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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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Zullig LL, Jazowski SA, Chawla N, Williams CD, Winski D, Slatore CG, Clary A, Rasmussen KM, Ticknor LM, Kelley MJ. Summary of Veterans Health Administration Cancer Data Sources. JOURNAL OF REGISTRY MANAGEMENT 2024; 51:21-28. [PMID: 38881982 PMCID: PMC11178113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Objectives The Veterans Health Administration (VHA) is a leader in generating transformational research across the cancer care continuum. Given the extensive body of cancer-related literature utilizing VHA data, our objectives are to: (1) describe the VHA data sources available for conducting cancer-related research, and (2) discuss examples of published cancer research using each data source. Methods We identified commonly used data sources within the VHA and reviewed previously published cancer-related research that utilized these data sources. In addition, we reviewed VHA clinical and health services research web pages and consulted with a multidisciplinary group of cancer researchers that included hematologist/oncologists, health services researchers, and epidemiologists. Results Commonly used VHA cancer data sources include the Veterans Affairs (VA) Cancer Registry System, the VA Central Cancer Registry (VACCR), the Corporate Data Warehouse (CDW)-Oncology Raw Domain (subset of data within the CDW), and the VA Cancer Care Cube (Cube). While no reference standard exists for cancer case ascertainment, the VACCR provides a systematic approach to ensure the complete capture of clinical history, cancer diagnosis, and treatment. Like many population-based cancer registries, a significant time lag exists due to constrained resources, which may make it best suited for historical epidemiologic studies. The CDW-Oncology Raw Domain and the Cube contain national information on incident cancers which may be useful for case ascertainment and prospective recruitment; however, additional resources may be needed for data cleaning. Conclusions The VHA has a wealth of data sources available for cancer-related research. It is imperative that researchers recognize the advantages and disadvantages of each data source to ensure their research questions are addressed appropriately.
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Affiliation(s)
- Leah L. Zullig
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Shelley A. Jazowski
- Duke University School of Medicine, Durham, North Carolina
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Neetu Chawla
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles, Los Angeles, California
| | - Christina D. Williams
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - David Winski
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Christopher G. Slatore
- VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland, Oregon
| | - Alecia Clary
- Durham VA Health Care System, Durham, North Carolina
| | | | | | - Michael J. Kelley
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
- Department of Veterans Affairs, Washington, DC
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3
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Schwartz AL, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Radomski TR, Thorpe CT. Variation in Low-Value Service Use Across Veterans Affairs Facilities. J Gen Intern Med 2023; 38:2245-2253. [PMID: 36964425 PMCID: PMC10406760 DOI: 10.1007/s11606-023-08157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/10/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA). OBJECTIVE To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use. DESIGN In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics. PARTICIPANTS 5,242,301 patients across 139 VA facilities. MAIN MEASURES Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery. KEY RESULTS The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics. CONCLUSIONS Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.
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Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Charlotte, NC, USA
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4
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Hofmann BM, Gransjøen AM. Geographical variations in the use of outpatient diagnostic imaging in Norway 2019. Acta Radiol Open 2022; 11:20584601221074561. [PMID: 35251700 PMCID: PMC8891857 DOI: 10.1177/20584601221074561] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Geographical variations in the use of outpatient imaging can reveal inappropriate use of radiological services. Knowledge about these variations is crucial in the strive for appropriate and improved services. Purpose To investigate the geographical variations in outpatient diagnostic imaging and analyze variations for main groups of examinations and for specific examinations. Material and methods Data on outpatient radiological procedures registered at the Norwegian Health Economics Administration in Norway for 2019 were accessed with county-based population rates for age adjustment accessed through Statistics Norway. Age-adjusted rates were used to calculate high/low ratios, means, standard deviations, and coefficients of variation were calculated per 10,000 inhabitants. Results There is high geographical variation for PET/CT and PET/MRI and moderate variation for neuroradiological outpatient examinations in Norway in 2019. Variations for the musculoskeletal systems and of thorax, abdomen, and vessels are almost 50%. We find high high-to-low ratios in CT—face (9.7), MRI—elbow joint (8.5), CT of the neck, thorax, abdomen, and pelvis (6.5) as well as MRI—prostate (6.2). Comparing with data from 2012–5, we find a reduction in variation for some examinations, such as MRI of the hip and MRI of the entire spine, and an increase in variations for others, such as CT of the face and MRI of the elbow joint. Conclusion Despite much attention to the problem, we demonstrate substantial variations in radiological services in Norway raising concern with respect to appropriateness, quality of care, equity, and justice. The findings provide important input for quality improvement in radiological services.
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Affiliation(s)
- Bjørn M Hofmann
- Institute for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
| | - Ann M Gransjøen
- Institute for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
- SHARE, University of Stavanger, Stavanger, Norway
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5
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Lindner S, Kaufman MR, Marino M, O'Malley J, Angier H, Cottrell EK, McConnell KJ, DeVoe JE, Heintzman JR. A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services. Health Aff (Millwood) 2021; 39:1194-1201. [PMID: 32634361 DOI: 10.1377/hlthaff.2019.01656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.
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Affiliation(s)
- Stephan Lindner
- Stephan Lindner is an assistant professor in the Center for Health Systems Effectiveness and in the Department of Emergency Medicine, both at Oregon Health & Science University, in Portland, Oregon
| | - Menolly R Kaufman
- Menolly R. Kaufman is a research associate in the Center for Health Systems Effectiveness, Oregon Health & Science University
| | - Miguel Marino
- Miguel Marino is an associate professor of biostatistics in the Department of Family Medicine, Oregon Health & Science University, and at the OHSU-Portland State University School of Public Health, in Portland
| | - Jean O'Malley
- Jean O'Malley is a biostatistician in the Research Department at Ochin, Inc., in Portland
| | - Heather Angier
- Heather Angier is an assistant professor in the Department of Family Medicine, Oregon Health & Science University
| | - Erika K Cottrell
- Erika K. Cottrell is an assistant professor in the Department of Family Medicine, Oregon Health & Science University, and an investigator at OCHIN, Inc
| | - K John McConnell
- K. John McConnell is director of the Center for Health Systems Effectiveness and a professor in the Department of Emergency Medicine, both at Oregon Health & Science University
| | - Jennifer E DeVoe
- Jennifer E. DeVoe is professor and chair in the Department of Family Medicine, Oregon Health & Science University
| | - John R Heintzman
- John R. Heintzman is an associate professor in the Department of Family Medicine, Oregon Health & Science University
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6
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Lavigne JE, Lagerberg T, Ambrosi JW, Chang Z. Study designs and statistical approaches to suicide and prevention research in real-world data. Suicide Life Threat Behav 2021; 51:127-136. [PMID: 33624870 DOI: 10.1111/sltb.12677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide researchers, clinicians and policy makers with a primer to study designs, statistical approaches and graphical reporting methods for suicide research in real world data (RWD). METHODS Study designs, statistical method and graphical reporting standards are detailed with examples from the recently published literature. RESULTS Data sources and codes for identifying suicidal behavior are described. Study designs are described in detail for post-market surveillance, retrospective cohort studies, case control and nested case-control studies, and self-controlled (within-individual) studies including applications of marginal structural models. Graphical reporting of designs is described using an original research study. CONCLUSIONS Compared to RCTs, RWE studies offer larger sample sizes, greater generalizability, and real-world validity. However, these non-experimental data risk uncontrolled confounding and potential introduction of bias unless data, design and statistical approaches are rigorously aligned.
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Affiliation(s)
- Jill E Lavigne
- Center of Excellence for Suicide Prevention, Department of Veterans Health Affairs, 400 Fort Hill Ave, Canandaigua, 14424, USA.,Wegmans School of Pharmacy, St John Fisher College, 3690 East Ave, Rochester, NY, 14618, USA
| | | | - John W Ambrosi
- Wegmans School of Pharmacy, St John Fisher College, 3690 East Ave, Rochester, NY, 14618, USA
| | - Zheng Chang
- Karolinska Institute, 171 77 Stockholm, Solna, Sweden
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7
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Gidwani R, Asch SM, Needleman J, Faricy-Anderson K, Boothroyd DB, Illarmo S, Lorenz KA, Patel MI, Hsin G, Ramchandran K, Wagner TH. End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration. J Am Geriatr Soc 2020; 69:916-923. [PMID: 33368171 DOI: 10.1111/jgs.16941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/29/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA). DESIGN A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region. SETTING Care received at VA facilities or by Medicare-reimbursed providers nationwide. PARTICIPANTS A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare. MEASUREMENTS We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life. RESULTS All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care. CONCLUSION Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.
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Affiliation(s)
- Risha Gidwani
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Katherine Faricy-Anderson
- Providence VA Medical Center, Providence, Rhode Island, USA.,Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Derek B Boothroyd
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Manali I Patel
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary Hsin
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Kavitha Ramchandran
- Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Surgery, Stanford University, Stanford, California, USA
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8
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Powell AC, Rogstad TL, Winchester DE, Shanser JD, Long JW, Deshmukh UU, Rao VM. Discordance in Clinical Recommendations Regarding the Use of Imaging. Am J Med Qual 2019; 35:117-124. [PMID: 31113208 DOI: 10.1177/1062860619851561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
As physicians strive to provide evidence-based care, challenges arise if different entities disseminate divergent Appropriate Use Criteria (AUC) or clinical guidelines on the same topic. To characterize these challenges in one field, this study reviews the literature on comparisons of clinical recommendations regarding medical imaging. The PubMed database was searched for the years 2013-2018 for studies describing discordance among clinical recommendations regarding the performance of imaging. Of the 406 articles identified, 15 met the selection criteria: 8 qualitative and 7 quantitative. Reasons for discordance varied, with lack of evidence often cited. Quantitative studies often found that different decisions would be reached depending on the clinical recommendation followed. Nonetheless, quantitative studies also tended not to consider one set of recommendations superior to another. The findings of this review might help clinicians seek guidance more thoughtfully and could inform use of guidelines and AUC for quality improvement and clinical decision support.
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Affiliation(s)
| | | | | | | | | | | | - Vijay M Rao
- Thomas Jefferson University, Philadelphia, PA
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9
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Hebert PL, Batten AS, Gunnink E, Reddy A, Wong ES, Fihn SD, Liu C. Reliance on Medicare Providers by Veterans after Becoming Age-Eligible for Medicare is Associated with the Use of More Outpatient Services. Health Serv Res 2018; 53 Suppl 3:5159-5180. [PMID: 30175401 PMCID: PMC6235815 DOI: 10.1111/1475-6773.13033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To estimate the effect of Medicare use on the receipt of outpatient services from 2001 through 2015 for a cohort of Veterans Administration (VA) users who became age-eligible for Medicare in 1998-2000. DATA SOURCES/STUDY SETTING VA administrative data linked with Medicare claims for veterans who participated in the 1999 Large Health Survey of Enrolled Veterans. STUDY DESIGN We coded each veteran as VA-reliant or Medicare-reliant based on the number of visits in each system and compared the health and social risk factors between VA-reliant and Medicare-reliant veterans. We used bivariate probit and instrumental variables models to estimate the association between a veteran's reliance on Medicare and the receipt of outpatient procedures in Medicare and the VA. PRINCIPAL FINDINGS Veterans who chose to rely on the VA (n = 4,317) had substantially worse social and health risk factors than Medicare-reliant veterans (n = 2,567). Medicare reliance was associated with greater use of outpatient services for 24 of the 28 types of services considered. Instrumental variable estimates found significant effects of Medicare reliance on receipt of advanced imaging and cardiovascular testing. CONCLUSIONS Expanded access to fee-for-service care in the community may be expensive, while the VA will likely continue to care for the most vulnerable veterans.
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Affiliation(s)
- Paul L. Hebert
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWA
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
| | - Adam S. Batten
- PACT Demonstration Laboratory InitiativeVeterans Health AdministrationSeattleWA
| | - Eric Gunnink
- PACT Demonstration Laboratory InitiativeVeterans Health AdministrationSeattleWA
| | - Ashok Reddy
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
- Department of MedicineUniversity of WashingtonSeattleWA
| | - Edwin S. Wong
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWA
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
| | | | - Chuan‐Fen Liu
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWA
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
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10
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Li Q, Rahman M, Gozalo P, Keohane LM, Gold MR, Trivedi AN. Regional Variations: The Use Of Hospitals, Home Health, And Skilled Nursing In Traditional Medicare And Medicare Advantage. Health Aff (Millwood) 2018; 37:1274-1281. [PMID: 30080454 PMCID: PMC6286089 DOI: 10.1377/hlthaff.2018.0147] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the traditional Medicare program, the use of health care services-particularly postacute care-varies substantially across geographic regions. Less is known about such variations in Medicare Advantage (MA), which is growing rapidly. Insurers that are paid on a risk basis, as in MA, may have incentives and tools to restrain the use of services, which could attenuate geographic variations. In this study of fifty-four million Medicare beneficiaries in the period 2007-13, we found that geographic variations in the use of skilled nursing facility and hospital care in the MA population exceeded those in traditional Medicare, though variations in the use of home health care were greater in traditional Medicare. Within hospital referral regions, the correlations between the use of services in MA and traditional Medicare were moderate to strong. The findings suggest that regional variations in hospital and postacute care reflect local factors that influence beneficiaries' use of services irrespective of the way they obtain coverage.
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Affiliation(s)
- Qijuan Li
- Qijuan Li is an adjunct assistant professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health, in Providence, Rhode Island, and director of innovation analytics at SCIO Health Analytics, in West Hartford, Connecticut
| | - Momotazur Rahman
- Momotazur Rahman is an assistant professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
| | - Pedro Gozalo
- Pedro Gozalo is an associate professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health, and a research investigator at the Providence Veterans Affairs (VA) Medical Center
| | - Laura M Keohane
- Laura M. Keohane is an assistant professor in the Department of Health Policy, Vanderbilt University School of Medicine, in Nashville, Tennessee
| | - Marsha R Gold
- Marsha R. Gold is senior fellow emeritus at Mathematica Policy Research in Washington, D.C
| | - Amal N Trivedi
- Amal N. Trivedi ( ) is an associate professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health, and a research investigator at the Providence VA Medical Center
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11
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Beatty AL, Truong M, Schopfer DW, Shen H, Bachmann JM, Whooley MA. Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement. Circulation 2018; 137:1899-1908. [PMID: 29305529 PMCID: PMC5930133 DOI: 10.1161/circulationaha.117.029471] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/15/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Cardiac rehabilitation is strongly recommended after myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery, but it is historically underused. We sought to evaluate variation in cardiac rehabilitation participation across the United States. METHODS From administrative data from the Veterans Affairs (VA) healthcare system and a 5% Medicare sample, we used International Classification of Diseases, 9th Revision codes to identify patients hospitalized for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery from 2007 to 2011. After excluding patients who died in ≤30 days of hospitalization, we calculated the percentage of patients who participated in ≥1 outpatient visits for cardiac rehabilitation during the 12 months after hospitalization. We estimated adjusted and standardized rates of participation in cardiac rehabilitation by state using hierarchical logistic regression models. RESULTS Overall, participation in cardiac rehabilitation was 16.3% (23 403/143 756) in Medicare and 10.3% (9123/88 826) in VA. However, participation rates varied widely across states, ranging from 3.2% to 41.8% in Medicare and 1.2% to 47.6% in VA. Similar regional variation was observed in both populations. Patients in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) had the highest participation, whereas those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% versus 10.6%) and VA (16.6% versus 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3% to 75% in Medicare and 1% to 43% in VA. CONCLUSIONS Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, remarkably similar regional variation exists, with some regions and hospitals achieving high rates of participation in both populations. This provides an opportunity to identify best practices from higher performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower performing hospitals and regions.
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Affiliation(s)
- Alexis L Beatty
- VA Puget Sound Health Care System, Seattle, WA (A.L.B.).
- Department of Medicine, University of Washington, Seattle (A.L.B., M.T.)
| | - Michael Truong
- Department of Medicine, University of Washington, Seattle (A.L.B., M.T.)
| | - David W Schopfer
- San Francisco VA Medical Center, CA (D.W.S., H.S., M.A.W.)
- Department of Medicine, University of California, San Francisco (D.W.S., M.A.W.)
| | - Hui Shen
- San Francisco VA Medical Center, CA (D.W.S., H.S., M.A.W.)
| | - Justin M Bachmann
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (J.M.B.)
| | - Mary A Whooley
- San Francisco VA Medical Center, CA (D.W.S., H.S., M.A.W.)
- Department of Medicine, University of California, San Francisco (D.W.S., M.A.W.)
- Department of Epidemiology and Biostatistics, University of California, San Francisco (M.A.W.)
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12
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Oakes AH, Sharma R, Jackson M, Segal JB. Determinants of the overuse of imaging in low-risk prostate cancer: A systematic review. Urol Oncol 2017; 35:647-658. [PMID: 28943200 PMCID: PMC5659754 DOI: 10.1016/j.urolonc.2017.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The overuse of radiologic services, where imaging tests are provided in circumstances where the propensity for harm exceeds the propensity for benefit, comprises a risk to patient safety and a burden on health care systems. Advanced imaging in the staging of low-risk prostate cancer is considered an overused procedure by many professional societies, yet the determinants that drive this phenomenon are not fully appreciated. METHODS We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that contain original data and describe determinants associated with the overuse of imaging in low-risk prostate cancer. Paired reviewers independently screened abstracts, assessed quality, and extracted data. We synthesized the identified determinants as patient-level, clinician-level, or system-level factors of overuse. RESULTS A total of 14 articles were included; the 13 empirical studies defined overuse as being the use of imaging that was discordant with clinical guidelines. Patient- and system-related factors were most commonly described as being associated with overuse; clinician-level determinants were examined infrequently. Older patient age (n = 5), more patient comorbidities (n = 7), and characteristics related to geography (n = 6), higher regional income (n = 6), and less education (n = 5) were the most consistently identified statistically significant determinants of overuse. Meaningful differences were detected between health care settings; large integrated health care systems provided less variable care and had lower rates of overuse. Clinical indicators related to prostate cancer were inconsistently associated with overuse. CONCLUSION Many patient- and system-related determinants were identified as contributing to the overuse of advanced imaging to stage low-risk prostate cancer. Overuse may be the consequence of systematized clinician behavior and be relatively invariant of patient characteristics. The identified system-level determinants suggest that payment models that are not tied to volume or that reward, enhanced care co-ordination may curb overuse. We propose further examination of physician-level determinants and implore researchers to rank the relative importance of the identified factors and to test their influence through experimental and quasi-experimental methods.
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Affiliation(s)
- Allison H Oakes
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Ritu Sharma
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Madeline Jackson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jodi B Segal
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins University Center for Health Services and Outcomes Research, Baltimore, MD
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13
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Westin GF, Dias AL, Go RS. Exploring Big Data in Hematological Malignancies: Challenges and Opportunities. Curr Hematol Malig Rep 2017; 11:271-9. [PMID: 27177742 DOI: 10.1007/s11899-016-0331-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Secondary analysis of large datasets has become a useful alternative to address research questions outside the reach of clinical trials. It is increasingly utilized in hematology and oncology. In this review, we provided an overview of some examples of commonly used large datasets in the USA and described common research themes that can be pursued using such a methodology. We selected a sample of 14 articles on adult hematologic malignancies published in 2015 and highlighted their contributions as well as limitations.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Databases, Factual
- Hematologic Neoplasms/diagnosis
- Hematologic Neoplasms/economics
- Hematologic Neoplasms/pathology
- Hematologic Neoplasms/therapy
- Hematopoietic Stem Cell Transplantation
- Hodgkin Disease/diagnosis
- Hodgkin Disease/economics
- Hodgkin Disease/pathology
- Hodgkin Disease/therapy
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/economics
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/economics
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Multiple Myeloma/diagnosis
- Multiple Myeloma/economics
- Multiple Myeloma/pathology
- Multiple Myeloma/therapy
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Affiliation(s)
- Gustavo F Westin
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajoy L Dias
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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14
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Hsu JC, Chang SM, Lu CY. Geographic Variations and Time Trends in Cancer Treatments in Taiwan. BMC Public Health 2017; 18:89. [PMID: 28768504 PMCID: PMC5541736 DOI: 10.1186/s12889-017-4615-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 07/20/2017] [Indexed: 01/25/2023] Open
Abstract
Background Targeted therapies have become important treatment options for cancer care in many countries. This study aimed to examine recent trends in utilization of antineoplastic drugs, particularly the use of targeted therapies for treatment of cancer, by geographic region in Taiwan (northern, midwestern, southern, and eastern regions and the outer islands). Methods This was a retrospective observational study of antineoplastic agents using 2009-2012 quarterly claims data from Taiwan’s National Health Insurance Research Database. Yearly market shares by prescription volume and costs for targeted therapies among total antineoplastic agents by region were estimated. We used multivariate regression model and ANOVA to examine variations in utilization of targeted therapies between geographic regions and used ARIMA models to estimate longitudinal trends. Results Population-adjusted use and costs of antineoplastic drugs (including targeted therapies) were highest in the southern region of Taiwan and lowest in the outer islands. We found a 4-fold difference in use of antineoplastic drugs and a 49-fold difference in use of targeted therapies between regions if the outer islands were included. There were minimal differences in use of antineoplastic drugs between other regions with about a 2-fold difference in use of targeted therapies. Without considering the outer islands, the market share by prescription volume and costs of targeted therapies increased almost 2-fold (1.84-1.90) and 1.5-fold (1.26-1.61) respectively between 2009 and 2012. Furthermore, region was not significantly associated with use of antineoplastic agents or use of targeted therapies after adjusting for confounders. Region was associated with costs of antineoplastic agents but it was not associated with costs of targeted therapies after confounding adjustments. Conclusions Use of antineoplastic drugs overall and use of targeted therapies for treatment of cancer varied somewhat between regions in Taiwan; use was notably low in the outer islands. Strategies might be needed to ensure access to cancer care in each region as economic burden of cancer care increase due to growing use of targeted therapies.
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Affiliation(s)
- Jason C Hsu
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, No.1, Daxue Rd., East Dist., Tainan, 70101, Taiwan.
| | - Sheng-Mao Chang
- Department of Statistics, College of Management, National Cheng Kung University, Tainan, Taiwan
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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15
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Yasaitis L, Bekelman JE, Polsky D. Relation Between Narrow Networks and Providers of Cancer Care. J Clin Oncol 2017; 35:3131-3135. [PMID: 28678667 DOI: 10.1200/jco.2017.73.2040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Health insurers offer plans covering a narrow subset of providers in an attempt to lower premiums and compete for consumers. However, narrow networks may limit access to high-quality providers, particularly those caring for patients with cancer. Methods We examined provider networks offered on the 2014 individual health insurance exchanges, assessing oncologist supply and network participation in areas that do and do not contain one of 69 National Cancer Institute (NCI)-Designated Cancer Centers. We characterized a network's inclusion of oncologists affiliated with NCI-Designated Cancer Centers relative to oncologists excluded from the network within the same region and assessed the relationship between this relative inclusion and each network's breadth. We repeated these analyses among networks offered in the same regions as the subset of 27 NCI-Designated Cancer Centers identified as National Comprehensive Cancer Network (NCCN) Cancer Centers. Results In regions containing NCI-Designated Cancer Centers, there were 13.7 oncologists per 100,000 residents and 4.9 (standard deviation [SD], 2.8) networks covering a mean of 39.4% (SD, 26.2%) of those oncologists, compared with 8.8 oncologists per 100,000 residents and 3.2 (SD, 2.1) networks covering on average 49.9% (SD, 26.8%) of the area's oncologists ( P < .001 for all comparisons). There was a strongly significant correlation ( r = 0.4; P < .001) between a network's breadth and its relative inclusion of oncologists associated with NCI-Designated Cancer Centers; this relationship held when considering only affiliation with NCCN Cancer Centers. Conclusion Narrower provider networks are more likely to exclude oncologists affiliated with NCI-Designated or NCCN Cancer Centers. Health insurers, state regulators, and federal lawmakers should offer ways for consumers to learn whether providers of cancer care with particular affiliations are in or out of narrow provider networks.
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Affiliation(s)
- Laura Yasaitis
- All authors: University of Pennsylvania, Philadelphia, PA
| | | | - Daniel Polsky
- All authors: University of Pennsylvania, Philadelphia, PA
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16
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Zullig LL, Sims KJ, McNeil R, Williams CD, Jackson GL, Provenzale D, Kelley MJ. Cancer Incidence Among Patients of the U.S. Veterans Affairs Health Care System: 2010 Update. Mil Med 2017; 182:e1883-e1891. [PMID: 28810986 PMCID: PMC5650119 DOI: 10.7205/milmed-d-16-00371] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Nearly 50,000 incident cancer cases are reported in Veterans Affairs (VA) Central Cancer Registry (VACCR) annually. This article provides an updated report of cancer incidence recorded in VACCR. MATERIALS AND METHODS Data were obtained from VACCR for incident cancers diagnosed in the VA health care system, focusing on 2010 data. Cancer incidence among VA patients is described by anatomical site, sex, race, stage, and geographic location, and was compared to the general U.S. cancer population. RESULTS In 2010, among 46,170 invasive cancers, 97% were diagnosed among men. Approximately 80% of newly diagnosed patients were white, 19% black, and less than 2% were other minority races. Median age at diagnosis was 65 years. The three most frequently diagnosed cancers among VA were prostate (29%), lung/bronchus (18%), and colon/rectum (8%). Melanoma and kidney/renal pelvis tied for fourth (4%), and urinary bladder tied for sixth with liver and intrahepatic bile duct (3.4%). Approximately 23% of prostate, 21% of lung/bronchus, and 31% of colon/rectum cancers were diagnosed with Stage I disease. The overall invasive cancer incidence rate among VA users was 505.8 per 100,000 person-years. CONCLUSIONS Although the composition of the VA population is shifting and includes a larger number of women, registry data indicate that incident cancers in VA in 2010 were most similar to those observed among U.S. men. Consistent reporting of VACCR data is important to provide accurate estimates of VA cancer incidence. This information can be used to plan efforts to improve quality of cancer care and access to services.
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Affiliation(s)
- Leah L. Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705
- Division of General Internal Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710
| | - Kellie J. Sims
- Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, 508 Fulton Street, Durham, NC 27705
| | - Rebecca McNeil
- Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, 508 Fulton Street, Durham, NC 27705
| | - Christina D. Williams
- Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, 508 Fulton Street, Durham, NC 27705
- Division of Medical Oncology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710
| | - George L. Jackson
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705
- Division of General Internal Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710
| | - Dawn Provenzale
- Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, 508 Fulton Street, Durham, NC 27705
- Division of Gastroenterology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710
| | - Michael J. Kelley
- Division of Medical Oncology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710
- Specialty Care Services, Department of Veterans Affairs, 810 Vermont Ave., Washington, DC 20420
- Hematology-Oncology Service, Durham Veterans Affairs Health Care System, Durham, NC, 508 Fulton Street, Durham, NC 27705
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17
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Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
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Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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18
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Colla CH, Morden NE, Sequist TD, Mainor AJ, Li Z, Rosenthal MB. Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations. Health Serv Res 2017; 53:730-746. [PMID: 28217968 DOI: 10.1111/1475-6773.12665] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care. DATA SOURCES 2009-2011 national Medicare and commercial insurance administrative data. DESIGN We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics. METHODS We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these. PRINCIPAL FINDINGS Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians. CONCLUSIONS Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.
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Affiliation(s)
| | | | - Thomas D Sequist
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Partners Healthcare System, Boston, MA.,Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, MA
| | | | - Zhonghe Li
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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19
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Sehdev A, Sherer EA, Hui SL, Wu J, Haggstrom DA. Patterns of computed tomography surveillance in survivors of colorectal cancer at Veterans Health Administration facilities. Cancer 2017; 123:2338-2351. [PMID: 28211937 DOI: 10.1002/cncr.30569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/21/2016] [Accepted: 12/26/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Annual computed tomography (CT) scans are a component of the current standard of care for the posttreatment surveillance of survivors of colorectal cancer (CRC) after curative-intent resection. The authors conducted a retrospective study with the primary aim of assessing patient, physician, and organizational characteristics associated with the receipt of CT surveillance among veterans. METHODS The Department of Veterans Affairs Central Cancer Registry was used to identify patients diagnosed with AJCC collaborative stage I to III CRC between 2001 and 2009. Patient sociodemographic and clinical (ie, CRC stage and comorbidity) characteristics, provider specialty, and organizational characteristics were measured. Hierarchical multivariable logistic regression models were used to assess the association between patient, provider, and organizational characteristics on receipt of 1) consistently guideline-concordant care (at least 1 CT every 12 months for both of the first 2 years of CRC surveillance) versus no CT receipt and 2) potential overuse (>1 CT every 12 months during the first 2 years of CRC surveillance) of CRC surveillance using CT. The authors also analyzed the impact of the 2005 American Society of Clinical Oncology update in CRC surveillance guidelines on care received over time. RESULTS For 2263 survivors of stage II/III CRC who were diagnosed after 2005, 19.4% of patients received no surveillance CT, whereas potential overuse occurred in both surveillance years for 14.9% of patients. Guideline-concordant care was associated with younger age, higher stage of disease (stage III vs stage II), and geographic region. In adjusted analyses, younger age and higher stage of disease (stage III vs stage II) were found to be associated with overuse. There was no significant difference in the annual rate of CT scanning noted across time periods (year ≤ 2005 vs year > 2005). CONCLUSIONS Among a minority of veteran survivors of CRC, both underuse and potential overuse of CT surveillance were present. Patient factors, but no provider or organizational characteristics, were found to be significantly associated with patterns of care. The 2005 change in American Society of Clinical Oncology guidelines did not appear to have an impact on rates of surveillance CT. Cancer 2017;123:2338-2351. © 2017 American Cancer Society.
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Affiliation(s)
- Amikar Sehdev
- Division of Hematology and Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana.,Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Eric A Sherer
- Department of Chemical Engineering, Louisiana Tech University, Ruston, Louisiana.,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana
| | - Siu L Hui
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - Jingwei Wu
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, Pennsylvania
| | - David A Haggstrom
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana.,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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20
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Kini V, McCarthy FH, Dayoub E, Bradley SM, Masoudi FA, Ho PM, Groeneveld PW. Cardiac Stress Test Trends Among US Patients Younger Than 65 Years, 2005-2012. JAMA Cardiol 2016; 1:1038-1042. [PMID: 27846640 DOI: 10.1001/jamacardio.2016.3153] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance After a period of rapid growth, use of cardiac stress testing has recently decreased among Medicare beneficiaries and in a large integrated health system. However, it is not known whether declines in cardiac stress testing are universal or are confined to certain populations. Objective To determine trends in rates of cardiac stress testing among a large and diverse cohort of commercially insured patients. Design, Setting, and Participants A serial cross-sectional study with time trends was conducted using administrative claims from all members aged 25 to 64 years belonging to a large, national managed care company from January 1, 2005, to December 31, 2012. Linear trends in rates were determined using negative binomial regression models with procedure count as the dependent variable, calendar quarter as the key independent variable, and the size of the population as a logged offset term. Data analysis was performed from January 1, 2005, to December 31, 2012. Main Outcomes and Measures Age- and sex-adjusted rates of cardiac stress tests per calendar quarter (reported as number of tests per 100 000 person-years). Results A total of 2 085 591 cardiac stress tests were performed among 32 921 838 persons (mean [SD] age, 43.2 [10.9] years; 16 625 528 women [50.5%] and 16 296 310 [49.5%] men; 7 604 945 nonwhite [23.1%]). There was a 3.0% increase in rates of cardiac stress testing from 2005 (3486 tests; 95% CI, 3458-3514) to 2012 (3589 tests; 95% CI, 3559-3619; P = .01 for linear trend). Use of nuclear single-photon emission computed tomography decreased by 14.9% from 2005 (1907 tests; 95% CI, 1888-1926) to 2012 (1623 tests; 95% CI, 1603-1643; P = .03). Use of stress echocardiography increased by 27.8% from 2005 (709 tests; 95% CI, 697-721) to 2012 (906 tests; 95% CI, 894 to 920; P < .001). Use of exercise electrocardiography increased by 12.5% from 2005 (861 tests; 95% CI, 847-873) to 2012 (969 tests; 95% CI, 953-985; P < .001). Use of other stress testing modalities increased 65.5% from 2006 (55 tests; 95% CI, 51-59) to 2012 (91 tests; 95% CI, 87-95; P < .001). For individuals aged 25 to 34 years, rates of cardiac stress testing increased 59.1% from 2005 (543 tests; 95% CI, 532-554) to 2012 (864 tests; 95% CI, 852-876; P < .001). For individuals aged 55 to 64 years, rates of cardiac stress testing decreased by 12.3% from 2005 (7894 tests; 95% CI, 7820-7968) to 2012 (6923 tests; 95% CI, 6853-6993; P < .001). Conclusions and Relevance In contrast to declines in the use of cardiac stress testing in some health care systems, we observed a small increase in its use among a nationally representative cohort of commercially insured patients. Our findings suggest that observed trends in the use of cardiac stress testing may have been driven more by unique characteristics of populations and health systems than national efforts to reduce the overuse of testing.
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Affiliation(s)
- Vinay Kini
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia2The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Fenton H McCarthy
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia3Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Elias Dayoub
- Division of General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Steven M Bradley
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver6Division of Cardiovascular Medicine, Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Frederick A Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver
| | - P Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver6Division of Cardiovascular Medicine, Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Peter W Groeneveld
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia4Division of General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia
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21
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Göpffarth D, Kopetsch T, Schmitz H. Determinants of Regional Variation in Health Expenditures in Germany. HEALTH ECONOMICS 2016; 25:801-815. [PMID: 25962986 DOI: 10.1002/hec.3183] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/02/2015] [Accepted: 03/24/2015] [Indexed: 06/04/2023]
Abstract
Health care expenditure in Germany shows clear regional differences. Such geographic variations are often seen as an indicator for inefficiency. With its homogeneous health care system, low co-payments and uniform prices, Germany is a particularly suited example to analyse regional variations. We use data for the year 2011 on expenditure, utilization of health services and state of health in Germany's statutory health insurance system. This data, which originate from a variety of administrative sources and cover about 90% of the population, are enriched with a wealth of socio-economic variables, data on pollutants, prices and individual preferences. State of health and demography explains 55% of the differences as measured by the standard deviation while all control variables account for a total of 72% of the differences at county level. With other measures of variation, we can account for an even greater proportion. A higher proportion of variation than usually supposed can thus be explained. Whilst this study cannot quantify inefficiencies, our results contradict the thesis that regional variations reflect inefficiency. Copyright © 2015 John Wiley & Sons, Ltd.
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22
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Gidwani R, Joyce N, Kinosian B, Faricy-Anderson K, Levy C, Miller SC, Ersek M, Wagner T, Mor V. Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. J Palliat Med 2016; 19:957-63. [PMID: 27228478 DOI: 10.1089/jpm.2015.0514] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Specialty societies recommend patients with advanced cancer receive early exposure to palliative care and exposure to hospice care. OBJECTIVE We sought to understand real-world practice of care, specifically, the timing of palliative care, and how timing and duration of hospice care varied across Medicare, VA, and VA-Purchased care. DESIGN We conducted a retrospective analysis of administrative data for veterans aged 65 years or older who died with cancer in 2012. Multilevel logistic regression was used to evaluate the likelihood of receiving palliative care, receiving hospice care, and receiving hospice care for at least three days. SETTING Medicare, VA, and VA-Purchased care environments. MEASUREMENTS The receipt and timing of palliative care within VA and the receipt and timing of hospice care across three healthcare environments. RESULTS Most veterans received hospice care (71%), whereas fewer received palliative care (52%). Among all cancer decedents, 59% received hospice care for their last three days of life. Patients who received hospice care did so a median of 20 days before death (interquartile range [IQR]: 7-46). Patients who received palliative care did so a median of 38 days before death (IQR: 13-94). Adjusted analyses revealed significant differences in receipt of palliative care across cancer type, and significant differences in receipt of hospice care across cancer type. After adjusting for age and cancer type, patients who received VA hospice care were significantly less likely to receive it for at least three days compared with patients who received VA-Purchased or Medicare hospice care. CONCLUSIONS There remains a gap between recommended timing of supportive services and real-world practice of care. Results suggest that difficulties in prognosticating death are not fully responsible for underexposure to hospice.
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Affiliation(s)
- Risha Gidwani
- 1 Health Economics Resource Center (HERC), Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Menlo Park, California.,2 Division of General Medical Disciplines, Stanford University , Stanford, California
| | - Nina Joyce
- 3 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island
| | - Bruce Kinosian
- 4 Philadelphia VA Medical Center , Philadelphia, Pennsylvania.,5 University of Pennsylvania Hospital , Philadelphia, Pennsylvania
| | - Katherine Faricy-Anderson
- 6 Alpert Medical School, Brown University , Providence, Rhode Island.,7 Providence VA Medical Center , Providence, Rhode Island
| | - Cari Levy
- 8 Eastern Colorado VA Healthcare System , Denver, Colorado
| | - Susan C Miller
- 3 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island.,7 Providence VA Medical Center , Providence, Rhode Island
| | - Mary Ersek
- 4 Philadelphia VA Medical Center , Philadelphia, Pennsylvania.,9 University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania
| | - Todd Wagner
- 1 Health Economics Resource Center (HERC), Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Menlo Park, California.,10 Department of Health Research and Policy, Stanford University , Stanford, California
| | - Vincent Mor
- 3 Department of Health Services, Policy, and Practice, Brown University School of Public Health , Providence, Rhode Island.,7 Providence VA Medical Center , Providence, Rhode Island
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23
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Healy MA, Yin H, Reddy RM, Wong SL. Use of Positron Emission Tomography to Detect Recurrence and Associations With Survival in Patients With Lung and Esophageal Cancers. J Natl Cancer Inst 2016; 108:djv429. [PMID: 26903519 DOI: 10.1093/jnci/djv429] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/15/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Positron emission tomography (PET) scans are often used in cancer patients for staging, restaging, and monitoring for treatment response. These scans are also often used to detect recurrence in asymptomatic patients, despite a lack of evidence demonstrating improved survival. We sought to evaluate utilization of PET for this purpose and relationships with survival for patients with lung and esophageal cancers. METHODS Using national Surveillance, Epidemiology, and End Results (SEER) and Medicare-linked data, we identified incident patient cases from 2005 to 2009, with follow-up through 2011. We identified cohorts with primary lung (n = 97 152) and esophageal (n = 4446) cancers. Patient and tumor characteristics were used to calculate risk-adjusted two-year overall survival. Using Medicare claims, we examined PET utilization in person-years (to account for variable time in cohorts), excluding scans for staging and for follow-up of CT findings. We then stratified hospitals by quintiles of PET utilization for adjusted two-year survival analysis. All statistical tests were two-sided. RESULTS There was statistically significant variation in utilization of PET. Lowest vs highest utilizing hospitals performed .05 (SD = 0.04) vs 0.70 (SD = 0.44) scans per person-year for lung cancer and 0.12 (SD = 0.06) vs 0.97 (SD = 0.29) scans per person-year for esophageal cancer. Despite this, for those undergoing PET, lowest vs highest utilizing hospitals had an adjusted two-year survival of 29.0% (SD = 12.1%) vs 28.8% (SD = 7.2%) for lung cancer (P = .66) and 28.4% (SD = 7.2%) vs 30.3% (SD = 5.9%) for esophageal cancer (P = .55). CONCLUSIONS Despite statistically significant variation in use of PET to detect tumor recurrence, there was no association with improved two-year survival. These findings suggest possible overuse of PET for recurrence detection, which current Medicare policy would not appear to substantially affect.
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Affiliation(s)
- Mark A Healy
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
| | - Huiying Yin
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
| | - Rishindra M Reddy
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
| | - Sandra L Wong
- Affiliations of authors:Department of Surgery (MAH, RMR, SLW) and Center for Healthcare Outcomes and Policy (MAH, HY, SLW), University of Michigan , Ann Arbor, MI
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24
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Alsan M, Morden N, Gottlieb JD, Zhou W, Skinner J. Antibiotic Use in Cold and Flu Season and Prescribing Quality: A Retrospective Cohort Study. Med Care 2015; 53:1066-71. [PMID: 26569644 PMCID: PMC4829738 DOI: 10.1097/mlr.0000000000000440] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Excessive antibiotic use in cold and flu season is costly and contributes to antibiotic resistance. The study objective was to develop an index of excessive antibiotic use in cold and flu season and determine its correlation with other indicators of prescribing quality. METHODS AND FINDINGS We included Medicare beneficiaries in the 40% random sample denominator file continuously enrolled in fee-for-service benefits for 2010 or 2011 (7,961,201 person-years) and extracted data on prescription fills for oral antibiotics that treat respiratory pathogens. We collapsed the data to the state level so they could be merged with monthly flu activity data from the Centers for Disease Control and Prevention. Linear regression, adjusted for state-specific mean antibiotic use and demographic characteristics, was used to estimate how antibiotic prescribing responded to state-specific flu activity. Flu-activity associated antibiotic use varied substantially across states-lowest in Vermont and Connecticut, highest in Mississippi and Florida. There was a robust positive correlation between flu-activity associated prescribing and use of medications that often cause adverse events in the elderly (0.755; P<0.001), whereas there was a strong negative correlation with beta-blocker use after a myocardial infarction (-0.413; P=0.003). CONCLUSIONS Adjusted flu-activity associated antibiotic use was positively correlated with prescribing high-risk medications to the elderly and negatively correlated with beta-blocker use after myocardial infarction. These findings suggest that excessive antibiotic use reflects low-quality prescribing. They imply that practice and policy solutions should go beyond narrow, antibiotic specific, approaches to encourage evidence-based prescribing for the elderly Medicare population.
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Affiliation(s)
- Marcella Alsan
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA
- National Bureau of Economic Research, Cambridge, MA
| | - Nancy Morden
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon NH
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Joshua D. Gottlieb
- Vancouver School of Economics, University of British Columbia, Vancouver, Canada
- National Bureau of Economic Research, Cambridge, MA
| | - Weiping Zhou
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon NH
| | - Jonathan Skinner
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon NH
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
- National Bureau of Economic Research, Cambridge, MA
- Department of Economics, Dartmouth College, Hanover, NH
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Schwartz AL, Chernew ME, Landon BE, McWilliams JM. Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program. JAMA Intern Med 2015; 175:1815-25. [PMID: 26390323 PMCID: PMC4928485 DOI: 10.1001/jamainternmed.2015.4525] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. OBJECTIVE To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. DESIGN, SETTING, AND PARTICIPANTS In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries' sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services. MAIN OUTCOMES AND MEASURES Use of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries. RESULTS During the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (-1.2 to -0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (-2.9% to -0.9%) and a 4.5% differential reduction in spending on low-value services (-7.5% to -1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets' mean baseline levels of low-value service use experienced greater service reductions (-1.2 services per 100 beneficiaries; -1.7 to -0.7; P < .001) than did ACOs with use below the mean (-0.2 services per 100 beneficiaries, -0.6 to -0.2; P = .41; P = .003 for test of difference between subgroups). CONCLUSIONS AND RELEVANCE During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization-like risk contracts may be able to discourage use of low-value services even without specifying services to target.
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Affiliation(s)
- Aaron L Schwartz
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts3Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Petersen H, Holdgaard PC, Madsen PH, Knudsen LM, Gad D, Gravergaard AE, Rohde M, Godballe C, Engelmann BE, Bech K, Teilmann-Jørgensen D, Mogensen O, Karstoft J, Johansen J, Christensen JB, Johansen A, Høilund-Carlsen PF. FDG PET/CT in cancer: comparison of actual use with literature-based recommendations. Eur J Nucl Med Mol Imaging 2015; 43:695-706. [PMID: 26519292 PMCID: PMC4764641 DOI: 10.1007/s00259-015-3217-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/06/2015] [Indexed: 12/22/2022]
Abstract
Purpose The Region of Southern Denmark (RSD), covering 1.2 of Denmark’s 5.6 million inhabitants, established a task force to (1) retrieve literature evidence for the clinical use of positron emission tomography (PET)/CT and provide consequent recommendations and further to (2) compare the actual use of PET/CT in the RSD with these recommendations. This article summarizes the results. Methods A Work Group appointed a professional Subgroup which made Clinician Groups conduct literature reviews on six selected cancers responsible for 5,768 (62.6 %) of 9,213 PET/CT scans in the RSD in 2012. Rapid Evidence Assessment was applied, using the methodology of systematic reviews with predefined limitations to search PubMed, Embase and the Cochrane Library for articles published in English/Danish/Swedish/Norwegian since 2002. PICO questions were defined, data recorded and quality appraised and rated with regard to strength and evidence level. Consequent recommendations for applications of PET/CT were established. The actual use of PET/CT was compared with these, where grades A and B indicated “established” and “useful” and grades C and D “potentially useful” and “non-recommendable” indications, respectively. Results Of 11,729 citations, 1,729 were considered for review, and 204 were included. The evidence suggested usefulness of PET/CT in lung, lymphoma, melanoma, head and neck, and colorectal cancers, whereas evidence was sparse in gynaecological cancers. The agreement between actual use of PET/CT and literature-based recommendations was high in the first five mentioned cancers in that 96.2 % of scans were made for grade A or B indications versus only 22.2 % in gynaecological cancers. Conclusion Evidence-based usefulness was reported in five of six selected cancers; evidence was sparse in the sixth, gynaecological cancers. Actual use of PET/CT agreed well with recommendations. Electronic supplementary material The online version of this article (doi:10.1007/s00259-015-3217-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | | | | | | | - Dorte Gad
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| | | | - Max Rohde
- Department of ORL Head & Neck Surgery, Odense University Hospital, Odense, Denmark
| | - Christian Godballe
- Department of ORL Head & Neck Surgery, Odense University Hospital, Odense, Denmark
| | | | - Karsten Bech
- Organ Centre, Aabenraa Sygehus, Aabenraa, Denmark
| | | | - Ole Mogensen
- Department of Gynaecoligcal and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Jens Karstoft
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - Allan Johansen
- Department of Nuclear Medicine, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
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Kini V, McCarthy FH, Rajaei S, Epstein AJ, Heidenreich PA, Groeneveld PW. Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare. Am Heart J 2015; 170:805-11. [PMID: 26386805 PMCID: PMC4777352 DOI: 10.1016/j.ahj.2015.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/19/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Rapid growth in the provision of cardiac imaging tests has led to concerns about overuse. Little is known about the degree to which health care delivery system characteristics influence use and variation in echocardiography. METHODS We analyzed administrative claims of veterans with heart failure older than 65 years from 2007 to 2010 across 34 metropolitan service areas (MSAs). We compared overall rates and geographic variation in use of transthoracic echocardiography (TTE) between veterans who used the Veterans Health Administration (VA) and propensity-matched veterans who used Medicare. "Dual users" were excluded. RESULTS There were no significant differences in clinical characteristics or mortality between the propensity-matched cohorts (overall n = 30,404 veterans, mean age 76 years, mortality rate 52%). The Medicare cohort had a significantly higher overall rate of TTE use compared with the VA cohort (1.25 vs 0.38 TTEs per person-year, incidence rate ratio 2.89 [95% CI 2.80-3.00], both P < .001), but a similar coefficient of variation across MSAs (0.36 [95% CI 0.27-0.45] vs 0.48 [95% CI 0.37-0.59]). There was a moderate to strong correlation in variation at the MSA level between cohorts (Spearman r = 0.58, P < .001). CONCLUSION Overall rates of TTE use were significantly higher in a Medicare cohort compared with a propensity score-matched VA cohort of veterans with heart failure living in urban areas, with similar relative degrees of geographic variation and moderate to strong regional correlation. Rates of TTE use may be strongly influenced by health care system characteristics, but local practice styles influence echocardiography rates irrespective of health system.
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Affiliation(s)
- Vinay Kini
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Fenton H McCarthy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sheeva Rajaei
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Andrew J Epstein
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Veterans Affairs Center for Health Equity and Research Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA; VA Palo Alto Health Care System, Palo Alto, CA
| | - Peter W Groeneveld
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Veterans Affairs Center for Health Equity and Research Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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28
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Smith CD, Korenstein D. Harnessing the power of peer pressure to reduce health care waste and improve clinical outcomes. Mayo Clin Proc 2015; 90:311-2. [PMID: 25638300 DOI: 10.1016/j.mayocp.2015.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 01/16/2015] [Indexed: 11/25/2022]
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29
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Pershing S, Pal Chee C, Asch SM, Baker LC, Boothroyd D, Wagner TH, Bundorf MK. Treating Age-Related Macular Degeneration: Comparing The Use Of Two Drugs Among Medicare And Veterans Affairs Populations. Health Aff (Millwood) 2015; 34:229-38. [DOI: 10.1377/hlthaff.2014.1032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Suzann Pershing
- Suzann Pershing is an assistant professor of ophthalmology at the Byers Eye Institute at Stanford, in Palo Alto, California, and chief of ophthalmology and eye care services at the Veterans Affairs (VA) Palo Alto Health Care System
| | - Christine Pal Chee
- Christine Pal Chee is a health economist at the VA Health Economics Resource Center, in Menlo Park, California
| | - Steven M. Asch
- Steven M. Asch is a professor of medicine at Stanford University School of Medicine, in Palo Alto, and chief of health services research and director of the Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Laurence C. Baker
- Laurence C. Baker is a professor in health research and policy at Stanford University and a research associate at the National Bureau of Economic Research in Cambridge, Massachusetts
| | - Derek Boothroyd
- Derek Boothroyd is a senior biostatistician in medicine at Stanford University School of Medicine
| | - Todd H. Wagner
- Todd H. Wagner is a health economist and associate director of the Health Economics Resource Center, VA Palo Alto Health Care System and Stanford University
| | - M. Kate Bundorf
- M. Kate Bundorf is an associate professor in health research and policy at Stanford University School of Medicine and a faculty research fellow at the National Bureau of Economic Research
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