1
|
Ahmadi A, Duval VF, Bartlett JD, Hofer IS, Mafi J, Villaflores CWA, Sarkisian CA. Examining patient perspectives on low-value care: Findings from a survey on preoperative testing for cataract surgery. J Am Geriatr Soc 2023; 71:3641-3644. [PMID: 37436065 PMCID: PMC11006278 DOI: 10.1111/jgs.18494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Alast Ahmadi
- Department of Internal Medicine, University of California Irvine, Irvine, California, United States
| | - Victor F. Duval
- Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - John D. Bartlett
- Department of Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Ira S. Hofer
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - John Mafi
- Division of General Internal Medicine and Health Services Research, Department of Medicine at the David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Chad Wes A. Villaflores
- Division of General Internal Medicine and Health Services Research, Department of Medicine at the David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Catherine A. Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine at the David Geffen School of Medicine at UCLA, Los Angeles, California, United States
- VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, United States
| |
Collapse
|
2
|
Diarra SS, Anand S, Lemuelu T, Areta F, Mathew E, Lehi E, Hoponoa S, Kava F, Mafi J, Taliauli F. Commercial Feed Diluted with Different Fiber Sources and Enzyme Product for Broilers: Growth Performance, Carcass and Gut Health. Braz J Poult Sci 2023. [DOI: 10.1590/1806-9061-2021-1546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- SS Diarra
- University of the South Pacific, Samoa
| | - S Anand
- University of the South Pacific, Samoa
| | - T Lemuelu
- University of the South Pacific, Samoa
| | - F Areta
- University of the South Pacific, Samoa
| | - E Mathew
- University of the South Pacific, Samoa
| | - E Lehi
- University of the South Pacific, Samoa
| | - S Hoponoa
- University of the South Pacific, Samoa
| | - F Kava
- University of the South Pacific, Samoa
| | - J Mafi
- University of the South Pacific, Samoa
| | | |
Collapse
|
3
|
Adams MA, Kerr EA, Dominitz JA, Gao Y, Yankey N, May FP, Mafi J, Saini SD. Development and validation of a new ICD-10-based screening colonoscopy overuse measure in a large integrated healthcare system: a retrospective observational study. BMJ Qual Saf 2022:bmjqs-2021-014236. [PMID: 36192148 DOI: 10.1136/bmjqs-2021-014236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/09/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Low-value use of screening colonoscopy is wasteful and potentially harmful to patients. Decreasing low-value colonoscopy prevents procedural complications, saves patient time and reduces patient discomfort, and can improve access by reducing procedural demand. The objective of this study was to develop and validate an electronic measure of screening colonoscopy overuse using International Classification of Diseases, Tenth Edition codes and then apply this measure to estimate facility-level overuse to target quality improvement initiatives to reduce overuse in a large integrated healthcare system. METHODS Retrospective national observational study of US Veterans undergoing screening colonoscopy at 119 Veterans Health Administration (VHA) endoscopy facilities in 2017. A measure of screening colonoscopy overuse was specified by an expert workgroup, and electronic approximation of the measure numerator and denominator was performed ('electronic measure'). The electronic measure was then validated via manual record review (n=511). Reliability statistics (n=100) were calculated along with diagnostic test characteristics of the electronic measure. The measure was then applied to estimate overall rates of overuse and facility-level variation in overuse among all eligible patients. RESULTS The electronic measure had high specificity (99%) and moderate sensitivity (46%). Adjusted positive predictive value and negative predictive value were 33% and 95%, respectively. Inter-rater reliability testing revealed near perfect agreement between raters (k=0.81). 269 572 colonoscopies were performed in VHA in 2017 (88 143 classified as screening procedures). Applying the measure to these 88 143 screening colonoscopies, 24.5% were identified as potential overuse. Median facility-level overuse was 22.5%, with substantial variability across facilities (IQR 19.1%-27.0%). CONCLUSIONS An International Classification of Diseases, Tenth Edition based electronic measure of screening colonoscopy overuse has high specificity and improved sensitivity compared with a previous International Classification of Diseases, Ninth Edition based measure. Despite increased focus on reducing low-value care and improving access, a quarter of VHA screening colonoscopies in 2017 were identified as potential low-value procedures, with substantial facility-level variability.
Collapse
Affiliation(s)
- Megan A Adams
- VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA .,Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Eve A Kerr
- VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of General Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Jason A Dominitz
- Gastroenterology Section, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Yuqing Gao
- VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Nicholas Yankey
- VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Folasade P May
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - John Mafi
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Sameer D Saini
- VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
4
|
Soroudi C, Mafi J, Myint A, Gardner J, Kahlon S, Mongare M, Yang L, Tseng CH, Reynolds C, Nair V, Villaflores C, Cates R, Gupta R, Sarkisian C, May FP. Leveraging Electronic Health Records to Measure Low-Value Screening Colonoscopy. Am J Med 2022; 135:715-720.e2. [PMID: 35219690 PMCID: PMC10176807 DOI: 10.1016/j.amjmed.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Camille Soroudi
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - John Mafi
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles; Division of Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Anthony Myint
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Juliana Gardner
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Sartajdeep Kahlon
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Margaret Mongare
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Liu Yang
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Courtney Reynolds
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Vishnu Nair
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Chad Villaflores
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Reinalyn Cates
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Reshma Gupta
- University of California Health, University of California Davis Medical Center, Sacramento
| | - Catherine Sarkisian
- Division of Geriatrics, David Geffen School of Medicine, University of California, Los Angeles; VA Greater Los Angeles Healthcare System Geriatrics Research Education & Clinical Center (GRECC), Los Angeles, Calif
| | - Folasade P May
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles; Division of Gastroenterology, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, Calif; UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, Los Angeles, Calif.
| |
Collapse
|
5
|
Adams M, Kerr E, Dominitz J, Gao Y, Yankey N, May F, Mafi J, Saini S. Updating an Electronic Measure of Screening Colonoscopy Overuse in a Large Integrated Healthcare System to Examine Trends and Variation in Overuse. Health Serv Res 2021. [DOI: 10.1111/1475-6773.13780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Megan Adams
- Ann Arbor Veterans Affairs Hospital Ann Arbor Michigan USA
- VA Ann Arbor Center for Clinical Management Research / University of Michigan Ann Arbor Michigan USA
| | - Eve Kerr
- VA Ann Arbor Healthcare System Ann Arbor Michigan USA
| | | | - Yuqing Gao
- VA Ann Arbor Center for Clinical Management Research Ann Arbor Michigan USA
| | - Nick Yankey
- VA Ann Arbor Healthcare System Ann Arbor Michigan USA
| | | | | | | |
Collapse
|
6
|
Abstract
The cost of health care in the United States is approaching 18% of the gross national product, an expenditure that is competing with dollars being used for other purposes. One way to reduce the cost of care is by identifying and reducing low-value care (LVC): patient care that offers little to no benefit in specific clinical scenarios, adds cost, and may, through adverse effects or adverse outcomes, actually harm patients. The authors have been involved in identifying and reducing LVC for more than 15 years and have created a practical, 10-step approach to effectively integrate LVC reduction programs into medical systems. The approach has been tested, with results reported in peer-reviewed journals. Key steps include assembling accurate, meaningful data; creating simple yet dramatic practitioner reports; learning to identify and manage the stages of change; and developing an outreach strategy anchored in nonjudgmental communication, explicit core values, and a well-articulated reason to focus on reducing LVC.
Collapse
Affiliation(s)
- Howard Beckman
- University of Rochester School of Medicine and Dentistry, 285 Westminster Rd, Rochester, NY 14607.
| | | | | |
Collapse
|
7
|
Lee B, Mafi J, Patel MK, Sorensen A, Vangala S, Wei E, Sarkisian C. Quality improvement time-saving intervention to increase use of a clinical decision support tool to reduce low-value diagnostic imaging in a safety net health system. BMJ Open Qual 2021; 10:bmjoq-2020-001076. [PMID: 33579745 PMCID: PMC7883856 DOI: 10.1136/bmjoq-2020-001076] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/30/2020] [Accepted: 10/24/2020] [Indexed: 11/21/2022] Open
Abstract
Importance Electronic health record (EHR) clinical decision support (CDS) tools can provide evidence-based feedback at the point of care to reduce low-value imaging. Success of these tools has been limited partly due to lack of engagement by busy clinicians. Objective Measure the impact of a time-saving quality improvement intervention to increase engagement with a CDS tool for low back pain imaging ordering. Design, setting and participants We conducted a quasi-experimental difference-in-differences analysis at (BLINDED), examining back pain imaging orders from 29 May 2015 to 07 January 2016. The intervention site was (BLINDED) Emergency Medicine/Urgent Care Center (n=5736) and control sites included all other (BLINDED) hospitals and clinics (n=1621). In May 2015, the Department of Health Services installed a CDS tool that triggered a survey when clinicians ordered an imaging test, generating an ‘appropriateness score’ based on the American College of Radiology guidelines. Clinicians often bypassed the tool, resulting in ‘unscored’ tests. Intervention To increase clinician engagement with the tool and decrease the rate of unscored imaging tests, a new policy was implemented at the intervention site on 15 August 2015. If clinicians completed the CDS survey and scored an appropriateness score >3, they could forego a previously mandatory telephone call for pre-imaging utilisation review with the radiology department. Main outcomes and measures We used EHR data to measure pre–post-intervention differences in: (1) percentage of unscored tests and (2) percentage of tests with high appropriateness scores (>7). Results Percentage of unscored tests decreased from 69.4% to 10.4% at the intervention site and from 50.6% to 34.8% at the control sites (between-group difference: −23.3%, p<0.001). Percentage of high scoring tests increased from 26.5% to 75.0% at the intervention site and from 17.2% to 22.7% at the control sites (between-group difference: 19%, p<0.001). Conclusion Workflow time-saving interventions may increase physician engagement with CDS tools and have potential to improve practice patterns.
Collapse
Affiliation(s)
- Bryanna Lee
- University of California Los Angeles Value-Based Care Research Consortium, Los Angeles, California, USA
| | - John Mafi
- University of California Los Angeles Value-Based Care Research Consortium, Los Angeles, California, USA.,Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Maitraya K Patel
- Department of Radiological Sciences, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Andrea Sorensen
- University of California Los Angeles Value-Based Care Research Consortium, Los Angeles, California, USA.,Division of Geriatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Eric Wei
- Office of Quality and Safety, New York City Health and Hospitals, New York, New York, USA
| | - Catherine Sarkisian
- University of California Los Angeles Value-Based Care Research Consortium, Los Angeles, California, USA.,Division of Geriatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.,Veterans Administration Greater Los Angeles Healthcare System Geriatrics Research Education & Clinical Center, Los Angeles, California, USA
| |
Collapse
|
8
|
Oronce C, Fendrick A, Ladapo J, Sarkisian C, Mafi J. The Utilization and Costs of USPSTF Grade D Services in Medicare, 2007‐2016. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- C.I. Oronce
- VA Greater Los Angeles Healthcare System Los Angeles CA United States
- UCLA National Clinician Scholars Program Los Angeles CA United States
| | | | - J. Ladapo
- UCLA Division of General Internal Medicine and Health Services Research David Geffen School of Medicine Los Angeles CA United States
| | - C. Sarkisian
- David Geffen School of Medicine at UCLA Los Angeles CA United States
| | - J. Mafi
- David Geffen School of Medicine at UCLA Los Angeles CA United States
| |
Collapse
|
9
|
Cuevas M, Carillo C, Reyes C, Stirland A, Rothschild B, Mafi J, Wei E, Sarkisian C. HEALTH INFORMATION SOURCES AMONG OLDER AND YOUNGER PATIENTS AT AN URBAN SAFETY-NET HEALTHCARE CENTER. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Cuevas
- UCLA David Geffen School of Medicine, Department of Medicine, Division of Geriatrics
| | - C Carillo
- Medicine-Division of Geriatrics, UCLA
| | - C Reyes
- UCLA David Geffen School of Medicine, Department of Medicine, Division of Geriatrics
| | - A Stirland
- Los Angeeles County Department of Public Health
| | | | - J Mafi
- UCLA David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine
| | | | - C Sarkisian
- UCLA David Geffen School of Medicine, Department of Medicine, Division of Geriatrics
| |
Collapse
|
10
|
McMullin N, Lindsell CJ, Lei L, Mafi J, Jois-Bilowich P, Anantharaman V, Pollack CV, Hollander JE, Gibler WB, Hoekestra JW, Diercks D, Peacock WF. Outcomes associated with small changes in normal-range cardiac markers. Am J Emerg Med 2010; 29:162-7. [PMID: 20825781 DOI: 10.1016/j.ajem.2009.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 07/22/2009] [Accepted: 08/18/2009] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS). MATERIALS AND METHODS This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk. Patients were included in this registry if they were at least 18 years old and had suspected ACS at the time of their ED visit. Inclusions in this analysis required that patients had at least 1 cardiac marker (creatine kinase-MB [CK-MB], troponin T, or troponin I) drawn twice within 6 hours of presentation, with both measures being below the institution's upper limit of normal. A marker change was defined as either an increase or decrease that exceeded 15% of the institutional upper limit of normal. Acute coronary syndrome was defined as a positive stress test, documented myocardial infarction, coronary revascularization, or death within 30 days of their ED admission. RESULTS Of 17,713 patient visits, 2162 met inclusion and exclusion criteria. There were 1872 patient visits with 2 troponin results and 1312 with 2 CK-MB results. Patient visits with increasing troponin had increased odds of ACS compared with those with stable troponin levels (odds ratio, 3.6; 95% confidence interval, 1.4-9.2). Changing CK-MB and decreasing troponin were not associated with increased odds of ACS. CONCLUSIONS Small increases in troponin concentration below the upper limit of normal are associated with increased odds of ACS.
Collapse
|
11
|
McMullin N, Lindsell C, Lei L, Mafi J, Jois-Bilowich P, Anantharaman V, Pollack C, Hollander J, Gibler B, Hoekstra J, Diercks D, Peacock W. Outcomes Associated with Small Changes in Normal Range Cardiac Markers. Acad Emerg Med 2007. [DOI: 10.1197/j.aem.2007.03.1038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|