Overuse and Systems of Care (original) (raw)
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Overuse of Health Care Services in the United States
Archives of Internal Medicine, 2012
Background: Overuse, the provision of health care services for which harms outweigh benefits, represents poor quality and contributes to high costs. A better understanding of overuse in US health care could inform efforts to reduce inappropriate care. We performed an extensive search for studies of overuse of therapeutic procedures, diagnostic tests, and medications in the United States and describe the state of the literature.
Trends in the Overuse of Ambulatory Health Care Services in the United States
JAMA Internal Medicine, 2013
Background: Given the rising costs of health care, policymakers are increasingly interested in identifying the inefficiencies in our health care system. The objective of this study was to determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade.
Identifying Possible Indicators of Systematic Overuse of Health Care Procedures With Claims Data
Medical Care, 2014
Background: Health care quality is frequently described with measures representing the overall performance of a health care system. Despite the growing attention to overuse of health care resources, there is little experience with aggregate measures of overuse. Objective: To identify a set of possible indicators of overuse that can be operationalized with claims data and to describe variation in these indicators across the hospital referral regions (HRRs). Design: Using an environmental scan, we identified published descriptions of overused procedures. We assessed each procedure's feasibility for measurement with claims and developed algorithms for occurrences of procedures in patients unlikely to benefit. Using a 5% sample of Medicare claims from 2008, we calculated summary statistics to illustrate variance in the use across HRRs. Results: A total of 613 procedures were identified as overused; 20 had abundant frequency and variance to be possible measures of systematic overuse. These included 13 diagnostic tests, 2 tests for screening, 1 for monitoring, and 4 therapeutic procedures. The usage varied markedly across HRRs. For illustration, 1 HRR used computed tomography for rhinosinusitis diagnosis in 80 of 1000 beneficiaries (mean usage across HRRs was 14/1000). Among 1,451,142 beneficiaries, 14% had at least one overuse event (range, 8.4%-27%). Conclusions: We identified a set of overused procedures that may be used as measures of overuse and that demonstrate significant variance in their usage. The implication is that an index of overuse might be built from these indicators that would reveal systematic patterns of overuse within regions. Alternatively, these indicators may be valuable in the quality improvement efforts.
Value in Health, 1999
As managed care has grown to dominate the US health care delivery system, questions have been raised about the impact on the quality of care provided to its enrollees. Two important aspects of health care quality are access to care and the appropriateness of care. This analysis evaluated the occurrence of preventable hospitalizations among managed care (MCO) versus fee for service (FFS) populations to compare access to and appropriateness of preventive, primary, and surgical health care services. Rates of preventable hospitalizations associated with ambulatory sensitive conditions (ASCs) were calculated based on all discharges from Massachusetts hospitals in 1995, and categorized by population characteristics including: age, sex, ethnicity, and insurance status. Multivariate logistic regression models were employed to explain the likelihood of hav-ing a preventable hospitalization. Rates of preventable hospitalizations for two of the conditions evaluated (perforated appendix and diabetes complications) were lower for MCO enrollees. For two additional indicators (immunization preventable pneumonia and low birth weight), MCO rates were no different from FFS rates. Results for pediatric asthma were inconclusive. For four out of five quality indicators evaluated, individuals in Massachusetts MCOs are doing better or no worse than their counterparts in FFS plans. Until populationbased data on managed care enrollees becomes available, and until such data can be linked to utilization and health outcomes information, investigations into the quality of services provided by MCOs compared to FFS plans cannot be definitive.
Mirror, mirror on the wall: an update on the quality of American health care …
The …
This report is based on two surveys of patients: the first was conducted in 2004 among a nationally representative sample of adults in Australia, Canada, New Zealand, the United Kingdom, and the United States; the second was conducted in 2005 among a sample of adults with health problems in the same five nations and Germany. It ranks patients' ratings of various dimensions of their health care, according to the Institute of Medicine's framework for quality. The U.S. system ranked first on measures of effectiveness but ranked last on other dimensions of quality. It performed particularly poorly in terms of providing care equitably, safely, efficiently, or in a patient-centered manner. For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than the United States. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. This and other Fund publications are online at www.cmwf.org. To learn more about new publications when they become available, visit the Fund's Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 915.
Initiatives for improving the quality of health care are now focused on stemming the underuse of "effective care"-therapy viewed as medically necessary care on the basis of clinical outcome evidence. But only a small proportion of the health care dollar is influenced by effective care. Most of the spending, at least regarding Medicare, is in two other categories. "Preference-sensitive care," in which treatment options involve tradeoffs that should be based on the patient's own values, tends not to be underused but misused. And "supply-sensitive care," in which the supply of resources governs the frequency of their use, is overused, particularly in the management of chronic illness. Hospital-specific measures that profile performance-such as the average number of days spent in the hospital during the last six months of life and physician labor inputs over that time-could help identify more efficient providers.
National Hospital Ambulatory Medical Care Survey: 2002 Outpatient Department Summary
2004
Objectives-This report describes ambulatory care visits to hospital outpatient departments (OPDs) in the United States. Statistics are presented on selected hospital, clinic, patient, and visit characteristics, as well as selected trends in OPD visits since 1992. Methods-The data presented in this report were collected from the 2002 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. Results-During 2002, an estimated 83.3 million visits were made to hospital OPDs in the United States, or about 29.4 visits per 100 persons. This 2002 rate represents a 31 percent increase since 1992, although rates have been stable since 1999. Females had higher OPD visit rates than males, and black or African American persons had higher OPD visit rates than white persons. The overwhelming majority of visits to hospital OPDs were made by established patients (82.8 percent); 23.8 percent of visits had six or more visits to the clinic within the past year. Private insurance was the most frequent expected payment source (37.3 percent), followed by Medicaid or State Children's Health Insurance Program (SCHIP) (27.3 percent). Since 1999, the percentage of children under 18 years of age relying on Medicaid/SCHIP increased by 23.4 percent. Preventive care visits comprised 18.0 percent of all OPD visits. Medicaid/SCHIP patients used OPDs for preventive care services more frequently than private pay patients. Diagnostic and screening services were ordered or provided at 88.3 percent of visits, therapeutic and preventive services were ordered or provided at 42.8 percent of visits, and medications were prescribed at 65.1 percent of visits. Most patients were given an appointment to return to the clinic (63.3 percent). The percentage of visits where any physician was seen decreased by 10.4 percent between 1992 and 2002, driven largely by a 50 percent decrease in visits to residents or interns. The percentage of visits in which either a physician assistant or nurse practitioner (midlevel providers) was seen increased by 47.0 percent between 1992 and 2002.
Measuring Hospital Quality: Can Medicare Data Substitute for All-Payer Data?
Health Services Research, 2003
Objectives. To assess whether adverse outcomes in Medicare patients can be used as a surrogate for measures from all patients in quality-of-care research using administrative datasets. Data Sources. Patient discharge abstracts from state data systems for 799 hospitals in 11 states. National MedPAR discharge data for Medicare patients from 3,357 hospitals. State hospital staffing surveys or financial reports. American Hospital Association Annual Survey. Study Design. We calculate rates for 10 adverse patient outcomes, examine the correlation between all-patient and Medicare rates, and conduct negative binomial regressions of counts of adverse outcomes on expected counts, hospital nurse staffing, and other variables to compare results using all-patient and Medicare patient data. Data Collection/Extraction. Coding rules were established for eight adverse outcomes applicable to medical and surgical patients plus two outcomes applicable only to surgical patients. The presence of these outcomes was coded for 3 samples: all patients in the 11-state sample, Medicare patients in the 11-state sample, and Medicare patients in the national Medicare MedPAR sample. Logistic regression models were used to construct estimates of expected counts of the outcomes for each hospital. Variables for teaching, metropolitan status, and bed size were obtained from the AHA Annual Survey. Principal Findings. For medical patients, Medicare rates were consistently higher than all-patient rates, but the two were highly correlated. Results from regression analysis were consistent across the 11-state all-patient, 11-state Medicare, and national Medicare samples. For surgery patients, Medicare rates were generally higher than allpatient rates, but correlations of Medicare and all-patient rates were lower, and regression results less consistent. Conclusions. Analyses of quality of care for medical patients using Medicare-only and all-patient data are likely to have similar findings. Measures applied to surgery patients must be used with more caution, as those tested only in Medicare patients may not provide results comparable to those from all-patient samples or across different samples of Medicare patients.
Lessons From the Choosing Wisely Campaign’s 10 Years of Addressing Overuse in Health Care
JAMA Health Forum
This year marks the 10th anniversary of Choosing Wisely, a partnership between the ABIM Foundation and specialty societies designed to promote clinician-patient conversations about frequently performed tests and treatments that might do more harm than good. The campaign was inspired by 2 developments. First, in 2010, medical ethicist Howard Brody called on medical societies to identify 5 overused tests and treatments in their specialties. 1 Second, the National Physicians Alliance, through an ABIM Foundation grant, piloted developing such lists for internal medicine, family practice, and pediatrics. 2 In 2012, the ABIM Foundation joined with 9 physician societies to announce 45 clinical recommendations that discouraged unnecessary care. The campaign now includes more than 80 clinical partners and more than 600 recommendations. 3 It has also generated commentary-and some criticism-across journals and the news media, with more than 10 000 stories and citations. In the spirit of the campaign's focus on 5 things that clinicians and patients should question, we offer 5 takeaways from this decade-long effort and thoughts on next steps. Lessons From the Past Decade Physician Professionalism and Leadership Changed How We Think About Overuse When Choosing Wisely began, many people in the US unquestioningly believed that "more care is better" and sometimes suspected that physicians were ignoring their patients' interests if they did not order a particular test or prescribe a certain medicine. Enlisting physicians as trusted advisers was essential to persuading the public that overuse could threaten their health and that more is not always better. Although many physicians remained unaware of the campaign, the engagement of the profession's leaders and their emphasis on the harms of unnecessary care changed the tone of the discussion and increased the issue's profile. For example, 34 articles were published in 2012 on the topics of low-value care and medical overuse in peer-reviewed English-language journals; in 2021, that number was 674. Consistent with the strategy of advancing professionalism, the campaign gave substantial autonomy to the societies engaging in the campaign, leading some to criticize Choosing Wisely for recommendations that lacked effect. 4 But societies took ownership, using their experience in guideline development to lead a vital effort to promote appropriate care. Choosing Wisely Increased the Frequency of Conversations About Overuse Many physicians report Choosing Wisely conversations occurring regularly. Multiple journals, including the Journal of Hospital Medicine and JAMA Internal Medicine, feature sections on Choosing Wisely and/or overuse. Specialty society meetings offer tracks on overuse and their Choosing Wisely recommendations. These conversations also occur in medical education and training, with the STARS (Students and Trainees Advocating for Resource Stewardship) program from the nonprofit organization Costs of Care focusing on developing curriculum and awareness. So the campaign has focused attention from new and potentially potent stakeholders. Author affiliations and article information are listed at the end of this article.