Elizabeth A. Howell

Overuse of health care services in the United States: an understudied problem.

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. METHODS We searched MEDLINE (1978-2009) for studies measuring US rates of overuse of procedures, tests, and medications, augmented by author tracking, reference tracking, and expert consultation. Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data including overuse rate, type of service, clinical area, and publication year. RESULTS We identified 172 articles measuring overuse: 53 concerned therapeutic procedures; 38, diagnostic tests; and 81, medications. Eighteen unique therapeutic procedures and 24 diagnostic services were evaluated, including 10 preventive diagnostic services. The most commonly studied services were antibiotics for upper respiratory tract infections (59 studies), coronary angiography (17 studies), carotid endarterectomy (13 studies), and coronary artery bypass grafting (10 studies). Overuse of carotid endarterectomy and antibiotics for upper respiratory tract infections declined over time. CONCLUSIONS The robust evidence about overuse in the United States is limited to a few services. Reducing inappropriate care in the US health care system likely requires a more substantial investment in overuse research.

Racial and ethnic differences in factors associated with early postpartum depressive symptoms.

OBJECTIVE: To explore racial differences in reporting of early postpartum depressive symptoms. To explore whether racial differences in early postpartum experience (such as mothers health status and social context) might account for racial differences in reported postpartum depressive symptoms. METHODS: This was a telephone survey of 655 white, African-American, and Hispanic mothers between 2 and 6 weeks postpartum. Mothers reported on demographic factors, physical symptoms, daily function, infant behaviors, social support, skills in managing infant and household, access, and trust in the medical system. We explored racial differences in report of early postpartum depressive symptoms using bivariate and multivariate statistics. RESULTS: African-American and Hispanic women more commonly reported postpartum depressive symptoms (43.9% and 46.8%, respectively) than white women (31.3%, P < .001). Similar factors (physical symptom burden, lack of social support, and lack of self-efficacy) were associated with early postpartum depressive symptoms in white, African-American, and Hispanic mothers. In a comprehensive model including other demographic factors, history of depression, physical symptoms, daily function, infant behavior, social support, skills in managing infant and household, access, and trust, the adjusted odds ratio for reported postpartum depressive symptoms remained elevated for African-American women at 2.16 (95% confidence interval 1.26–3.70) and Hispanic women at 1.89 (95% confidence interval 1.19–3.01) as compared with white women. CONCLUSION: African-American and Hispanic mothers are at higher risk for reporting early postpartum depressive symptoms as compared with white mothers. Factors associated with these symptoms are similar among African-American, Hispanic, and white mothers. LEVEL OF EVIDENCE: II-2

When Does A Difference Become A Disparity? Conceptualizing Racial And Ethnic Disparities In Health

Definitions of racial and ethnic disparities fall along a continuum from differences with little connotation of being unjust to those that result from overt discrimination. Where along this continuum one decides that a racial difference becomes a disparity is subjective, but the magnitude of the injustice is generally proportional to how much control a person is perceived to have over the cause of the difference in health. The degree to which one sees environmental factors and social context as shaping choices has important implications for the measurement of disparities and ultimately for directing efforts to eliminate them.

Black/White Differences in Very Low Birth Weight Neonatal Mortality Rates Among New York City Hospitals

OBJECTIVE. We sought to determine whether differences in the hospitals at which black and white infants are born contribute to black/white disparities in very low birth weight neonatal mortality rates in New York City. METHODS. We performed a population-based cohort study using New York City vital statistics records on all live births and deaths of infants weighing 500 to 1499 g who were born in 45 hospitals between January 1, 1996, and December 31, 2001 (N = 11 781). We measured very low birth weight risk-adjusted neonatal mortality rates for each New York City hospital and assessed differences in the distributions of non-Hispanic black and non-Hispanic white very low birth weight births among these hospitals. RESULTS. Risk-adjusted neonatal mortality rates for very low birth weight infants in New York City hospitals ranged from 9.6 to 27.2 deaths per 1000 births. White very low birth weight infants were more likely to be born in the lowest mortality tertile of hospitals (49%), compared with black very low birth weight infants (29%). We estimated that, if black women delivered in the same hospitals as white women, then black very low birth weight mortality rates would be reduced by 6.7 deaths per 1000 very low birth weight births, removing 34.5% of the black/white disparity in very low birth weight neonatal mortality rates in New York City. Volume of very low birth weight deliveries was modestly associated with very low birth weight mortality rates but explained little of the racial disparity. CONCLUSION. Black very low birth weight infants more likely to be born in New York City hospitals with higher risk-adjusted neonatal mortality rates than were very low birth weight infants, contributing substantially to black-white disparities.

Association Between Hospital-Level Obstetric Quality Indicators and Maternal and Neonatal Morbidity

IMPORTANCE In an effort to improve the quality of care, several obstetric-specific quality measures are now monitored and publicly reported. The extent to which these measures are associated with maternal and neonatal morbidity is not known. OBJECTIVE To examine whether 2 Joint Commission obstetric quality indicators are associated with maternal and neonatal morbidity. DESIGN, SETTING, AND PARTICIPANTS Population-based observational study using linked New York City discharge and birth certificate data sets from 2010. All delivery hospitalizations were identified and 2 perinatal quality measures were calculated (elective, nonmedically indicated deliveries at 37 or more weeks of gestation and before 39 weeks of gestation; cesarean delivery performed in low-risk mothers). Published algorithms were used to identify severe maternal morbidity (delivery associated with a life-threatening complication or performance of a lifesaving procedure) and morbidity in term newborns without anomalies (births associated with complications such as birth trauma, hypoxia, and prolonged length of stay). Mixed-effects logistic regression models were used to examine the association between maternal morbidity, neonatal morbidity, and hospital-level quality measures while risk-adjusting for patient sociodemographic and clinical characteristics. MAIN OUTCOMES AND MEASURES Individual- and hospital-level maternal and neonatal morbidity. RESULTS Severe maternal morbidity occurred among 2372 of 115,742 deliveries (2.4%), and neonatal morbidity occurred among 8057 of 103,416 term newborns without anomalies (7.8%). Rates for elective deliveries performed before 39 weeks of gestation ranged from 15.5 to 41.9 per 100 deliveries among 41 hospitals. There were 11.7 to 39.3 cesarean deliveries per 100 deliveries performed in low-risk mothers. Maternal morbidity ranged from 0.9 to 5.7 mothers with complications per 100 deliveries and neonatal morbidity from 3.1 to 21.3 neonates with complications per 100 births. The maternal quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers were not associated with severe maternal complications (risk ratio [RR], 1.00 [95% CI, 0.98-1.02] and RR, 0.99 [95% CI, 0.96-1.01], respectively) or neonatal morbidity (RR, 0.99 [95% CI, 0.97-1.01] and RR, 1.01 [95% CI, 0.99-1.03], respectively). CONCLUSIONS AND RELEVANCE Rates for the quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers varied widely in New York City hospitals, as did rates of maternal and neonatal complications. However, there were no correlations between the quality indicator rates and maternal and neonatal morbidity. Current quality indicators may not be sufficiently comprehensive for guiding quality improvement in obstetric care.

Overuse and Systems of Care A Systematic Review

Background:Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system. Objective:To compare rates of overuse in different health care systems and examine whether certain systems of care or insurers have lower rates of overuse of health care services. Data Sources:Articles published in MEDLINE between 1978, the year of publication of the first framework to measure quality, and June 21, 2012. Study Selection:Included studies compared rates of overuse of procedures, diagnostic tests, or medications in at least 2 systems of care. Data Extraction:Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data. Results:We identified 7 studies which compared rates of overuse of 5 services across multiple different health care settings. National rates of inappropriate coronary angiography were similar in Medicare HMOs and Medicare FFS (13% vs. 13%, P=0.33) and in a state-based study comparing 15 hospitals in New York and 4 hospitals in a Massachusetts-managed care plan (4% vs. 6%, P>0.1). Rates of carotid endarterectomy in New York State were similar in Medicare HMOs and Medicare FFS plans (8.4% vs. 8.6%, P=0.55) but nonrecommended use of antibiotics for the treatment of upper respiratory infection was higher in a managed care organization than a FFS private plan (31% vs. 21%, P=0.02). Rates of inappropriate myocardial perfusion imaging were similar in VA and private settings (22% vs. 16.6%, P=0.24), but rates of inappropriate surveillance endoscopy in the management of gastric ulcers were higher in the VA compared with private settings (37.4% vs. 20.4%–23.3%, P<0.0001). Conclusions:The available evidence is limited but there is no consistent evidence that any 1 system of care has been more effective at minimizing the overuse of health care services. More research is necessary to inform current health care reform efforts directed at reducing overuse.

The relationship between geographic variations and overuse of healthcare services: a systematic review.

Objective:To examine the relationship between overuse of healthcare services and geographic variations in medical care. Design:Systematic Review. Data Sources:Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009. Study Selection:Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data. Data Extraction:We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured. Results:Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%). Conclusions:The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.

Black-white differences in severe maternal morbidity and site of care.

BACKGROUND For every maternal death, >100 women experience severe maternal morbidity, which is a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. Similar to racial/ethnic disparities in maternal death, black women are more likely to experience severe maternal morbidity than white women. Site of care has received attention as a mechanism to explain disparities in other areas of medicine. Data indicate that black women receive care in a concentrated set of hospitals and that these hospitals appear to provide lower quality of care. Whether racial differences in the site of delivery contribute to observed black-white disparities in severe maternal morbidity rates is unknown. OBJECTIVE The purpose of this study was to determine whether hospitals with high proportions of black deliveries have higher severe maternal morbidity and whether such differences contribute to overall black-white disparities in severe maternal morbidity. STUDY DESIGN We used a published algorithm to identify cases of severe maternal morbidity during deliveries in the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for 2010 and 2011. We ranked hospitals by their proportion of black deliveries into high black-serving (top 5%), medium black-serving (5% to 25% range), and low black-serving hospitals. We analyzed the risks of severe maternal morbidity for black and white women by hospital black-serving status using logistic regressions that were adjusted for patient characteristics, comorbidities, hospital characteristics, and within-hospital clustering. We then derived adjusted rates from these models. RESULTS Seventy-four percent of black deliveries occurred at high and medium black-serving hospitals. Overall, severe maternal morbidity occurred more frequently among black than white women (25.8 vs 11.8 per 1000 deliveries, respectively; P < .001); after adjustment for the distribution of patient characteristics and comorbidities, this differential declined but remained elevated (18.8 vs 13.3 per 1000 deliveries, respectively; P < .001). Women who delivered in high and medium black-serving hospitals had elevated rates of severe maternal morbidity rates compared with those in low black-serving hospitals in unadjusted (29.4 and 19.4 vs 12.2 per 1000 deliveries, respectively; P < .001) and adjusted analyses (17.3 and 16.5 vs 13.5 per 1000 deliveries, respectively; P < .001). Black women who delivered at high black-serving hospitals had the highest risk of poor outcomes. CONCLUSION Most black deliveries occur in a concentrated set of hospitals, and these hospitals have higher severe maternal morbidity rates. Targeting quality improvement efforts at these hospitals may improve care for all deliveries and disproportionately impact care for black women.

Racial disparities in the treatment of advanced epithelial ovarian cancer.

OBJECTIVE: To examine whether treatment with guideline-recommended care (surgery and chemotherapy) is associated with mortality differences between black and white women with advanced epithelial ovarian cancer. METHODS: We conducted an observational cohort study using the Surveillance, Epidemiology, and End Results (SEER) linked to Medicare claims for 1995–2007. We evaluated long-term survival for 4,695 black and white women with stage III or stage IV epithelial ovarian cancer with Kaplan-Meier analysis and Cox regression, and then in patients matched by propensity score to create two similar cohorts for comparison. We investigated the association between race, stage, and survival among women who were treated with guideline-recommended care and those who received incomplete treatment. RESULTS: Black women with advanced epithelial ovarian cancer were more likely to die than white women (unadjusted hazard ratio [HR] 1.27; 95% confidence interval [CI] 1.10–1.46). Black women were less likely than white women to receive guideline-recommended care (54% compared with 68%; P<.001), and women who did not receive recommended treatment had lower survival rates than women who received recommended care. Cox proportional hazards models demonstrated no differences in black women compared with white women regarding mortality among women who were treated with guideline-recommended care (adjusted HR 1.04; 95% CI 0.85–1.26), or among women who received incomplete treatment (adjusted HR 1.09; 95% CI 0.89–1.34). The survival analysis of patients matched by propensity score confirmed these analyses. CONCLUSIONS: Differences in rates of treatment with guideline-recommended care are associated with black–white mortality disparities among women with advanced epithelial ovarian cancer. LEVEL OF EVIDENCE: III

An intervention to extend breastfeeding among black and Latina mothers after delivery.

OBJECTIVE The purpose of this study was to compare breastfeeding duration in mothers after delivery who were assigned randomly to a behavioral educational intervention vs enhanced usual care. STUDY DESIGN We conducted a randomized trial. Self-identified black and Latina mothers early after delivery were assigned randomly to receive a behavioral educational intervention or enhanced usual care. The 2-step intervention aimed to prepare and educate mothers about postpartum symptoms and experiences (including tips on breastfeeding and breast/nipple pain) and to bolster social support and self-management skills. Enhanced usual care participants received a list of community resources and received a 2-week control call. Intention-to-treat analyses examined breastfeeding duration (measured in weeks) for up to 6 months of observation. This study was registered with clinicaltrial.gov (NCT01312883). RESULTS Five hundred forty mothers were assigned randomly to the intervention (n = 270) vs control subjects (n = 270). Mean age was 28 years (range, 18-46 years); 62% of the women were Latina, and 38% were black. Baseline sociodemographic, clinical, psychosocial, and breastfeeding characteristics were similar among intervention vs control subjects. Mothers in the intervention arm breastfed for a longer duration than did the control subjects (median, 12.0 vs 6.5 weeks, respectively; P = .02) Mothers in the intervention arm were less likely to quit breastfeeding over the first 6 months after delivery (hazard ratio, 0.79; 95% confidence interval, 0.65-0.97). CONCLUSION A behavioral educational intervention increased breastfeeding duration among low-income, self-identified black and Latina mothers during the 6-month postpartum period.