals), defined by sex, race, screening history, background risk for CRC, and comorbidity status. We applied a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY) gained. RESULTS Less intensive screening history, higher background risk for CRC, and fewer comorbidities were associated with cost-effective screening at older ages. Sex and race had only a small effect on the appropriate age to stop screening. For some individuals likely to be screened in current practice (for example, 74-year-old white women with moderate comorbidities, half the average background risk for CRC, and negative findings from a screening colonoscopy 10 years previously), screening resulted in a loss of QALYs, rather than a gain. For some individuals unlikely to be screened in current practice (for example, 81-year-old black men with no comorbidities, an average background risk for CRC, and no previous screening), screening was highly cost effective. Although screening some previously screened, low-risk individuals was not cost effective even when they were 66 years old, screening some healthy, high-risk individuals remained cost effective until they reached the age of 88 years old. CONCLUSIONS The current approach to CRC screening in elderly individuals, in which decisions are often based primarily on age, is inefficient, resulting in underuse of screening for some and overuse of screening for others. CRC screening could be more effective and cost effective if individual factors for each patient are considered.
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Affiliation(s)
- Frank van Hees
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sameer D Saini
- Veteran Affairs Health Services Research and Development Center for Clinical Management Research, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sandeep Vijan
- Veteran Affairs Health Services Research and Development Center for Clinical Management Research, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Reinier G S Meester
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Good NM, Macrae FA, Young GP, O'Dywer J, Slattery M, Venables W, Lockett TJ, O'Dwyer M. Ideal colonoscopic surveillance intervals to reduce incidence of advanced adenoma and colorectal cancer. J Gastroenterol Hepatol 2015; 30:1147-54. [PMID: 25611802 DOI: 10.1111/jgh.12904] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS There is limited information about the interplay between multiple risk factors contributing to the risk of advanced neoplasia. We determined the actual risk for advanced neoplasia in relation to lapsed time between colonoscopies in people enrolled in a structured surveillance program. This risk information can be used to guide the selection of optimal surveillance intervals. METHODS Patients were recruited into programs at two major tertiary hospitals, with a personal or family history of advanced neoplasia. Five thousand one hundred forty-one patients had an index and one or more surveillance colonoscopies. Fifty-one percent had a family history of colorectal neoplasia while the remainder had a personal history. RESULTS Patients with an immediately prior colonoscopy result (prior result) of advanced adenoma had a risk for advanced neoplasia 7.1 times greater than those with a normal prior result. Cancer as a prior result did not confer a greater risk than either a hyperplastic polyp or a nonadvanced adenoma. Being female reduced risk, age increased risk. Only a family history of a first-degree relative diagnosed under 55, or definite or suspected hereditary nonpolyposis colorectal cancer (HNPCC) conferred an increased risk over a personal history of advanced neoplasia. CONCLUSIONS Most family history categories did not confer excess risk above personal history of advanced neoplasia. A prior cancer poses less of a risk than a prior advanced adenoma. Based on our models, a person with an advanced adenoma should be scheduled for colonoscopy at 3 years, corresponding to a 15% risk of advanced neoplasia for a male aged under 56. Guidelines should be updated that uses a 15% risk as a benchmark for calculating surveillance intervals.
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Affiliation(s)
- Norm M Good
- CSIRO Digital Productivity, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Australian e-Health Research Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Finlay A Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Graeme P Young
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia, Australia
| | - John O'Dywer
- Australian e-Health Research Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Masha Slattery
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - William Venables
- CSIRO Digital Productivity, Ecosciences Precinct, Dutton Park, Queensland, Australia
| | - Trevor J Lockett
- CSIRO Food & Nutrition, Riverside Corporate Park, North Ryde, New South Wales, Australia
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Kruse GR, Khan SM, Zaslavsky AM, Ayanian JZ, Sequist TD. Overuse of colonoscopy for colorectal cancer screening and surveillance. J Gen Intern Med 2015; 30:277-83. [PMID: 25266407 PMCID: PMC4351286 DOI: 10.1007/s11606-014-3015-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/08/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources. OBJECTIVE Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse. DESIGN, SETTING, AND PARTICIPANTS Our approach was a retrospective cohort study using electronic health record data for patients 50-65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice. MAIN OUTCOME MEASURES We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies. KEY RESULTS We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88%) and many surveillance colonoscopies (49%) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1-10.0; hyperplastic polyp: 5.7 years, IQR: 4.9-9.7; low-risk adenoma: 5.1 years, IQR: 3.3-6.3; high-risk adenoma: 2.9 years, IQR: 2.0-3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95% CI: 3.15-12.50) and surveillance colonoscopy (OR 13.47, 95% CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam. CONCLUSIONS Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.
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Affiliation(s)
- Gina R Kruse
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA,
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Affiliation(s)
- Sameer D. Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Frank van Hees
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sandeep Vijan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Saini SD, Waljee AK, Schoenfeld P, Kerr EA, Vijan S. The increasing importance of quality measures for trainees. Gastroenterology 2014; 147:725-9. [PMID: 25157667 PMCID: PMC4426945 DOI: 10.1053/j.gastro.2014.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Sameer D. Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI,Department of Internal Medicine, University of Michigan Medical School
| | - Akbar K. Waljee
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI,Department of Internal Medicine, University of Michigan Medical School
| | - Philip Schoenfeld
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI,Department of Internal Medicine, University of Michigan Medical School
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI,Department of Internal Medicine, University of Michigan Medical School
| | - Sandeep Vijan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI,Department of Internal Medicine, University of Michigan Medical School
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Prasad V, Jena AB. The Peltzman effect and compensatory markers in medicine. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2014; 2:170-172. [PMID: 25396116 DOI: 10.1016/j.hjdsi.2014.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Unintended consequences of health care interventions are unavoidable. For example, computerized order entry systems, implemented to reduce prescription errors, catalyze novel errors of their own, with providers unexpectedly relying on these systems to provide default dosing information rather than locating appropriate treatment guidelines. We argue that unintended behavioral responses by patients and physicians to health care interventions may explain why certain health care interventions that seem logical and foolproof fail to demonstrate real-world benefits. We argue that compensatory markers which measure behavioral responses in clinical trials should be implemented to better understand why real-world benefits fail to materialize.
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Affiliation(s)
- Vinay Prasad
- Medical Oncology Branch, National Cancer Institute, National Institutes of Health, 10 Center Dr. 10/12N226, Bethesda, MD 20892
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; Tel: 617-432-8322; Massachusetts General Hospital, Boston, MA; and National Bureau of Economic Research, Cambridge, MA
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Djulbegovic B. A Framework to Bridge the Gaps Between Evidence-Based Medicine, Health Outcomes, and Improvement and Implementation Science. J Oncol Pract 2014; 10:200-2. [DOI: 10.1200/jop.2013.001364] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Enhancing application of evidence-based medicine along with rigorous monitoring of quality of care is the key to improvement of the current unsatisfactory situation. However, calls to improve use of evidence-based interventions remain unheeded.
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