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Hicks CW, Conte MS, Dun C, Makary MA. Appropriateness of Care Measures: A Novel Approach to Quality. Ann Vasc Surg 2024; 107:186-194. [PMID: 38582205 PMCID: PMC11365803 DOI: 10.1016/j.avsg.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Abstract
The clinical judgment of a physician is one of the most important aspects of medical quality, yet it is rarely captured with quality measures in use today. We propose a novel approach using individualized physician benchmarking that measures the appropriateness of care that a physician delivers by looking at their practice pattern in a specific clinical situation. A prime application of our novel approach to appropriateness measures is the surgical management of peripheral artery disease and claudication. We discuss 4 potential consensus metrics for the treatment of claudication that explore appropriateness of care of claudication management and are meaningful, actionable, and quantifiable. Given the multitude of medical specialties involved in the care of patients with peripheral artery disease and the consequences of both preemptive and delayed care, it is in all of our interests to promote data transparency with confidential communications to outlier physicians while advocating for evidence-based management.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Dun C, Walsh CM, Hicks CW, Stasko T, Vidimos AT, Leshin B, Billingsley EM, Coldiron BM, Bennett RG, Marks VJ, Otley C, Rogers HW, Goldman GD, Albertini JG, Makary MA. 5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study. Dermatol Surg 2024; 50:558-564. [PMID: 38578837 PMCID: PMC11136260 DOI: 10.1097/dss.0000000000004165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.
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Affiliation(s)
- Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christi M. Walsh
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas Stasko
- Department of Dermatology, University of Oklahoma, Oklahoma City, Oklahoma
| | | | - Barry Leshin
- The Skin Surgery Center, Winston Salem, North Carolina
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | | | | | | | | | - Clark Otley
- College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | | | | | - John G. Albertini
- The Skin Surgery Center, Winston Salem, North Carolina
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Martin A. Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Carey Business School, Baltimore, Maryland
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Dun C, Overton HN, Walsh CM, Hennayake S, Wang P, Fahim C, Bicket MC, Makary MA. A Peer Data Benchmarking Intervention to Reduce Opioid Overprescribing: A Randomized Controlled Trial. Am Surg 2023; 89:4379-4387. [PMID: 35762831 DOI: 10.1177/00031348221111519] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Driving physician behavior change has been an elusive goal for quality improvement efforts aimed at reducing low-value care. We proposed the use of "nudge" interventions at the surgeon level in order to reduce post-surgical opioid overprescribing in accordance with consensus guidelines. METHODS We used 2017 Medicare data to identify outlier surgeons. A peer data benchmarking report that showed each surgeon the average number of opioid tablets they prescribed for an open inguinal hernia repair procedure from January 1, 2017 to December 31, 2017. We conducted a 1:1 randomized controlled trial providing outlier surgeons a report of their opioid prescribing patterns for a standard operation compared to the national average and prescribing guidelines. RESULTS There were 489 surgeons randomized to the intervention, of which 180 (36.8%) had data in the post-intervention period. Data was available for 87 surgeons in the intervention group and 93 surgeons in the control group. 97.7% of surgeons in the intervention group reduced their opioid prescribing pattern compared to 95.7% in the control group. Surgeons who received the data benchmarking report intervention prescribed 14.3% less opioids than surgeons in the control group (10.54 (SD 5.34) vs. 12.30 (SD 6.02), P = .04). The intervention was associated with a 1.83 lower mean number of opioid tablets prescribed per patient in the multivariable linear regression model after controlling for other factors (Intervention group vs. control group 95% CI [-3.61, -.04], P = .04). DISCUSSION The implementation of a peer data benchmarking intervention can drive physician behavior change towards high-value care.
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Affiliation(s)
- Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heidi N Overton
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christi M Walsh
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sanuri Hennayake
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine Fahim
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, MA, USA
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MA, USA
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
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Nardi A, Mitrova S, Angelici L, De Gregorio CG, Biliotti D, De Vito C, Vecchi S, Davoli M, Agabiti N, Acampora A. Developing a Questionnaire Evaluating Knowledge, Attitudes and Behaviors on Audit & Feedback among General Practitioners: A Mixed Methods Study. Healthcare (Basel) 2023; 11:healthcare11091211. [PMID: 37174753 PMCID: PMC10178397 DOI: 10.3390/healthcare11091211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Audit and Feedback (A&F) is one of the most common strategies used to improve quality in healthcare. However, there is still lack of awareness regarding the enabling factors and barriers that could influence its effectiveness. The aim of this study was to develop a questionnaire to measure the knowledge, attitudes and behaviors of general practitioners (GPs) regarding A&F. The study was performed in the context of the EASY-NET program (project code NET-2016-02364191). METHODS The survey was developed according to two steps. Firstly, a scoping review was performed in order to map the literature on the existing similar instruments with the aim of identifying the sub-domains and possible items to include in a preliminary version of the questionnaire. In the second phase, the questionnaire was reviewed by a multidisciplinary group of experts and administrated to a convenience sample in a pilot survey. RESULTS Ten papers were included in the scoping review. The survey target and development methodology were heterogenous among the studies. The knowledge, attitudes and behaviors domains were assessed in six, nine and seven studies, respectively. In the first step, 126 pertinent items were extracted and categorized as follows: 8 investigated knowledge, 93 investigated attitudes, and 25 investigated behaviors. Then, 2 sub-domains were identified for knowledge, 14 for attitudes and 7 for behavior. Based on these results, a first version of the survey was developed via consensus among two authors and then revised by the multidisciplinary group of experts in the field of A&F. The final version of the survey included 36 items: 8 in the knowledge domain, 19 in the attitudes domain and 9 in the behaviors domain. The results of the pilot study among 15 GPs suggested a good acceptability and item relevance and accuracy, with positive answers totaling 100% and 93.3% in the proposed questions. CONCLUSIONS The methodology used has shown to be a good strategy for the development of the survey. The survey will be administrated before and after the implementation of an A&F intervention to assess both baseline characteristics and changes after the intervention.
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Affiliation(s)
- Angelo Nardi
- Local Health District 2, Local Health Authority Roma 1, 00193 Rome, Italy
| | - Suzanna Mitrova
- Department of Epidemiology of the Regional Health Service of the Lazio Region, Local Health Authority Roma 1, Via Cristoforo Colombo, 112, 00154 Rome, Italy
| | - Laura Angelici
- Department of Epidemiology of the Regional Health Service of the Lazio Region, Local Health Authority Roma 1, Via Cristoforo Colombo, 112, 00154 Rome, Italy
| | | | - Donatella Biliotti
- Local Health District 13, Local Health Authority Roma 1, 00193 Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Rome, Italy
| | - Simona Vecchi
- Department of Epidemiology of the Regional Health Service of the Lazio Region, Local Health Authority Roma 1, Via Cristoforo Colombo, 112, 00154 Rome, Italy
| | - Marina Davoli
- Department of Epidemiology of the Regional Health Service of the Lazio Region, Local Health Authority Roma 1, Via Cristoforo Colombo, 112, 00154 Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology of the Regional Health Service of the Lazio Region, Local Health Authority Roma 1, Via Cristoforo Colombo, 112, 00154 Rome, Italy
| | - Anna Acampora
- Department of Epidemiology of the Regional Health Service of the Lazio Region, Local Health Authority Roma 1, Via Cristoforo Colombo, 112, 00154 Rome, Italy
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Parker G, Shahid N, Rappon T, Kastner M, Born K, Berta W. Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review. Implement Sci 2022; 17:6. [PMID: 35057832 PMCID: PMC8772067 DOI: 10.1186/s13012-021-01177-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care. METHODS We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review. RESULTS Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently. CONCLUSIONS This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.
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Affiliation(s)
- Gillian Parker
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Nida Shahid
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Tim Rappon
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Monika Kastner
- Centre for Research and Innovation, North York General Hospital, 4001, Leslie Street, Toronto, Ontario M2K 1E1 Canada
| | - Karen Born
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6 Canada
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