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Tchou MJ, Hall M, Markham JL, Stephens JR, Steiner MJ, McCoy E, Aronson PL, Shah SS, Molloy MJ, Cotter JM. Changing patterns of routine laboratory testing over time at children's hospitals. J Hosp Med 2024; 19:671-679. [PMID: 38643414 PMCID: PMC11296890 DOI: 10.1002/jhm.13372] [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: 11/06/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A >2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all 10 years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.
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Affiliation(s)
- Michael J. Tchou
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas, USA
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John R. Stephens
- North Carolina Children’s Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J. Steiner
- North Carolina Children’s Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of General Pediatrics, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samir S. Shah
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew J. Molloy
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jillian M. Cotter
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children’s Hospital Colorado, Aurora, Colorado, USA
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Baskar D, Jarmul JA, Donnelly LF. Expenditure mapping of pediatric imaging costs using a resource utilization band analysis of claims data. Curr Probl Diagn Radiol 2024:S0363-0188(24)00129-4. [PMID: 39048500 DOI: 10.1067/j.cpradiol.2024.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE To segregate imaging expenditures from claims data by resource utilization bands (RUBs) and underlying conditions to create an "expenditure map" of pediatric imaging costs. METHODS A Claims data for children enrolled in a commercial value-based plan were categorized by RUB 0 non-user, 1 healthy user, 2 low morbidity, 3 moderate morbidity, 4 high morbidity, & 5 very high morbidity. The per member per year (PMPY) expense, total imaging spend, and imaging modality with the highest spend were assessed for each RUB. Diagnosis categories associated with high imaging costs were also evaluated. RESULTS There were 40,022 pediatric plan members. 14% had imaging-related claims accounting for approximately $2.8 million in expenditures. Member distribution and mean PMPY expenditure RUB was respectively: RUB 0 (3,037, $0), RUB 1 (6,604, $7), RUB 2 - 13,698, $27), RUB 3 - 13,341, $87), RUB 4 (2,810, $268), RUB 5 (532, $841). RUB 3 had the largest total imaging costs at $1,159,523. The imaging modality with the greatest mean PMPY expense varied by RUB with radiography highest in lower RUBs and MRI highest in higher RUBs. The top 3 diagnoses associated with the highest total imaging costs were developmental disorders ($443,980), asthma ($388,797), and congenital heart disease ($294,977) and greatest mean PMPY imaging expenditures malignancy/leukemia ($3,100), transplant ($2,639), and tracheostomy ($1,661). DISCUSSION Expense mapping using claims data allows for a better understanding of the distribution of imaging costs across a covered pediatric population. This tool may assist organizations in planning effective cost-reduction initiatives and learning how imaging utilization varies by patient complexity in their system.
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Affiliation(s)
- Danika Baskar
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jamie A Jarmul
- University of North Carolina Health Alliance, Morrisville, NC, USA
| | - Lane F Donnelly
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA; University of North Carolina Health Alliance, Morrisville, NC, USA.
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Kjelle E, Brandsæter IØ, Andersen ER, Hofmann BM. Cost of Low-Value Imaging Worldwide: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:485-501. [PMID: 38427217 PMCID: PMC11178636 DOI: 10.1007/s40258-024-00876-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide. METHODS This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive. RESULTS Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients. CONCLUSIONS This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.
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Affiliation(s)
- Elin Kjelle
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Ingrid Øfsti Brandsæter
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Bjørn Morten Hofmann
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics at the University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
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Dindinger-Hill K, Horns J, Ambrose J, Vehawn J, Choudry M, Hunt TC, Chipman J, Haaland B, Li J, Hanson HA, O’Neil B. Effect of Health Service Area on Primary Care Physician Provision of Low-Value Cancer Screening. Ann Intern Med 2024; 177:583-591. [PMID: 38648640 PMCID: PMC11200206 DOI: 10.7326/m23-1456] [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] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Using a health systems approach to investigate low-value care (LVC) may provide insights into structural drivers of this pervasive problem. OBJECTIVE To evaluate the influence of service area practice patterns on low-value mammography and prostate-specific antigen (PSA) testing. DESIGN Retrospective study analyzing LVC rates between 2008 and 2018, leveraging physician relocation in 3-year intervals of matched physician and patient groups. SETTING U.S. Medicare claims data. PARTICIPANTS 8254 physicians and 56 467 patients aged 75 years or older. MEASUREMENTS LVC rates for physicians staying in their original service area and those relocating to new areas. RESULTS Physicians relocating from higher-LVC areas to low-LVC areas were more likely to provide lower rates of LVC. For mammography, physicians staying in high-LVC areas (LVC rate, 10.1% [95% CI, 8.8% to 12.2%]) or medium-LVC areas (LVC rate, 10.3% [CI, 9.0% to 12.4%]) provided LVC at a higher rate than physicians relocating from those areas to low-LVC areas (LVC rates, 6.0% [CI, 4.4% to 7.5%] [difference, -4.1 percentage points {CI, -6.7 to -2.3 percentage points}] and 5.9% [CI, 4.6% to 7.8%] [difference, -4.4 percentage points {CI, -6.7 to -2.4 percentage points}], respectively). For PSA testing, physicians staying in high- or moderate-LVC service areas provided LVC at a rate of 17.5% (CI, 14.9% to 20.7%) or 10.6% (CI, 9.6% to 13.2%), respectively, compared with those relocating from those areas to low-LVC areas (LVC rates, 9.9% [CI, 7.5% to 13.2%] [difference, -7.6 percentage points {CI, -10.9 to -3.8 percentage points}] and 6.2% [CI, 3.5% to 9.8%] [difference, -4.4 percentage points {CI, -7.6 to -2.2 percentage points}], respectively). Physicians relocating from lower- to higher-LVC service areas were not more likely to provide LVC at a higher rate. LIMITATION Use of retrospective observational data, possible unmeasured confounding, and potential for relocating physicians to practice differently from those who stay. CONCLUSION Physicians relocating to service areas with lower rates of LVC provided less LVC than physicians who stayed in areas with higher rates of LVC. Systemic structures may contribute to LVC. Understanding which factors are contributing may present opportunities for policy and interventions to broadly improve care. PRIMARY FUNDING SOURCE National Cancer Institute of the National Institutes of Health.
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Affiliation(s)
| | - Joshua Horns
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Jacob Ambrose
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey Vehawn
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | | | - Trevor C. Hunt
- Department of Urology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jonathan Chipman
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Benjamin Haaland
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Jiaming Li
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Heidi A. Hanson
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, USA
- Computational Sciences and Engineering Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee, USA
| | - Brock O’Neil
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
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Donnelly LF, Dellva BP, Jarmul JA, Steiner MJ, Shaheen AW. Evaluation of claims data from a commercial value-based insurance product shows pediatric imaging is not a major driver of overall or pediatric healthcare expenditures. Pediatr Radiol 2024; 54:842-848. [PMID: 38200270 DOI: 10.1007/s00247-023-05845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Initiatives to reduce healthcare expenditures often focus on imaging, suggesting that imaging is a major driver of cost. OBJECTIVE To evaluate medical expenditures and determine if imaging was a major driver in pediatric as compared to adult populations. METHODS We reviewed all claims data for members in a value-based contract between a commercial insurer and a healthcare system for calendar years 2021 and 2022. For both pediatric (<18 years of age) and adult populations, we analyzed average per member per year (PMPY) medical expenditures related to imaging as well as other categories of large medical expenses. Average PMPY expenditures were compared between adult and pediatric patients. RESULTS Children made up approximately 20% of members and 21% of member months but only 8-9% of expenditures. Imaging expenditures in pediatric members were 0.2% of the total healthcare spend and 2.9% of total pediatric expenditures. Imaging expenditures per member were seven times greater in adults than children. The rank order of imaging expenditures and imaging modalities was also different in pediatric as compared to adult members. CONCLUSION Evaluation of claims data from a commercial value-based insurance product shows that pediatric imaging is not a major driver of overall, nor pediatric only, healthcare expenditures.
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Affiliation(s)
- Lane F Donnelly
- University of North Carolina Health Alliance, Morrisville, NC, USA.
- Departments of Radiology, University of North Carolina School of Medicine, 101 Manning Drive, 2000 Old Clinic, CB# 7510, Chapel Hill, NC, 27599-7510, USA.
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | | | - Jamie A Jarmul
- University of North Carolina Health Alliance, Morrisville, NC, USA
| | - Michael J Steiner
- University of North Carolina Health Alliance, Morrisville, NC, USA
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Amy W Shaheen
- University of North Carolina Health Alliance, Morrisville, NC, USA
- Department of Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Rung JM, Aliu O, Barrett TS, LeJeune K, Farah TG. Prevalence and Cost of Routine Preoperative Care for Low-Risk Cataract Surgery a Decade after Choosing Wisely. Ophthalmology 2024; 131:577-588. [PMID: 38092081 DOI: 10.1016/j.ophtha.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/07/2023] [Accepted: 12/01/2023] [Indexed: 01/30/2024] Open
Abstract
PURPOSE Examine the frequency and cost of procedural clearance tests and examinations in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the United States. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts postsurgical adverse events. DESIGN Retrospective healthcare claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania. PARTICIPANTS Members aged ≥ 65 years who were continuously enrolled 6 months before and after undergoing cataract surgery from 2018 to 2021 and had approved surgery claims. METHODS Preoperative exams or tests occurring in the 30 days before surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., Current Procedural Terminology codes for blood panels and preprocedural International Classification of Diseases, 10th Revision, Clinical Modification codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling. MAIN OUTCOME MEASURES Total costs, prevalence, and strength of association as indicated by odds ratios. RESULTS Up to 42% of members undergoing cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed in isolation or along with clearance visits. The combined costs for the preoperative visits and tests were $4.3 million (approximately $107-$114 per impacted member). There was little difference in member characteristics between those receiving and not receiving preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member's care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two. CONCLUSIONS Rates of routine preoperative testing before cataract surgery appear similar to those prior to the implementation of the Choosing Wisely campaign, which was meant to reduce this use. Additionally, preoperative evaluations, many likely unnecessary, were common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
| | - Oluseyi Aliu
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Keith LeJeune
- Highmark Health, Pittsburgh, Pennsylvania; Allegheny Health Network, Pittsburgh, Pennsylvania
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Kuo YC, Lin KC, Tan ECH. Discrepancies Among Hospitals and Regions in the Provision of Low-Value Care. Int J Health Policy Manag 2024; 13:7876. [PMID: 38618842 PMCID: PMC11270608 DOI: 10.34172/ijhpm.2024.7876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 03/16/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Low-value care (LVC) is a critical issue in terms of patient safety and fiscal policy; however, little has been known in Asia. For the purpose of better understanding the extent of LVC on a national level, the utilization, costs, and associated characteristics of selected international recommendations were assessed in this study. METHODS This retrospective cohort study used the National Health Insurance (NHI) claims data during 2013-2017 to evaluate the LVC utilization. Adult beneficiaries who enrolled in the NHI program and received at least one of the low-value services in hospitals were included. We measured seven procedures derived from the international recommendations at the hospital level, and a composite measure was created by summing the total utilization of selected services to determine the overall prevalence and corresponding cost. The generalized estimating equation (GEE) model was adopted to estimate the association. RESULTS A total of 1 970 496 episodes of LVC was identified among 1 218 146 beneficiary-year observations and 2054 hospital-year observations. Overall, the utilization rate of the composite measure increased from 150.70 to 186.23 episodes per 10 000 beneficiaries with the growth in cost from US$ 5.40 to US$ 6.90 million. LVC utilization was proportional to the volume of outpatient visits and length of stay. Also, hospitals with a large volume of outpatient visits (adjusted odds ratio [aOR]: 95% CI, 2.10: 1.26 to 3.49 for Q2-Q3, 2.88: 1.45 to 5.75 for ≥Q3) and a higher proportion of older patients (aOR: 95% CI, 1.06: 1.02 to 1.11) were more likely to have high costs. CONCLUSION The utilization and corresponding cost of LVC appeared to increase annually despite the relatively lower prevalence compared to other countries. Multicomponent interventions such as recommendations, de-implementation policies and payment reforms are considered effective ways to reduce LVC. Repeated measurements would be needed to evaluate the effectiveness of interventions.
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Affiliation(s)
- Yu-Chen Kuo
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuan-Chia Lin
- Community Medicine Research Center, Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Elise Chia-Hui Tan
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung, Taiwan
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Romero-Velez G, Noureldine SI, Burneikis T, Siperstein A. High-volume endocrine surgeons perform thyroid surgery at decreased cost despite increased case relative value units. Surgery 2024; 175:782-787. [PMID: 37770347 DOI: 10.1016/j.surg.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/21/2023] [Accepted: 07/08/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Healthcare systems are transitioning to value-based payment models based on analysis of quality over cost. To gain an understanding of the relationship between surgeon volume and health care costs, we compared the direct costs of thyroidectomy performed by dedicated high-volume endocrine surgeons and low-volume surgeons within a large health care system. METHODS We evaluated all thyroid surgeries performed within a single billing year at a single health care system. We defined high-volume surgeons as those who treated >50 thyroid cases yearly and compared them to low-volume surgeons. To account for multicomponent procedures, we added the relative value units for the components of the cases. Then, we divided them into low-relative value units, intermediate-relative value units, and high-relative value units groups. We analyzed categorical and continuous variables using the χ2 analysis and Wilcoxon rank sum test, respectively. RESULTS We identified 674 thyroidectomy procedures performed by 27 surgeons, of whom 6 high-volume surgeons performed 79% of cases. Relative value unit distribution differed between the groups, with high-volume surgeons performing more intermediate-relative value unit (58% vs 34.7%, P < .01) and high-relative value unit (24.6% vs 20.6%, P < .01) cases, whereas low-volume surgeons performed more low-relative value unit cases (45% vs 17%, P < .01). Overall, high-volume surgeons incurred a 26% reduction in total costs (P < .01) and a 33% reduction in discretionary expenses (P < .01) across all relative value unit groups. CONCLUSION High-volume endocrine surgeons perform thyroid procedures at a lower cost than their low-volume counterparts, a difference that is magnified when stratified by relative value unit groups.
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Affiliation(s)
| | - Salem I Noureldine
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC. https://twitter.com/snoureldine
| | - Talia Burneikis
- Department of Endocrine and General Surgery, Integris Baptist Medical Center, Oklahoma City, OK
| | - Allan Siperstein
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
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Reynolds CA, Nair V, Villaflores C, Dominguez K, Arbanas JC, Treasure M, Skootsky S, Tseng CH, Sarkisian C, Patel A, Ghassemi K, Fendrick AM, May FP, Mafi JN. Developing an electronic health record measure of low-value esophagogastroduodenoscopy for GERD at a large academic health system. BMJ Open Qual 2023; 12:e002363. [PMID: 38135304 DOI: 10.1136/bmjoq-2023-002363] [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: 03/31/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES Low-value esophagogastroduodenoscopies (EGDs) for uncomplicated gastro-oesophageal reflux disease (GERD) can harm patients and raise patient and payer costs. We developed an electronic health record (EHR) 'eMeasure' to detect low-value EGDs. DESIGN Retrospective cohort of 518 adult patients diagnosed with GERD who underwent initial EGD between 1 January 2019 and 31 December 2019. SETTING Outpatient primary care and gastroenterology clinics at a large, urban, academic health centre. PARTICIPANTS Adult primary care patients at the University of California Los Angeles who underwent initial EGD for GERD in 2019. MAIN OUTCOME MEASURES EGD appropriateness criteria were based on the American College of Gastroenterology 2012 guidelines. An initial EGD was considered low-value if it lacked a documented guideline-based indication, including alarm symptoms (eg, iron-deficiency anaemia); failure of an 8-week proton pump inhibitor trial or elevated Barrett's oesophagus risk. We performed manual chart review on a random sample of 204 patients as a gold standard of the eMeasure's validity. We estimated EGD costs using Medicare physician and facility fee rates. RESULTS Among 518 initial EGDs performed (mean age 53 years; 54% female), the eMeasure identified 81 (16%) as low-value. The eMeasure's sensitivity was 42% (95% CI 22 to 61) and specificity was 93% (95% CI 89 to 96). Stratifying across clinics, 62 (74.6%) low-value EGDs originated from 2 (12.5%) out of 16 clinics. Total cost for 81 low-value EGDs was approximately US$75 573, including US$14 985 in patients' out-of-pocket costs. CONCLUSIONS We developed a highly specific eMeasure that showed that low-value EGDs occurred frequently in our healthcare system and were concentrated in a minority of clinics. These results can inform future QI efforts at our institution, such as best practice alerts for the ordering physician. Moreover, this open-source eMeasure has a much broader potential impact, as it can be integrated into any EHR and improve medical decision-making at the point of care.
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Affiliation(s)
- Courtney A Reynolds
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Vishnu Nair
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Chad Villaflores
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Katherine Dominguez
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Julia Cave Arbanas
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Madeline Treasure
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Samuel Skootsky
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Catherine Sarkisian
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Veterans' Administration Greater Los Angeles Healthcare System, Geriatric Research Education & Clinical Center (GRECC), birmingham, Alabama, USA
| | - Arpan Patel
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kevin Ghassemi
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - A Mark Fendrick
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Folasade P May
- UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, Los Angeles, Calif, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- RAND Health, RAND Corporation, Santa Monica, California, USA
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Hery D, Schwarte B, Patel K, Elliott JO, Vasko S. Plastic Surgery Tourism: Complications, Costs, and Unnecessary Spending? Aesthet Surg J Open Forum 2023; 6:ojad113. [PMID: 38213470 PMCID: PMC10783483 DOI: 10.1093/asjof/ojad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Background The liability of plastic surgery tourism in patient health and postoperative resource allocation is significant. Procedures completed within the context of medical tourism often lack rigorous quality assurance and provide limited preoperative evaluation or postoperative care. Not only does this jeopardize the patient's well-being, but it also increases the financial burden and redirects invaluable resources domestically through often unnecessary diagnostic tests and hospitalizations. Objectives This manuscript will examine the complications and associated costs following plastic surgery tourism and highlight unnecessary expenses for patients with outpatient complications. Methods A retrospective review was conducted of all patients 18 years or older who underwent destination surgery and were seen within 1 year postoperatively in consultation with plastic surgery at our health system between January 11, 2015 and January 7, 2022. Patient admissions were reviewed and deemed necessary or unnecessary after review by 2 physicians. Results The inclusion criteria were met by 41 patients, of whom hospitalization was deemed necessary in 28 patients vs unnecessary in 13 patients. The most common procedures included abdominoplasty, liposuction, breast augmentation, and "Brazilian butt lift." The most common complications were seroma and infection. Patients deemed to have a necessary admission often required at least 1 operation, were more likely to need intravenous antibiotics, were less likely to have the diagnosis of "pain," necessitated a longer hospitalization, and incurred a higher cost. The total financial burden was $523,272 for all 41 patients. Conclusions Plastic surgery tourism poses substantial health risks, the morbidities are expensive, and it strains hospital resources. Level of Evidence 5
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Affiliation(s)
- Danielle Hery
- Corresponding Author: Dr Danielle Hery, OhioHealth Riverside Methodist Hospital, 3535 Olentangy River Rd, Columbus, OH 43214, USA. E-mail:
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11
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McCormick C, Ahluwalia S, Segon A. Effect of a Performance Feedback Dashboard on Hospitalist Laboratory Test Utilization. Am J Med Qual 2023; 38:273-278. [PMID: 37908029 DOI: 10.1097/jmq.0000000000000150] [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: 11/02/2023]
Abstract
BACKGROUND Healthcare spending continues to be an area of improvement across all forms of medicine. Overtreatment or low-value care, including overutilization of laboratory testing, has an estimated annual cost of waste of $75.7-$101.2 billion annually. Providing performance feedback to hospitalists has been shown to be an effective way to encourage the practice of quality-improvement-focused medicine. There remains limited data regarding the implementation of performance feedback and direct results on hospital laboratory testing spending in the short term. OBJECTIVE The objective of this project was to identify whether performance-based feedback on laboratory utilization between both hospitalists and resident teams results in more conservative utilization of laboratory testing. DESIGN, SETTING, PARTICIPANTS This quality improvement project was conducted at a tertiary academic medical center, including both direct-care and house-staff teams. INTERVENTION OR EXPOSURE A weekly performance feedback report was generated and distributed to providers detailing laboratory test utilization by all hospitalists in a ranked system, normalized by the census of patients, for 3 months. MAIN OUTCOMES AND MEASURES The outcome measure was cumulative laboratory utilization during the intervention period compared to baseline utilization during the corresponding 3 months in the year prior and the weekly trend in laboratory utilization over 52 weeks. The aggregate laboratory utilization rate during intervention and control time periods was defined as the total number of laboratory tests ordered divided by the total number of patient encounters. Additionally, the cost difference was averaged per quarter and reported. The week-by-week trend in laboratory utilization was evaluated using a statistical process control (SPC) chart. RESULTS We found that following intervention during January-March 2020, the cumulative complete blood count utilization rate decreased from 5.54 to 4.83 per patient encounter and the basic metabolic panels/CMP utilization rate decreased from 6.65 to 6.11 per patient encounter compared with January-March 2019. This equated to cost savings of ~$42,700 in total for the quarter. Nonrandom variation was seen on SPC charts in weekly laboratory utilization rates for common laboratory tests during the intervention period. CONCLUSIONS We found that our intervention did result in a decrease in laboratory test utilization rates across direct-care and house-staff teams. This study lays promising groundwork for one tool that can be used to eliminate a source of hospital waste and improve the quality and efficiency of patient care.
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Affiliation(s)
| | | | - Ankur Segon
- Medicine, University of Texas Health Science Center, San Antonio, TX
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Harris AHS, Finlay AK, Hagedorn HJ, Manfredi L, Jones G, Kamal RN, Sears ED, Hawn M, Eisenberg D, Pershing S, Mudumbai S. Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. J Gen Intern Med 2023; 38:3209-3215. [PMID: 37407767 PMCID: PMC10651557 DOI: 10.1007/s11606-023-08287-0] [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: 12/20/2022] [Accepted: 06/14/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described. OBJECTIVE We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice. DESIGN Qualitative study of semi-structured telephone interviews. PARTICIPANTS We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate. APPROACH Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations. KEY RESULTS Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures). CONCLUSIONS We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.
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Affiliation(s)
- Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA.
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Luisa Manfredi
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Gabrielle Jones
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Erika D Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System , Ann Arbor, MI, USA
- University of Michigan Department of Surgery, Ann Arbor, MI, USA
| | - Mary Hawn
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dan Eisenberg
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Suzann Pershing
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Seshadri Mudumbai
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Ellenbogen MI, Drmanovic A, Segal JB, Kapoor S, Wagner PC. Patient, provider, and system-level factors associated with preoperative cardiac testing: A systematic review. J Hosp Med 2023; 18:1021-1033. [PMID: 37728150 PMCID: PMC10877614 DOI: 10.1002/jhm.13206] [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: 08/08/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Overuse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system-level factors associated with variation in testing have not been systematically studied. OBJECTIVE To conduct a systematic review to better delineate the patient, provider, and system-level factors associated with variation in preoperative cardiac testing. METHODS We included studies of an adult US population evaluating a patient, provider, or system-level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle-Ottawa Scale and Evidence Project Risk of Bias tool. RESULTS Twenty-eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher-intensity testing. The evidence for provider and system-level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low-value testing can be successful. CONCLUSIONS There is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well-defined. Further work should aim to better understand these factors.
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Affiliation(s)
| | - Aleksandra Drmanovic
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins Carey School of Business, 100 International Drive, Baltimore, MD, 21202, USA
| | - Jodi B. Segal
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Shrey Kapoor
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins Carey School of Business, 100 International Drive, Baltimore, MD, 21202, USA
| | - Phillip C. Wagner
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
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Ganguli I, Mackwood MB, Yang CWW, Crawford M, Mulligan KL, O'Malley AJ, Fisher ES, Morden NE. Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study. BMJ 2023; 383:e074908. [PMID: 37879735 PMCID: PMC10599254 DOI: 10.1136/bmj-2023-074908] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States. DESIGN Retrospective cohort study SETTING: 100% Medicare fee-for-service administrative data (2016-18). PARTICIPANTS Black and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States. MAIN OUTCOME MEASURES Receipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system's population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt. RESULTS The cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v 3.2%) and head computed tomography scans for dizziness (3.1% v 1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v 6.5%), prostate specific antigen tests (31.0% v 25.7%), and antibiotics for upper respiratory infections (36.6% v 32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems. CONCLUSIONS Black patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew B Mackwood
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Ching-Wen Wendy Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maia Crawford
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elliott S Fisher
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- UnitedHealthcare, Minnetonka, MN, USA
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Rockwell MS, Armbruster SD, Capucao JC, Russell KB, Rockwell JA, Perkins KE, Huffstetler AN, Mafi JN, Fendrick AM. Reallocating Cervical Cancer Preventive Service Spending from Low- to High-Value Clinical Scenarios. Cancer Prev Res (Phila) 2023; 16:385-391. [PMID: 36976753 PMCID: PMC10320459 DOI: 10.1158/1940-6207.capr-22-0531] [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: 12/06/2022] [Revised: 01/16/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023]
Abstract
Timely follow-up care after an abnormal cervical cancer screening test result is critical to the prevention and early diagnosis of cervical cancer. The current inadequate and inequitable delivery of these potentially life-saving services is attributed to several factors, including patient out-of-pocket costs. Waiving of consumer cost-sharing for follow-up testing (e.g., colposcopy and related cervical services) is likely to improve access and uptake, especially among underserved populations. One approach to defray the incremental costs of providing more generous coverage for follow-up testing is reducing expenditures on "low-value" cervical cancer screening services. To explore the potential fiscal implications of a policy that redirects cervical cancer screening resources from potentially low- to high-value clinical scenarios, we analyzed 2019 claims from the Virginia All-Payer Claims Database to quantify (i) total spending on low-value cervical cancer screening and (ii) out-of-pocket costs associated with colposcopy and related cervical services among commercially insured Virginians. In a cohort of 1,806,921 female patients (ages 48.1 ± 24.8 years), 295,193 claims for cervical cancer screening were reported, 100,567 (34.0%) of which were determined to be low-value ($4,394,361 total; $4,172,777 for payers and $221,584 out-of-pocket [$2/patient]). Claims for 52,369 colposcopy and related cervical services were reported ($40,994,016 total; $33,457,518 for payers and $7,536,498 out-of-pocket [$144/patient]). These findings suggest that reallocating savings incurred from unnecessary spending to fund more generous coverage of necessary follow-up care is a feasible approach to enhancing cervical cancer prevention equity and outcomes. PREVENTION RELEVANCE Out-of-pocket fees are a barrier to follow-up care after an abnormal cervical cancer screening test. Among commercially insured Virginians, out-of-pocket costs for follow-up services averaged $144/patient; 34% of cervical cancer screenings were classified as low value. Reallocating low-value cervical cancer screening expenditures to enhance coverage for follow-up care can improve screening outcomes. See related Spotlight, p. 363.
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Affiliation(s)
- Michelle S. Rockwell
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Shannon D. Armbruster
- Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | | | | | | | - Karen E. Perkins
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Alison N. Huffstetler
- The Robert Graham Center, Washington, District of Columbia
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - John N. Mafi
- Division of Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - A. Mark Fendrick
- Center for Value-Based Insurance Design, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Olivares-Tirado P, Zanga R. Waste in health care spending: A scoping review. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2023. [DOI: 10.1080/20479700.2023.2185580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Affiliation(s)
- Pedro Olivares-Tirado
- Research and Development Department of the Superintendency of Health of Chile, Santiago, Chile
- Adjunct researcher at Health Service Development Research Center, University of Tsukuba, Tsukuba, Japan
| | - Rosendo Zanga
- Research and Development Department of the Superintendency of Health of Chile, Santiago, Chile
- School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile
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Harper J, Hunt T, Choudry M, Kapron AL, Cooney KA, Martin C, Ambrose J, O'Neil B. Clinician interest in clinical decision support for PSA-based prostate cancer screening. Urol Oncol 2023; 41:145.e17-145.e23. [PMID: 36610816 PMCID: PMC9992103 DOI: 10.1016/j.urolonc.2022.11.015] [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: 05/29/2022] [Revised: 11/13/2022] [Accepted: 11/21/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the interest of primary care clinicians in utilizing CDS for PSA screening. Evidence suggests that electronic clinical decision support (CDS) may decrease low-value prostate-specific antigen (PSA) testing. However, physician attitudes towards CDS for PSA screening are largely unknown. METHODS A survey was sent to 201 primary care clinicians, including both physicians and Advanced Practice Providers (APP), within a large academic health system. Eligible clinicians cared for male patients aged 40 to 80 years and ordered ≥5 PSA tests in the past year. Respondents were stratified into 3 groups, appropriate screeners, low-value screeners, or rare-screeners, based on responses to survey questions assessing PSA screening practices. The degree of interest in electronic CDS was determined via a composite Likert score comprising relevant survey items. RESULTS Survey response rate was 29% (59/201) consisting of 85% MD/DO and 15% APP respondents. All clinicians surveyed were interested in CDS (P < 0.001) without significant difference between screener groups. Clinicians agreed most uniformly that CDS be evidence-based. Clinicians disagreed on whether CDS would decrease professional discretion over patient decisions. CONCLUSIONS Primary care clinicians are interested in CDS for PSA screening regardless of their current screening practices. Prioritizing CDS features that clinicians value, such as ensuring CDS recommendations are evidence-based, may increase the likelihood of successful implementation, whereas perceived threat to autonomy may be a hinderance to utilization.
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Affiliation(s)
- Jonathan Harper
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Trevor Hunt
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT; Department of Urology, University of Rochester Medical Center, Rochester, NY
| | - Mouneeb Choudry
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ashley L Kapron
- Utah Clinical & Translational Science Institute, University of Utah Health, Salt Lake City, UT
| | - Kathleen A Cooney
- Department of Medicine, Duke Cancer Institute, Duke University School of Medicine, Durham, NC
| | - Christopher Martin
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jacob Ambrose
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Brock O'Neil
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
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Fendrick AM, Mease P, Davis M, Patel P, Matthias W, Nunag D, Mittal M. Continuity of Care Within a Single Patient Support Program for Patients with Rheumatoid Arthritis Prescribed Second or Later Line Advanced Therapy. Adv Ther 2023; 40:990-1004. [PMID: 36604404 PMCID: PMC9815672 DOI: 10.1007/s12325-022-02413-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/16/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Guidelines suggest patients with rheumatoid arthritis (RA) inadequately controlled by tumor-necrosis-factor-inhibitors (TNFis) may benefit from switching to Janus-kinase-inhibitors (JAKis); however, care coordination and access can be complicated. Disruptions in transitioning to JAKi treatment could lead to disease flares requiring hospitalization; however, transitioning between products within the same patient support program (PSP) services aimed at ensuring continuity of care may minimize disruptions. METHODS A retrospective, longitudinal cohort study of adult patients with RA newly prescribed JAKi following TNFi treatment in the Symphony Health claims database. Patients with baseline TNFi use and ≥ 6 months of data before (baseline) and after (follow-up) the initial JAKi claim (approved or denied) were included. Cohorts were defined by transitions between products within the same PSP [adalimumab (ADA) and upadacitinib (UPA)] or not. Disruptions were defined as gap in care ≥ 15 days due to failure/delay in receiving coverage approval or picking up an approved prescription. Disruptions followed by JAKi dispense were considered temporary and those without permanent. Odds ratios (ORs) of disruption and hospitalization were estimated from logistic regressions controlling for patient characteristics and treatment history. RESULTS A total of 2371 patients were included: 317 transitioning from ADA-UPA, 321 TNFi-UPA, 860 ADA-another JAKi, and 873 another TNFi-another JAKi. Temporary and permanent disruptions increased odds of hospitalization by 47% and 123% (both p < 0.05). Temporary disruption rates were lowest for ADA-UPA patients (19%) compared to other TNFi-UPA (25%; OR = 1.46), ADA-other JAKi (29%; OR = 1.59), and other TNFi-other JAKi (31%; OR = 1.74), all p < 0.05. For transitions to UPA, temporary disruptions were lower for patients using the PSP (17%) versus not (24%; OR = 1.45, p < 0.05). No differences were found for permanent disruptions. CONCLUSION Disruptions for patients with RA transitioning from TNFi to JAKi treatment are associated with increased hospitalization rates. Transitioning between drugs within the same PSP could lower the risk of disruption.
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Affiliation(s)
| | - Philip Mease
- Swedish Medical Center/Providence St. Joseph Health and University of Washington School of Medicine, Seattle, WA, USA
| | | | - Pankaj Patel
- AbbVie, Inc, 26525 North Riverwoods Blvd., Mettawa, IL, 60045, USA
| | - Wes Matthias
- AbbVie, Inc, 26525 North Riverwoods Blvd., Mettawa, IL, 60045, USA
| | | | - Manish Mittal
- AbbVie, Inc, 26525 North Riverwoods Blvd., Mettawa, IL, 60045, USA.
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Increasing the value of PSA through improved implementation. Urol Oncol 2023; 41:96-103. [PMID: 34750055 DOI: 10.1016/j.urolonc.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/25/2021] [Indexed: 11/21/2022]
Abstract
Low-value testing and treatment contribute to billions of dollars in waste to the United States health care system annually. High frequency, low-cost testing, including prostate-specific antigen (PSA) testing, is a major contributor to this inefficient health care delivery. Despite decreasing mortality of prostate cancer over the last few decades, the reputation of prostate specific antigen (PSA) for prostate cancer screening has fluctuated over the last decade due to lack of clarity of the benefits of screening and high risk for overtreatment. The value of PSA could be improved by efficient implementation of smarter testing strategies that reduce the harms and increase the benefits.
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Factors Associated with Potentially Inappropriate Screening for Vitamin D Deficiency among Women in Medically Underserved Regions of West Texas. J Clin Med 2023; 12:jcm12030993. [PMID: 36769641 PMCID: PMC9917744 DOI: 10.3390/jcm12030993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
Testing for vitamin D deficiency (VDD) has been on the increase due to its association with several diseases. However, inappropriate testing for VDD, defined as screening for VDD among individuals with a low risk, has been reported. The aim of this study was to evaluate the prevalence and factors associated with potentially inappropriate screening for VDD among medically underserved populations in West Texas. Data were from 21,407 women who were hospitalized from 2016 to 2018 at a large regional health system. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). The median age of patients was 40 years. While the proportion of patients tested for VDD reduced from 8.9% to 7.6% (p = 0.013) from 2016 to 2018, the prevalence of inappropriate testing increased from 32.3% to 46.8% (p < 0.001), with the 3-year prevalence of VDD being 27.6%. White race (OR = 2.71, CI: 1.95-3.78), an age ≥ 65 years (OR = 3.07, CI: 2.05-4.59), the use of public-sponsored insurance (OR = 1.62, CI: 1.20-2.17), cardiovascular disease (OR = 0.75, CI: 0.63-0.90), and vitamin D supplement use (OR = 7.05, CI: 5.82-8.54) were associated with inappropriate testing for VDD. In this study, an increasing prevalence of potentially inappropriate testing for VDD was observed. Sociodemographic and health-related conditions were associated with potentially inappropriate testing for VDD.
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Hoseini Kasnavieh M, Kookli K, Veisi M, Amerzadeh M, Hosseinifar H, Tahmasebi A. Investigating the Rate and Affecting Factors of Unnecessary Cervical Collar Use in Trauma Patients. Bull Emerg Trauma 2023; 11:178-183. [PMID: 38143523 PMCID: PMC10743316 DOI: 10.30476/beat.2023.98793.1441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/05/2023] [Accepted: 08/29/2023] [Indexed: 12/26/2023] Open
Abstract
Objective This study aimed to investigate the necessity of cervical collars in patients with neck problems. Methods This cross-sectional study was conducted on 114 patients who were admitted to the Haft Tir and Rasoul Akram Hospitals (Tehran, Iran) from August to September 2022. The Nexus protocol was used to select the patients with cervical collars. According to the protocol, a cervical collar was required for individuals who had at least one symptom. If none of these symptoms existed, the cervical collar was deemed unnecessary. The data were analyzed using the Chi-square test and Fisher's exact test. Results Of the 114 trauma patients, the cervical collar was used unnecessarily by 49 (43%) patients. Tenderness was the most common complication in 62 patients (54.4%). The prevalence of unnecessary cervical collar use was 37.5% in female trauma patients and 43.88% in male trauma patients, which was not statistically significant (p=0.63). The prevalence of unnecessary cervical collar use in trauma patients with multiple trauma was 39.42% and 80% in patients without multiple trauma, which was statistically significant (p=0.018). Patients with a medical history had a higher rate of unnecessary use of the cervical collar (47.96%) than those without a history (12.5%), and this difference was statistically significant (p=0.008). Conclusion The guidelines for using cervical collars need to be updated by the EMS. Due to the large number of trauma patients in Iran, cervical collars for necessary conditions can help to reduce the healthcare expenses and injuries caused by unnecessary cervical collars.
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Affiliation(s)
| | - Keihan Kookli
- International Campus, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Veisi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amerzadeh
- Department of Health Services Management, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Hossein Hosseinifar
- Evidence-Based Medicine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Tahmasebi
- Hospital Management Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
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22
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Ingvarsson S, Nilsen P, Hasson H. Low-Value Care: Convergence and Challenges Comment on "Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands". Int J Health Policy Manag 2022; 11:2762-2764. [PMID: 36404499 PMCID: PMC9818099 DOI: 10.34172/ijhpm.2022.7017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 10/19/2022] [Indexed: 11/21/2022] Open
Abstract
Interest has increased in the topic of de-implementation, ie, reducing so-called low-value care (LVC). The article "Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands" by Verkerk and colleagues identifies national-level factors affecting LVC use in those three countries. This commentary raises three critical points regarding the study. First, the study does not clearly define the national level. Secondly, national-level factors might not be relevant for all types of LVCs and thirdly, the study's rather limited sample makes it difficult to draw firm conclusions. We also include some critical comments related to some of the study's findings in relation to results of our recently published scoping review of the international literature on de-implementation and use of LVC and an interview study with primary care physicians on LVC use. Finally, we provide some suggestions for further research that we believe is needed to improve understanding of LVC use and facilitate its de-implementation.
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Affiliation(s)
- Sara Ingvarsson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
| | - Henna Hasson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm, Sweden
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23
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Fusco KM, Hylind RJ, Cirino AL, Harris SL, Lubitz SA, Abrams DJR, Lakdawala NK. Cascade testing for inherited cardiac conditions: Risk perception and screening after a negative genetic test result. J Genet Couns 2022; 31:1273-1281. [PMID: 35763674 DOI: 10.1002/jgc4.1602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 12/14/2022]
Abstract
First-degree relatives of a proband with an inherited cardiac condition (ICC) are offered predictive genetic testing for the pathogenic or likely pathogenic (P/LP) cardiac gene variant (CGV) to clarify their risk for the familial condition. Relatives who test negative for a familial P/LP CGV typically do not require longitudinal cardiac surveillance. To our knowledge, no previous study has investigated adjustment to risk reduction and subsequent screening practices in genotype-negative relatives from an ICC population. We thus investigated risk perception and ongoing screening practices in genotype-negative adults who received cardiac genetic counseling. Correlations between clinical and demographic variables and risk perception and screening practices were also investigated. On average, participants (n = 71) reported a perceived 19.5% lifetime risk of developing the ICC in their family, despite their negative genetic test result. The majority (54%) of participants reported having undergone cardiac screening after disclosure of their negative result. There were no significant correlations between clinical and demographic variables and risk perception or screening practices. Furthermore, risk perception was not found to impact the likelihood of cardiac screening. These findings suggest that even with comprehensive cardiac genetic counseling, a proportion of this population did not accurately comprehend or recall their cardiac disease risk. Additional interventions beyond traditional result disclosure should be explored to help genotype-negative individuals adjust to their reduction in risk for a familial ICC.
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Affiliation(s)
- Kelsey M Fusco
- MGH Institute of Health Professions Genetic Counseling Program, Boston, Massachusetts, USA.,New England Cancer Specialists, Scarborough, Maine, USA
| | - Robyn J Hylind
- Boston Children's Hospital Inherited Cardiac Arrhythmia Program, Boston, Massachusetts, USA
| | - Allison L Cirino
- MGH Institute of Health Professions Genetic Counseling Program, Boston, Massachusetts, USA.,Brigham and Women's Hospital Cardiovascular Genetics Center, Boston, Massachusetts, USA
| | - Stephanie L Harris
- Massachusetts General Hospital Cardiovascular Genetics Program, Boston, Massachusetts, USA
| | - Steven A Lubitz
- Massachusetts General Hospital Cardiovascular Genetics Program, Boston, Massachusetts, USA
| | - Dominic J R Abrams
- Boston Children's Hospital Inherited Cardiac Arrhythmia Program, Boston, Massachusetts, USA
| | - Neal K Lakdawala
- Brigham and Women's Hospital Cardiovascular Genetics Center, Boston, Massachusetts, USA
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24
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Shin E, Fleming C, Ghosh A, Javadi A, Powell R, Rich E. Assessing patient, physician, and practice characteristics predicting the use of low-value services. Health Serv Res 2022; 57:1261-1273. [PMID: 36054345 PMCID: PMC9643094 DOI: 10.1111/1475-6773.14053] [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] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices. DATA SOURCES This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018. STUDY DESIGN We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level. DATA COLLECTION/EXTRACTION METHODS The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites. PRINCIPAL FINDINGS Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level. CONCLUSIONS Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.
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25
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Harris AHS, Bowe T, Kamal RN, Sears ED, Hawn M, Eisenberg D, Finlay AK, Hagedorn HJ, Mudumbai S. Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration. Perioper Med (Lond) 2022; 11:33. [PMID: 36096937 PMCID: PMC9469517 DOI: 10.1186/s13741-022-00265-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures. METHODS Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined. RESULTS Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476. CONCLUSIONS Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure.
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Affiliation(s)
- Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA.
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, USA.
| | - Thomas Bowe
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, USA
| | - Erika D Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Michigan Medicine Department of Surgery, Ann Arbor, USA
| | - Mary Hawn
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, USA
| | - Dan Eisenberg
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Medical Center, Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, USA
| | - Seshadri Mudumbai
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
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26
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Radomski TR, Zhao X, Lovelace EZ, Sileanu FE, Rose L, Schwartz AL, Schleiden LJ, Oakes AH, Pickering AN, Yang D, Hale JA, Gellad WF, Fine MJ, Thorpe CT. Use and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration. JAMA Intern Med 2022; 182:832-839. [PMID: 35788786 PMCID: PMC9257674 DOI: 10.1001/jamainternmed.2022.2482] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/08/2022] [Indexed: 01/11/2023]
Abstract
Importance Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified. Objective To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased community care. Design, Setting, and Participants This cross-sectional study assessed a national population of VA-enrolled veterans. Data on enrollment, sociodemographic characteristics, comorbidities, and health care services delivered by VA facilities or paid for by the VA through VACC programs were compiled for fiscal year 2018 from the VA Corporate Data Warehouse. Data analysis was conducted from April 2020 to January 2022. Main Outcomes and Measures VA administrative data were applied using an established low-value service metric to quantify the use of 29 potentially low-value tests and procedures delivered in VA facilities and by VACC programs across 6 domains: cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other procedures. Sensitive and specific criteria were used to determine the low-value service counts per 100 veterans overall, by domain, and by individual service; count and percentage of each low-value service delivered by each setting; and estimated cost of each service. Results Among 5.2 million enrolled veterans, the mean (SD) age was 62.5 (16.0) years, 91.7% were male, 68.0% were non-Hispanic White, and 32.3% received any service through VACC. By specific criteria, 19.6 low-value services per 100 veterans were delivered in VA facilities or by VACC programs, involving 13.6% of veterans at a total cost of $205.8 million. Overall, the most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older (5.9 per 100 veterans); this was also the service with the greatest proportion delivered by VA facilities (98.9%). The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4% of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9% of spending). Conclusions and Relevance This cross-sectional study found that among veterans enrolled in the VA, more than 1 in 10 have received a low-value service from VA facilities or VACC programs, with approximately $200 million in associated costs. Such information on the use and costs of low-value services are essential to guide the VA's efforts to reduce delivery and spending on such care.
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Affiliation(s)
- Thomas R. Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Elijah Z. Lovelace
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Liam Rose
- Health Economics Resource Center, VA Palo Alto Healthcare System, California
| | - Aaron L. Schwartz
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy and Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Loren J. Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Allison H. Oakes
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Aimee N. Pickering
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Dylan Yang
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Carolyn T. Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy
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27
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Juang WC, Chiou SMJ, Yang HL, Li YC. Exploring emergency physicians’ knowledge, attitudes, and behaviour towards Choosing Wisely in Taiwan. PLoS One 2022; 17:e0271346. [PMID: 35819965 PMCID: PMC9275691 DOI: 10.1371/journal.pone.0271346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/28/2022] [Indexed: 11/27/2022] Open
Abstract
Background In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to reduce unnecessary care. However, it is unclear how much emergency physicians in Taiwan understand about Choosing Wisely. The purpose of this study was to explore the knowledge, attitude, and behaviour of emergency physicians in Taiwan regarding Choosing Wisely and its related factors; the intention was to identify the baseline knowledge on the basis of which to promote Choosing Wisely in Taiwan. Methods This was a cross-sectional study including emergency physicians in Taiwan as research subjects who answered online questionnaires. A 42-item questionnaire was designed according to the Knowledge, Attitude, and Behaviour model (KAB). The questionnaire linkages were delivered to emergency physicians through social media (eg., Line, Facebook) and received assistance from different hospital directors. A total of 162 valid questionnaires were collected. Data analyses include t-test, analysis of variance, chi-square test, Pearson’s correlation, and multivariate linear regression model. Results The study determined that although only 38.9% of emergency physicians had heard of Choosing Wisely, the mean correct rate of knowledge score among emergency physicians was 70.1%. Attitude and the behaviour related to Choosing Wisely were positively associated, which means that the more positive the attitude towards Choosing Wisely is, the more positive the behaviour towards Choosing Wisely is. In multiple linear regression analyses, having served as a supervisor, belonging to divisions of health insurance service, and having heard of Choosing Wisely (P < 0.05) positively affect the knowledge of Choosing Wisely, but age presented a negative association. Conclusion This study found that physicians’ knowledge does not influence their attitudes and behaviours, which may be related to barriers of practicing Choosing Wisely activities. To effectively promote Choosing Wisely campaign, it is recommended to focus on the significant factors associated with emergency physicians’ perceptions regarding knowledge, attitude, and behavior of Choosing Wisely. Based on these factors, appropriate practice guidelines for Choosing Wisely can be formulated and promoted.
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Affiliation(s)
- Wang-Chuan Juang
- Department of Quality Management Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Sonia Ming-Jiu Chiou
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Hui-Ling Yang
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Department of Planning, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung, Taiwan
| | - Ying-Chun Li
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- * E-mail:
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28
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Srikumaran U. CORR Insights®: Is Advanced Imaging to Assess Rotator Cuff Integrity Before Shoulder Arthroplasty Cost-effective? A Decision Modeling Study. Clin Orthop Relat Res 2022; 480:1140-1142. [PMID: 35258505 PMCID: PMC9263502 DOI: 10.1097/corr.0000000000002169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Uma Srikumaran
- Division of Shoulder Surgery, Department of Orthopaedics, Johns Hopkins School of Medicine, Columbia, MD, USA
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29
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Mafi JN, Chen A, Guo R, Choi K, Smulowitz P, Tseng CH, Ladapo JA, Landon BE. US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis. BMJ Open 2022; 12:e055138. [PMID: 35443951 PMCID: PMC9021799 DOI: 10.1136/bmjopen-2021-055138] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Nurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians. DESIGN, SETTING AND PARTICIPANTS Using nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination. EXPOSURES NPs/PAs. MAIN OUTCOME MEASURES Use of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines. RESULTS Before propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p<0.001) and worsening triage acuity scores (3.03, 2.85 and 2.67, p<0.001), respectively. After weighting, NPs/PAs-alone used fewer medications (2.62 vs 2.80, p=0.002), diagnostic tests (3.77 vs 4.66, p<0.001), procedures (0.67 vs 0.77, p<0.001), hospitalisations (OR 0.35 (95% CI 0.26 to 0.46)) and low-value CT/MRI studies (OR 0.65 (95% CI 0.53 to 0.80)) than physicians. Contrastingly, the NP/PA-physician combination used more medications (3.08 vs 2.80, p<0.001), diagnostic tests (5.07 vs 4.66, p<0.001), procedures (0.86 vs 0.77, p<0.001), hospitalisations OR 1.33 (95% CI 1.17 to 1.51) and low-value CT/MRI studies (OR 1.23 (95% CI 1.07 to 1.43)) than physicians-results were similar among EDs with >95% of NP/PA visits including the NP/PA-physician combination. CONCLUSIONS AND RELEVANCE While U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.
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Affiliation(s)
- John N Mafi
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- RAND Health, RAND Corporation, Santa Monica, California, USA
| | - Alexander Chen
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Kristen Choi
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- School of Nursing, University of California Los Angeles, Los Angeles, California, USA
| | - Peter Smulowitz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Joseph A Ladapo
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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30
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Roberts DJ, Sypes EE, Nagpal SK, Niven D, Mamas M, McIsaac DI, van Walraven C, Shorr R, Graham ID, Stelfox HT, Grimshaw J. Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e053920. [PMID: 35393307 PMCID: PMC8991042 DOI: 10.1136/bmjopen-2021-053920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Overuse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system inefficiencies and costs. We seek to systematically review the evidence for overuse of different cardiovascular healthcare services in high-income countries. METHODS AND ANALYSIS We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2010 onwards. Two investigators will independently review titles and abstracts and full-text studies. We will include published English-language studies conducted in high-income countries that enrolled adults (mean/median age ≥18 years) and reported the incidence or prevalence of overuse of cardiovascular tests, medications or procedures; adjusted risk factors for overuse; or adjusted associations between overuse and outcomes (reported estimates of morbidity, mortality, costs or lengths of hospital stay). Acceptable methods of defining low-value care will include literature review and multidisciplinary iterative panel processes, healthcare services with reproducible evidence of a lack of benefit or harm, or clinical practice guideline or Choosing Wisely recommendations. Two investigators will independently extract data and evaluate study risk of bias in duplicate. We will calculate summary estimates of the incidence and prevalence of overuse of different cardiovascular healthcare services across studies unstratified and stratified by country; method of defining low-value care; the percentage of included females, different races, and those with low and high socioeconomic status or cardiovascular risk; and study risks of bias using random-effects models. We will also calculate pooled estimates of adjusted risk factors for overuse and adjusted associations between overuse and outcomes overall and stratified by country using random-effects models. We will use the Grading of Recommendations, Assessment, Development and Evaluation to determine certainty in estimates. ETHICS AND DISSEMINATION No ethics approval is required for this study as it deals with published data. Results will be presented at meetings and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021257490.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Daniel I McIsaac
- Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carl van Walraven
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeremy Grimshaw
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Cassim N, Rebbeck TR, Glencross DK, George JA. Retrospective analysis to describe trends in first-ever prostate-specific antigen (PSA) testing for primary healthcare facilities in the Gauteng Province, South Africa, between 2006 and 2016. BMJ Open 2022; 12:e050646. [PMID: 35314469 PMCID: PMC8938704 DOI: 10.1136/bmjopen-2021-050646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/09/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES The objective of our study was to use laboratory data to describe prostate-specific antigen (PSA) testing trends for primary healthcare (PHC) services from a single province. PHC is a basic package of services offered to local communities, serving as the first point of contact within the health system. These services are offered at clinics and community health centres (CHC), the latter providing additional maternity, accident and emergency services. DESIGN The retrospective descriptive study design was used. METHODS We analysed national laboratory data between 2006 and 2016 for men ≥30 years in the Gauteng Province. We used the probabilistic matching algorithm to create first-ever PSA cohort. We used the hot-deck imputation to assign missing race group values and the district health information system facility descriptors to identify PHC testing. We reported patient numbers by calendar year, age category and race group as well as descriptive statistics. We used multivariable logistic regression to assess any association for race group and age with a PSA ≥4 µg/L. RESULTS Between 2006 and 2016, numbers of men tested increased from 1782 to 67 025, respectively, with 186 984/239 506 (78.1%) tests were from clinics. The majority of testing was for men in the 50-59 age category (31.5%) and Black Africans (86.4%). We reported a median of 0.9 µg/L that increased with age. A PSA ≥4 µg/L was reported for 11.7% of men, increasing to 35.5% for the ≥70 age category. The logistic regression reported that the adjusted odds of having a PSA ≥4 µg/L was significantly lower for Indian/Asians, multiracials and whites than for Black Africans (p value<0.0001). CONCLUSIONS Our study has shown a marked increase in PSA testing from clinics and CHC suggestive of screening for prostate cancer. The approaches reported in this study can be extended for national data.
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Affiliation(s)
- Naseem Cassim
- Faculty of Health Sciences, Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, Gauteng, South Africa
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Johannesburg, Gauteng, South Africa
| | - Timothy R Rebbeck
- Dana Farber Cancer Institute, Harvard TH Chan School of Public Health, Harvard University, Cambridge, Massachusetts, USA
| | - Deborah K Glencross
- Faculty of Health Sciences, Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, Gauteng, South Africa
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Johannesburg, Gauteng, South Africa
| | - Jaya A George
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Johannesburg, Gauteng, South Africa
- Department of Chemical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Latifi N, Redberg RF, Grady D. The Next Frontier of Less Is More-From Description to Implementation. JAMA Intern Med 2022; 182:103-105. [PMID: 34870674 DOI: 10.1001/jamainternmed.2021.6908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Niloofar Latifi
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rita F Redberg
- Department of Medicine, University of California, San Francisco.,Editor, JAMA Internal Medicine
| | - Deborah Grady
- Department of Medicine, University of California, San Francisco.,Deputy Editor, JAMA Internal Medicine
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Ganguli I, Thakore N, Rosenthal MB, Korenstein D. Longitudinal Content Analysis of the Characteristics and Expected Impact of Low-Value Services Identified in US Choosing Wisely Recommendations. JAMA Intern Med 2022; 182:127-133. [PMID: 34870673 PMCID: PMC8649907 DOI: 10.1001/jamainternmed.2021.6911] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The US Choosing Wisely campaign has had substantial reach in mobilizing efforts to reduce low-value care, achieved largely by engaging physician specialty societies in stewardship. While some early recommendations were criticized for avoiding revenue-generating services, there is limited evidence of how the composition of recommendations shifted as more societies contributed. OBJECTIVE To analyze the characteristics and expected impact of Choosing Wisely recommendations. DESIGN, SETTING, AND PARTICIPANTS This qualitative study included content and trend analyses of all 626 Choosing Wisely recommendations by US physician societies as of March 1, 2021. Data were analyzed between March and May 2021. MAIN OUTCOMES AND MEASURES Primary outcomes were proportions of identified low-value services by characteristics (society type, service type, indication, do vs avoid, and clinical context) and expected impact (effect on the revenue of society members, cost, number of individuals at risk, direct harm potential, and cascade potential). RESULTS Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging (168 [26.8%]) and laboratory studies (156 [24.9%]) in the context of chronic conditions (169 [27.0%]) and healthy patients with risk factors alone (126 [20.1%]). Most of the identified low-value services were revenue neutral for the recommending society (402 [64.2%]) and the plurality were low cost (<$200; 284 [45.4%]); low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations (1.2 percentage points per year; P = .001). Nearly half (280 [44.7%]) of recommendations identified services with high direct harm potential, and 388 (62.0%) identified those with high potential for cascades (ie, triggering downstream services). CONCLUSIONS AND RELEVANCE The results of this qualitative study suggest that the Choosing Wisely recommendations identified services with a range of expected impacts. Stakeholders could explicitly set priorities for future recommendations, while clinical leaders and payers might target intervention efforts on recommendations with the greatest potential for impact based on spending across populations, direct harms, and cascades.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Deborah Korenstein
- Department of Medicine and Primary Care, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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Segal JB, Sen AP, Glanzberg-Krainin E, Hutfless S. Factors Associated With Overuse of Health Care Within US Health Systems. JAMA HEALTH FORUM 2022; 3:e214543. [PMID: 35977230 PMCID: PMC8903118 DOI: 10.1001/jamahealthforum.2021.4543] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022] Open
Abstract
Question What features of health care systems in the US are associated with overuse of health care? Findings In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital. Meaning In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care. Importance Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions. Objective To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery. Design, Setting, and Participants In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018. Exposures We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites. Main Outcomes and Measures Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0. Results There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively. Conclusions and Relevance In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.
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Affiliation(s)
- Jodi B. Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Aditi P. Sen
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Eliana Glanzberg-Krainin
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Susan Hutfless
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Rockwell MS, Michaels KC, Epling JW. Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study. BMC Health Serv Res 2022; 22:37. [PMID: 34991573 PMCID: PMC8733793 DOI: 10.1186/s12913-021-07345-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods
Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). Conclusions In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07345-9.
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Affiliation(s)
- Michelle S Rockwell
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA.
| | - Kenan C Michaels
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, VA, 24016, Roanoke, USA
| | - John W Epling
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA
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Ford V, Frischtak H, Wiencek JR, Parsons AS. A High-Value Care Curriculum Using Individual and Group Structured Reflection. South Med J 2021; 114:797-800. [PMID: 34853857 DOI: 10.14423/smj.0000000000001325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE One-third of all healthcare dollars are wasted, primarily in the form of clinician-ordered unnecessary diagnostic tests and treatments. Medical education has likely played a central role in the creation and perpetuation of this problem. We aimed to create a curriculum for medical students to promote their contribution to high-value care conversations in the clinical environment. METHODS At a large university medical center between March 2017 and February 2018, we implemented a 3-phase curriculum combining multimodal educational initiatives with individual and group reflection for third-year medical students during their 12-week long Internal Medicine clerkship rotation. Students were asked to identify examples of clinical decision making that lacked attention to high-value care, propose solutions to the identified situation, and pinpoint barriers to the implementation of effective solutions using a structured reflection framework and then participate in a debrief debate with fellow students. To assess the curriculum, reflective narratives were coded by frequency and codes were compared with one another and with relevant high-value care literature to identify patterns and themes. RESULTS In total, 151 medical students participated in phase 1 and 119 in phase 3. For phase 2, 126 reflective narratives (94.7% participation rate) comprised 226 problems, 280 solutions, and 179 barriers. CONCLUSIONS When provided appropriate resources, medical students are able to identify relevant examples of low-value care, downstream solutions, and barriers to implementation through a structured reflection curriculum comprising written narratives and in-person debate.
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Affiliation(s)
- Vanessa Ford
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
| | - Helena Frischtak
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
| | - Joesph R Wiencek
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
| | - Andrew S Parsons
- From the Department of Pediatrics, Emory University, Atlanta, Georgia, the Department of Family Medicine, Contra Costa Regional Medical Center, Martinez, California, the Department of Pathology, Vanderbilt University, Nashville, Tennessee, and the Department of Medicine, University of Virginia, Charlottesville
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The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016. J Gen Intern Med 2021; 36:3711-3718. [PMID: 33852141 PMCID: PMC8045442 DOI: 10.1007/s11606-021-06784-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/31/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed. OBJECTIVE To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries. DESIGN We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services. SETTING/PARTICIPANTS NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees. MAIN MEASURES We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources. KEY RESULTS During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study. CONCLUSIONS US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.
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House SA, Hall M, Ralston SL, Marin JR, Coon ER, Schroeder AR, De Souza HG, Davidson A, Duda P, Ho T, Genies MC, Mestre M, Reyes MA. Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children's Hospitals. JAMA Netw Open 2021; 4:e2135184. [PMID: 34967884 PMCID: PMC8719236 DOI: 10.1001/jamanetworkopen.2021.35184] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/23/2021] [Indexed: 11/14/2022] Open
Abstract
Importance The scope of low-value care in children's hospitals is poorly understood. Objective To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. Design, Setting, and Participants This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Exposures Eligible condition-specific hospital encounters. Main Outcomes and Measures The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. Results There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). Conclusions and Relevance This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.
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Affiliation(s)
- Samantha A. House
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | | | - Eric R. Coon
- Department of Pediatrics, University of Utah, Salt Lake City
| | | | | | | | - Patti Duda
- Children’s Hospital Association, Lenexa, Kansas
| | - Timmy Ho
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Marquita C. Genies
- Department of Pediatrics, Johns Hopkins Medical School, Baltimore, Maryland
| | - Marcos Mestre
- Department of Pediatrics, Division of Hospital Medicine, Nicklaus Children’s Hospital, Miami, Florida
| | - Mario A. Reyes
- Department of Pediatrics, Division of Hospital Medicine, Nicklaus Children’s Hospital, Miami, Florida
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Ahmadi A, Sorensen A, Villaflores CWA, Mafi JN, Vangala SS, Hofer IS, Bartlett JD, Cheng EM, Duval VF, Damberg C, Elashoff D, Goldstein NJ, Ladapo JA, Moore JM, Pessegueiro AM, Shu SB, Skootsky SA, Turner A, Sarkisian CA. Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges' into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery. BMJ Open 2021; 11:e049568. [PMID: 34732478 PMCID: PMC8572383 DOI: 10.1136/bmjopen-2021-049568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory. METHODS AND ANALYSIS This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings. ETHICS AND DISSEMINATION The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT04104256.
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Affiliation(s)
- Alast Ahmadi
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Internal Medicine, University of California Irvine School of Medicine, Irvine, California, USA
| | - Andrea Sorensen
- Division of Geriatrics, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Chad Wes A Villaflores
- Division of Geriatrics, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Sitaram S Vangala
- Department of Medicine Statistics Core, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ira S Hofer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - John D Bartlett
- Department of Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Eric M Cheng
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Victor F Duval
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | | | - David Elashoff
- Department of Medicine Statistics Core, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Noah J Goldstein
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- UCLA Anderson School of Management, Los Angeles, California, USA
| | - Joseph A Ladapo
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - James M Moore
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Antonio M Pessegueiro
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Suzanne B Shu
- SC Johnson College of Business at Cornell University, Ithaca, New York, USA
- The Charles H. Dyson School of Applied Economics and Management, Ithaca, New York, USA
| | - Samuel A Skootsky
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ashley Turner
- Pharmacogenomics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Catherine A Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA
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40
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Affiliation(s)
- Niloofar Latifi
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Deborah Grady
- Department of Medicine, University of California, San Francisco.,Deputy Editor, JAMA Internal Medicine
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Rhon DI, Mayhew RJ, Greenlee TA, Fritz JM. The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial. BMC FAMILY PRACTICE 2021; 22:200. [PMID: 34627152 PMCID: PMC8502287 DOI: 10.1186/s12875-021-01549-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks. OBJECTIVE Assess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups. METHODS This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs. RESULTS Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention. CONCLUSION Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process. TRIAL REGISTRATION clinicaltrials.gov NCT02777983 .
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA. .,Uniformed Services University of the Health Sciences , Bethesda, MD, USA.
| | - Rachel J Mayhew
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
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Schuttner L, Haraldsson B, Maynard C, Helfrich CD, Reddy A, Parikh T, Nelson KM, Wong E. Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Netw Open 2021; 4:e2130581. [PMID: 34677595 PMCID: PMC8536952 DOI: 10.1001/jamanetworkopen.2021.30581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. OBJECTIVE To understand rates and factors associated with outpatient low-value cancer screenings. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. EXPOSURES Receipt of cancer screening test. MAIN OUTCOMES AND MEASURES Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. RESULTS Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. CONCLUSIONS AND RELEVANCE This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | | | - Charles Maynard
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Christian D. Helfrich
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Ashok Reddy
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Toral Parikh
- Department of Medicine, University of Washington, Seattle
- Geriatrics and Extended Care, VA Puget Sound Healthcare System
| | - Karin M. Nelson
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Edwin Wong
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
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Vash-Margita A, Kobernik EK, Flagler EN, Quint EH, Dalton VK. National Trends in Cervical Cancer Screening in Adolescents. J Pediatr Adolesc Gynecol 2021; 34:717-724. [PMID: 33601068 DOI: 10.1016/j.jpag.2021.02.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 02/07/2021] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE To characterize patterns of cervical cancer screening among adolescents ages 14-20 years before and after the 2009 American College of Obstetrics and Gynecology recommendations. DESIGN Retrospective cohort study. SETTING National Ambulatory Medical Care Survey 2005-2016 data. PARTICIPANTS Female adolescents and young women ages 14-26 years. INTERVENTIONS Multivariable logistic regression models identified independent predictors of unindicated cervical cancer screening at office-based visits among adolescents ages 14-20 years. MAIN OUTCOME MEASURES Cervical cancer screening in women ages 14-20 and 21-26 years in 2 time periods: 2005-2008 and 2009-2016. RESULTS Between 2005 and 2016, 11,768 office visits were among adolescents ages 14-20 years. Overall, the cervical cancer screening rate for young women ages 14-20 years was 4.0%, which decreased from 4.5% to 0.4% (P = .008) during the study period. Adolescents who received cervical cancer screening during an office visit were older (18-20 years: 24.1% vs 14-17 years: 8.2%; P < .001), had a preventive care visit (preventive care: 79.7% vs other visit types: 20.3%; P < .001), and saw an obstetrician/gynecologist (obstetrician/gynecologist: 74.81% vs other specialties: 25.1%; P < .001). After adjusting for age, year, period, insurance status, region, and provider type, screening for cervical cancer was associated with living in the Southern region of the United States (adjusted odds ratio, 1.88; 95% confidence interval, 1.09-3.25; P = .02) and public insurance (adjusted odds ratio, 0.47, 95% confidence interval, 0.34-0.64; P < .001). CONCLUSION Despite recommendations, cervical cancer screening continued to occur in the adolescent population-especially older adolescents-creating unnecessary costs and potential harms. These findings show a slow uptake of guidelines nationally and the need for initiatives that encourage implementation of performance measures for providers, including ongoing provider and patient education.
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Affiliation(s)
- Alla Vash-Margita
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
| | - Emily K Kobernik
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Emily N Flagler
- The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Elisabeth H Quint
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Vanessa K Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Bevins NJ, Luevano DR, Nuspl R, Wang-Rodriguez J. Test Volume Ratio Benchmarking to Identify and Reduce Low-Value Laboratory Utilization. Am J Clin Pathol 2021; 156:708-714. [PMID: 33940591 DOI: 10.1093/ajcp/aqab017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We analyzed test volume data to identify low-value test utilization. We subsequently tracked the efficacy of interventions to improve test utilization by decreasing low-value testing. METHODS Test volume data for analytes included in the Choosing Wisely guidelines were analyzed to identify population outliers. Outliers were defined by test volume ratios of either analyte to sodium or paired analytes to correct for variation in patient volumes at each site. Interventions to improve test utilization were targeted to outlier sites. Relative efficacy in reducing low-value testing was tracked at those sites. RESULTS After appropriate data cleaning, test volume ratios for 17 analytes paired with sodium and 8 pairs of analytes were acquired from 108 national sites. A site with abnormally high Clostridium difficile/sodium ratio was selected for intervention, leading to a 71% decrease in C difficile tests. Two different interventions to decrease creatine kinase MB isoform (CKMB) testing were performed at two unique sites with abnormally high CKMB/troponin ratios. These interventions decreased CKMB by 11% and 98% at the different sites, showing the efficacy of the different kinds of interventions. CONCLUSIONS Test volume ratio analysis and benchmarking enable identification of low-value test utilization.
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Affiliation(s)
- Nicholas J Bevins
- Department of Pathology, University of California at San Diego, San Diego, CA, USA
| | - Daniel R Luevano
- Pathology and Laboratory Medicine, Southern Arizona VA Healthcare System, Tucson, AZ, USA
| | - Robin Nuspl
- Pathology and Laboratory Medicine, San Diego VA Healthcare System, San Diego, CA, USA
| | - Jessica Wang-Rodriguez
- Department of Pathology, University of California at San Diego, San Diego, CA, USA
- Pathology and Laboratory Medicine, San Diego VA Healthcare System, San Diego, CA, USA
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Reid RO, Mafi JN, Baseman LH, Fendrick AM, Damberg CL. Waste in the Medicare Program: a National Cross-Sectional Analysis of 2017 Low-Value Service Use and Spending. J Gen Intern Med 2021; 36:2478-2482. [PMID: 32728953 PMCID: PMC8342744 DOI: 10.1007/s11606-020-06061-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Rachel O Reid
- RAND Corporation, Boston, MA, USA. .,Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - John N Mafi
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
| | | | - A Mark Fendrick
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Abstract
Value-based care within insurance design utilizes evidence-based medicine as a means of defining high-value versus low-value diagnostics and treatments. The goals of value-based care are to shift spending and coverage toward high-value care and reduce the use of low-value practices. Within oncology, several value-based methods have been proposed and implemented. We review value-based care being used within oncology, including defining the value of oncology drugs through frameworks, clinical care pathways, alternative payment models including the Oncology Care Model, value-based insurance design, and reducing low-value care including the Choosing Wisely initiatives.
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Larkin C, Sanseverino AM, Joseph J, Eisenhauer L, Reznek MA. Accuracy of emergency physicians' self-estimates of CT scan utilization and its potential effect on an audit and feedback intervention: a randomized trial. Implement Sci Commun 2021; 2:83. [PMID: 34315533 PMCID: PMC8317272 DOI: 10.1186/s43058-021-00182-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 07/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Audit and feedback (A&F) has been used as a strategy to modify clinician behavior with moderate success. Although A&F is theorized to work by improving the accuracy of clinicians' estimates of their own behavior, few interventions have included assessment of clinicians' estimates at baseline to examine whether they account for intervention success or failure. We tested an A&F intervention to reduce computed tomography (CT) ordering by emergency physicians, while also examining the physicians' baseline estimates of their own behavior compared to peers. METHODS Our study was a prospective, multi-site, 20-month, randomized trial to examine the effect of an A&F intervention on CT ordering rates, overall and by test subtype. From the electronic health record, we obtained 12 months of baseline CT ordering per 100 patients treated for every physician from four emergency departments. Those who were randomized to receive A&F were shown a de-identified graph of the group's baseline CT utilization, asked to estimate wherein the distribution of their own CT order practices fell, and then shown their actual performance. All participants also received a brief educational intervention. CT ordering rates were collected for all physicians for 6 months after the intervention. Pre-post ordering rates were compared using independent and repeated measures t tests. RESULTS Fifty-one of 52 eligible physicians participated. The mean CT ordering rate increased significantly in both experimental conditions after the intervention (intervention pre = 35.7, post = 40.3, t = 4.13, p < 0.001; control pre = 33.9, post = 38.9, t = 3.94, p = 0.001), with no significant between-group difference observed at follow-up (t = 0.43, p = 0.67). Within the intervention group, physicians had poor accuracy in estimating their own ordering behavior at baseline: most overestimated and all guessed that they were in the upper half of the distribution of their peers. CT ordering increased regardless of self-estimate accuracy. CONCLUSIONS Our A&F intervention failed to reduce physician CT ordering: our feedback to the physicians showed most of them that they had overestimated their CT ordering behavior, and they were therefore unlikely to reduce it as a result. After "audit," it may be prudent to assess baseline clinician awareness of behavior before moving toward a feedback intervention.
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Affiliation(s)
- Celine Larkin
- University of Massachusetts Medical School, Worcester, USA.
| | | | - James Joseph
- University of Massachusetts Medical School, Worcester, USA
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Chalmers K, Gopinath V, Brownlee S, Saini V, Elshaug AG. Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries. JAMA HEALTH FORUM 2021; 2:e211719. [PMID: 35977201 PMCID: PMC8796970 DOI: 10.1001/jamahealthforum.2021.1719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/29/2021] [Indexed: 12/19/2022] Open
Abstract
Question What is the prevalence and cost of hospital-acquired conditions (HACs) and patient safety events (PSIs) associated with procedures that may be low value? Findings In this retrospective claims analysis of a cohort of Medicare fee-for-service beneficiaries, there were 231 HACs and 1764 PSIs in 197 755 claims for 7 inpatient procedures from 2016 to 2018. Meaning Patients with flagged, potential low-value procedures were harmed while in hospital, resulting in an extended length of stay and additional costs. Importance There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population. Objective To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. Design, Setting, and Participants This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020. Main Outcomes and Measures For inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs), as well as the unadjusted and adjusted difference in mean LOS and Medicare costs between admissions with and without a HAC/PSI. For outpatient procedures, we report the number of claims where the beneficiary had an unplanned hospital admission within seven days and the number of these admissions with a HAC/PSI. Results There were 573 351 patients included in the study, with 617 264 procedures; the mean (SD) age was 74.2 (6.7) years, with 320 637 women (55.9%), and mostly White patients (520 735; 90.8%). Among the 197 755 claims for the inpatient procedures, 231 had an HAC and 1764 had a PSI. Spinal fusion was associated with the most HACs (123 admissions) and PSIs (1015 admissions). Overall, HACs during a PCI admission were associated with the highest adjusted additional mean LOS (17.5 days; 95% CI, 10.3-23.6), with also the highest adjusted additional mean cost ($22 000; 95% CI, $9100-$32 600). There were 419 509 included outpatient procedures, and 7514 (1.8%) had an unplanned admission within 7 days. A total of 17 HACs and PSIs occurred in these admissions. Conclusions and Relevance In this cross-sectional cohort study of Medicare fee-for-service claims, patients receiving potential low-value care were exposed to risk of unnecessary harm associated with higher cost and LOS.
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Affiliation(s)
- Kelsey Chalmers
- Lown Institute, Needham, Massachusetts
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Australia, NSW
| | | | | | | | - Adam G. Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, University of Sydney, Australia, NSW
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Australia, VIC
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Jo S, Jun DB, Park S. Impact of differential copayment on patient healthcare choice: evidence from South Korean National Cohort Study. BMJ Open 2021; 11:e044549. [PMID: 34162638 PMCID: PMC8231052 DOI: 10.1136/bmjopen-2020-044549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We evaluate the effectiveness of mild disease differential copayment policy aimed at reducing unnecessary patient visits to secondary/tertiary healthcare institutions in South Korea. DESIGN Retrospective study using difference-in-difference design. SETTING Sample Research database provided by the Korean National Health Insurance Service, between 2010 and 2013. PARTICIPANTS 206 947 patients who visited healthcare institutions to treat mild diseases during the sample period. METHODS A linear probability model with difference-in-difference approach was adopted to estimate the changes in patients' healthcare choices associated with the differential copayment policy. The dependent variable was a binary variable denoting whether a patient visited primary healthcare or secondary/tertiary healthcare to treat her/his mild disease. Patients' individual characteristics were controlled with a fixed effect. RESULTS We observed significant decrease in the proportion of patients choosing secondary/tertiary healthcare over primary healthcare by 2.99 per cent point. The decrease associated with the policy was smaller by 14% in the low-income group compared with richer population, greater by 19% among the residents of Seoul metropolitan area than among people living elsewhere, and greater among frequent healthcare visitors by 33% than among people who less frequently visit healthcare. CONCLUSION The mild disease differential copayment policy of South Korea was successful in discouraging unnecessary visits to secondary/tertiary healthcare institutions to treat mild diseases that can be treated well in primary healthcare.
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Affiliation(s)
- Sangkyun Jo
- College of Business, KAIST, Seoul, South Korea
| | - Duk Bin Jun
- College of Business, KAIST, Seoul, South Korea
| | - Sungho Park
- SNU Business School, Seoul National University, Seoul, South Korea
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Baum A, Bazemore A, Peterson L, Basu S, Humphreys K, Phillips RL. Primary Care Physicians and Spending on Low-Value Care. Ann Intern Med 2021; 174:875-878. [PMID: 33460344 DOI: 10.7326/m20-6257] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Aaron Baum
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Lars Peterson
- American Board of Family Medicine, Lexington, Kentucky
| | - Sanjay Basu
- Collective Health, San Francisco, California
| | - Keith Humphreys
- Center for Innovation to Implementation, Veterans Affairs and Stanford University Medical Centers, Palo Alto, California
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