Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims

Chalmers, Kelsey; Smith, Philip E.; Garber, Judith A.; Gopinath, Valérie; Brownlee, Shannon; Schwartz, Allen D.; Elshaug, Adam G; Saini, Vikas

doi:10.1001/jamanetworkopen.2021.8075

Cited by 33 publications

(29 citation statements)

References 34 publications

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“…We used previously published measures of low-value care if they were for procedures likely to be the main reason for a hospital visit. 5 , 12 , 13 These procedures were knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy (CEA), renal stenting, and hysterectomy for benign conditions.…”

Section: Methodsmentioning

confidence: 99%

Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries

et al. 2021

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IMPORTANCE There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population. OBJECTIVE To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020. MAIN OUTCOMES AND MEASURESFor inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs), as well as the unadjusted and adjusted difference in mean LOS and Medicare costs between admissions with and without a HAC/PSI. For outpatient procedures, we report the number of claims where the beneficiary had an unplanned hospital admission within seven days and the number of these admissions with a HAC/PSI. RESULTS There were 573 351 patients included in the study, with 617 264 procedures; the mean (SD) age was 74.2 (6.7) years, with 320 637 women (55.9%), and mostly White patients (520 735; 90.8%). Among the 197 755 claims for the inpatient procedures, 231 had an HAC and 1764 had a PSI.

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Section: Methodsmentioning

confidence: 99%

Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries

et al. 2021

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“…The substantial variability in performance across VHA’s 119 endoscopy facilities may be reflective of cultural or other unmeasured facility-level characteristics that enhance or impede efforts to reduce low-value care at those sites. Indeed, substantial variability in use of other low-value diagnostic testing has been demonstrated across facilities in other studies 18 19. For example, sites may have varying levels of available resources to carefully triage colonoscopy consults to detect low-value procedures, differences in leadership support and stakeholder engagement to support these efforts, and varying levels of recognition of the strong link between minimising low-value care (ie, decreasing demand) and improving overall endoscopy access.…”

Section: Discussionmentioning

confidence: 99%

Development and validation of a new ICD-10-based screening colonoscopy overuse measure in a large integrated healthcare system: a retrospective observational study

et al. 2022

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BackgroundLow-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.MethodsRetrospective 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.ResultsThe 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%).ConclusionsAn 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.

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“…Over utilization of tests and treatments puts frail older patients at particular risk for harm ( American Geriatrics Society, 2021 ; Chalmers et al, 2021 ; Hajjar et al, 2005 ; Kouladjian et al, 2014 ; Wald, 2017 ) and increases the costs of medical care ( Chalmers et al, 2021 ). Geriatric hospitals would offer the best opportunity to address this problem because they could more easily monitor utilization and develop standards for frail patients since all of the patients are frail.…”

Section: Challengesmentioning

confidence: 99%

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States

Flaherty

Rodin

Morley

2022

Gerontology and Geriatric Medicine

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Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).

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Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims

Cited by 33 publications

References 34 publications

Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries

Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries

Development and validation of a new ICD-10-based screening colonoscopy overuse measure in a large integrated healthcare system: a retrospective observational study

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States

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