Allison Lipitz-Snyderman

Overuse of Health Care Services: When Less Is More … More or Less

There is widespread agreement that ‘more’ is not always better in health care. Doing ‘more’ can harm patients, generate excess costs, and defy patient preferences. All are major threats to the delivery of high quality health care. Reflecting this notion, the Institute of Medicine (IOM) National Roundtable on Health Care Quality coined the term ‘overuse’ in 1998,1 adapting the definition of an ‘inappropriate’ service developed for the RAND Appropriateness Method in the 1980s.2 Overuse was defined as “a health care service [that] is provided under circumstances in which its potential for harm exceeds the possible benefit.”1 Initiatives to address overuse of medical services3 will be crucial in reducing total health care spending and iatrogenic harms.4 But recent initiatives also illustrate a potential obstacle – what is meant by overuse may be conceptually vague. In 2008, the National Priorities Partnership identified eliminating overuse as a national priority, describing it as “unscientific,” “redundant,” and “excessive” care.3 The American College of Physicians identified examples of overused screening and diagnostic tests that “clinicians often use in a manner that does not reflect high-value, cost-conscious care and does not adhere to currently available clinical guidelines.”5 The American Board of Internal Medicine Foundation’s Choosing Wisely campaign provides yet another description of overuse and helps to demonstrate the potential consequences of this ambiguity. The campaign is intended to help physicians and patients choose care that is “supported by evidence, not duplicative of other tests or procedures already received, free from harm [to patients], [and] truly necessary.”6 But the diversity of scenarios identified is substantially broader than this description. Three scenarios in Choosing Wisely differ strikingly in their underlying premise of what constitutes overuse: ‘do not repeat colorectal cancer screening for 10 years after a high-quality colonoscopy is negative in average-risk individuals,’ ‘don’t use DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors,’ and ‘don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.’6 For too frequent colorectal cancer screening, potential for harm (e.g., perforation of the colon) outweighs the benefit. Although in theory any health care intervention can cause ‘harm,’ DEXA screening for low-risk groups would not have a measureable effect on quality of life or mortality. Rather, the low likelihood of meaningful benefit is associated with the high costs of DEXA screening (estimated

Long-Term Central Venous Catheter Use and Risk of Infection in Older Adults With Cancer

70 per scan, totaling

Use of Disinfection Cap to Reduce Central-Line-Associated Bloodstream Infection and Blood Culture Contamination Among Hematology-Oncology Patients.

527 million per year in the United States for women under age 657). The reasons not to initiate chronic dialysis without shared decision-making are more complex than merely avoiding the initiation of a service expected to do more harm than good. Rather, integrating individual preferences and goals into clinical decisions can help to avoid the provision of undesired care.8 Among these and other examples, no clear conceptual pattern emerges. Rather, the lists are a loose collection of services joined only by the broad notion that they should not be delivered, at least in some contexts. In our view, this lack of conceptual backbone will impede the acceptance of these initiatives by physicians. Absent a clearer conceptual framework, it will be difficult to answer key questions. For example, what types of services should next be included on a list? How should a potential area of overuse be identified a priori? How should a culture that encourages overuse or fails to discourage it be mended? A conceptual framework contemplating different dimensions of overuse might help. The framework we propose has three categories: the tradeoff between benefits and harms, the tradeoff between benefits and costs, and consideration of patient preferences. Examples of overuse can be found in each category. Making the categories explicit can help clarify the reasons to diminish a service’s use, and help those who develop and use the recommendations to make sense of seemingly disjointed issues within and across initiatives.

Reducing Overuse—Is Patient Safety the Answer?

PURPOSE Long-term central venous catheters (CVCs) are often used in patients with cancer to facilitate venous access to administer intravenous fluids and chemotherapy. CVCs can also be a source of bloodstream infections, although this risk is not well understood. We examined the impact of long-term CVC use on infection risk, independent of other risk factors such as chemotherapy, in a population-based cohort of patients with cancer. PATIENTS AND METHODS We conducted a retrospective analysis using SEER-Medicare data for patients age > 65 years diagnosed from 2005 to 2007 with invasive colorectal, head and neck, lung, or pancreatic cancer, non-Hodgkin lymphoma, or invasive or noninvasive breast cancer. Cox proportional hazards regression was used to examine the relationship between CVC use and infections, with CVC exposure as a time-dependent predictor. We used multivariable analysis and propensity score methods to control for patient characteristics. RESULTS CVC exposure was associated with a significantly elevated infection risk, adjusting for demographic and disease characteristics. For patients with pancreatic cancer, risk of infections during the exposure period was three-fold greater (adjusted hazard ratio [AHR], 2.93; 95% CI, 2.58 to 3.33); for those with breast cancer, it was six-fold greater (AHR, 6.19; 95% CI, 5.42 to 7.07). Findings were similar when we accounted for propensity to receive a CVC and limited the cohort to individuals at high risk of infections. CONCLUSION Long-term CVC use was associated with an increased risk of infections for older adults with cancer. Careful assessment of the need for long-term CVCs and targeted strategies for reducing infections are critical to improving cancer care quality.

Performance of a Trigger Tool for Identifying Adverse Events in Oncology.

OBJECTIVE In this study, we examined the impact of routine use of a passive disinfection cap for catheter hub decontamination in hematology-oncology patients. SETTING A tertiary care cancer center in New York City. METHODS In this multiphase prospective study, we used 2 preintervention phases (P1 and P2) to establish surveillance and baseline rates followed by sequential introduction of disinfection caps on high-risk units (HRUs: hematologic malignancy wards, hematopoietic stem cell transplant units and intensive care units) (P3) and general oncology units (P4). Unit-specific and hospital-wide hospital-acquired central-line-associated bloodstream infection (HA-CLABSI) rates and blood culture contamination (BCC) with coagulase negative staphylococci (CONS) were measured. RESULTS Implementation of a passive disinfection cap resulted in a 34% decrease in hospital-wide HA-CLABSI rates (combined P1 and P2 baseline rate of 2.66-1.75 per 1,000 catheter days at the end of the study period). This reduction occurred only among high-risk patients and not among general oncology patients. In addition, the use of the passive disinfection cap resulted in decreases of 63% (HRUs) and 51% (general oncology units) in blood culture contamination, with an estimated reduction of 242 BCCs with CONS. The reductions in HA-CLABSI and BCC correspond to an estimated annual savings of

ReCAP: Detection of Potentially Avoidable Harm in Oncology From Patient Medical Records

3.2 million in direct medical costs. CONCLUSION Routine use of disinfection caps is associated with decreased HA-CLABSI rates among high-risk hematology oncology patients and a reduction in blood culture contamination among all oncology patients.

Impact of Observation Status on Hospital Use for Patients With Cancer

In this issue of JAMA, Zapata and colleagues discuss framing the provision of unnecessary medical care as a patient safety problem and managing this problem using the hospital patient safety committee.1 The case presented highlights the lack of clarity about who is accountable for addressing overuse issues. All hospitals are concerned with the safety of their patients, and the authors provide a thoughtful discussion of the merits and challenges of using patient safety infrastructure to target overuse. To retain focus on safety issues while facilitating greater attention to overuse requires defining the relationship between overuse and patient safety.

Preventable and mitigable adverse events in cancer care: Measuring risk and harm across the continuum

PURPOSE Although patient safety is a priority in oncology, few tools measure adverse events (AEs) beyond treatment-related toxicities. The study objective was to assemble a set of clinical triggers in the medical record and assess the extent to which triggered events identified AEs. METHODS We performed a retrospective cohort study to assess the performance of an oncology medical record screening tool at a comprehensive cancer center. The study cohort included 400 patients age 18 years or older diagnosed with breast (n = 128), colorectal (n = 136), or lung cancer (n = 136), observed as in- and outpatients for up to 1 year. RESULTS We identified 790 triggers, or 1.98 triggers per patient (range, zero to 18 triggers). Three hundred four unique AEs were identified from medical record reviews and existing AE databases. The overall positive predictive value (PPV) of the original tool was 0.40 for total AEs and 0.15 for preventable or mitigable AEs. Examples of high-performing triggers included return to the operating room or interventional radiology within 30 days of surgery (PPV, 0.88 and 0.38 for total and preventable or mitigable AEs, respectively) and elevated blood glucose (> 250 mg/dL; PPV, 0.47 and 0.40 for total and preventable or mitigable AEs, respectively). The final modified tool included 49 triggers, with an overall PPV of 0.48 for total AEs and 0.18 for preventable or mitigable AEs. CONCLUSION A valid medical record screening tool for AEs in oncology could offer a powerful new method for measuring and improving cancer care quality. Future improvements could optimize the tools efficiency and create automated electronic triggers for use in real-time AE detection and mitigation algorithms.

Complications Associated With Use of Long-Term Central Venous Catheters Among Commercially Insured Women With Breast Cancer.

PURPOSE Widespread consensus exists about the importance of addressing patient safety issues in oncology, yet our understanding of the frequency, spectrum, and preventability of adverse events (AEs) across cancer care is limited. METHODS We developed a screening tool to detect AEs across cancer care settings through medical record review. Members of the study team reviewed the scientific literature and obtained structured input from an external multidisciplinary panel of clinicians by using a modified Delphi process. RESULTS The screening tool comprises 76 triggers-readily identifiable findings to screen for possible AEs that occur during cancer care. Categories of triggers are general care, vital signs, medication related, laboratory tests, other orders, and consultations. CONCLUSION Although additional testing is required to assess its performance characteristics, this tool may offer an efficient mechanism for identifying possibly preventable AEs in oncology and serve as an instrument for quality improvement.

Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments

PURPOSE For patients with cancer, the impact of observation status on hospital and patient outcomes is not well understood. Our objective was to assess the impact that an observation unit had on hospital use for patients with cancer who presented to the Urgent Care Center at a comprehensive cancer center. METHODS We assessed the proportion of Urgent Care Center visits that resulted in an admission to the hospital at a comprehensive cancer center, before (July 9, 2012-December 31, 2012) versus after (July 9, 2013-December 31, 2013) implementation of the observation unit. We also assessed differences in length of stay and stratified the data by presenting complaint. RESULTS During each 6-month study interval, there were more than 10,000 patient visits to the Urgent Care Center, representing approximately 6,000 unique patients. Fewer visits resulted in an inpatient admission postimplementation (47%) compared with preimplementation (50%). The duration of hospital stay for admitted patients was higher in the post period (median 108 hours) than in the pre period (median 96 hours). Alternatively, the proportion of hospital admissions with a length of stay less than 24 hours was lower in the post period (pre: 7%; post: 5%). Lower admission rates postimplementation were observed for patients who presented with fluid and electrolyte disorders, nausea and vomiting, syncope, and chest pain. CONCLUSION We observed reductions in hospital use for patients with cancer related to an observation unit in a comprehensive cancer center. Adoption of this approach for this patient population has the potential to reduce hospital use, which is of interest to hospitals, payers, and patients.