Eva Chang

The state of overuse measurement: A critical review.:

Health care overuse contributes to unnecessary expenditures and patient exposure to harm. Understanding and addressing this problem requires a comprehensive set of valid metrics. This article describes and critiques the current state of overuse measurement through a review of the published and gray literature, measures clearinghouses and ongoing work by major measure developers. Our review identified 37 fully specified measures and 123 measurement development opportunities. Many services were considered overuse due to the extension of diagnostic or screening services to low-risk populations. There were more diagnostic or therapeutic overuse measures than for screening or monitoring/surveillance. Imaging services is a major focus of current measures, but opportunities exist to expand overuse measurement in medication, laboratory services. Future development of overuse measures would benefit from new empirical research and clinical guidelines focused on identifying indications or populations for which there is likely to be no or low benefit.

Identifying possible indicators of systematic overuse of health care procedures with claims data.

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.

Systematic Overuse of Healthcare Services: A Conceptual Model

A perfect storm of factors influences the overuse of healthcare services in the USA. Considerable attention has been placed on geographic variation in utilization; however, empiric data has shown that geographic variation in utilization is not associated with overuse. While there has been renewed interest in overuse in recent years, much of the focus has been on the overuse of individual procedures. In this paper we argue that overuse should be thought of as a widespread and pervasive phenomenon that we coin as systematic overuse. While not directly observable (i.e., a latent phenomenon), we suggest that systematic overuse could be identified by tracking a portfolio of overused procedures. Such a portfolio would reflect systematic overuse if it is associated with higher healthcare costs and no health benefit (including worse health outcomes) across a healthcare system. In this report we define and conceptualize systematic overuse and illustrate how it can be identified and validated via a simple empirical example using several Choosing Wisely indicators. The concept of systematic overuse requires further development and empirical verification, and this paper provides an important first step, a conceptual framework, to that end.

Effect of Acculturation on Variations in Having a Usual Source of Care Among Asian Americans and Non-Hispanic Whites in California

OBJECTIVES We examined variations in having a usual source of care (USC) among non-Hispanic White and Asian American adults in California. METHODS Data were from the 2005 and 2009 California Health Interview Survey. Using a modified Anderson model, we used multiple logistic regression to compare odds of having a USC between non-Hispanic White (n=38554) and Asian American adults (n=7566) and to examine associations with acculturation factors (English proficiency, length of residence, residence in a racially concordant neighborhood) and key enabling (employment, income, insurance) and predisposing (education) factors. RESULTS Race-related disparities between Asian Americans and non-Hispanic Whites in having a USC were no longer significant after accounting for acculturation factors. Limited English proficiency and short time in the United States (<5 years) were significantly associated with not having a USC for both races. Increasing levels of education and insurance were not associated with better access among Asian Americans. CONCLUSIONS Key differences exist in how Asian American and non-Hispanic White adults access care. Acculturation factors are key drivers of disparities and should be included in access-to-care models with Asians. Insurance and education are differentially significant for Asian Americans and non-Hispanic Whites.

An index for measuring overuse of health care resources with medicare claims

Background:Overuse can be defined as use of a service when the risk of harm exceeds its likely benefit. Yet, there has been little work with composite measures of overuse. Objective:Our goal was to create a composite measure of overuse with claims data. Design:Observational study using 5% of Medicare claims from 2008. Setting:All inpatient and outpatient settings of care, excluding nursing homes. Participants:Older Americans receiving health care services in hospitals or outpatient settings. Measures:We applied algorithms to identify specific cases of overuse across 20 previously identified procedures and used multilevel modeling techniques to examine variation in overuse across all procedures. Included in the model were patient-level factors and both procedure and regional fixed effects for the 306 hospital referral regions (HRR). These estimated regional fixed effects, representing the systematic, region variation in overuse across all measures, was then normalized compared with the overall average to generate a Z score for each HRR. The resulting “Overuse Index” was then compared with total costs, 30-day postdischarge mortality, and total mortality at the HRR level, graphically, and associations were tested using Spearman &rgr;. Results:The Overuse Index varied markedly across regions, but 23 were higher than the average (P<0.05). The Index was positively associated with total costs (&rgr;=0.28, P<0.0001). It was positively correlated with 30-day postdischarge mortality (&rgr;=0.18 P⩽0.005), and neither positively or negatively correlated with total mortality. Conclusions:This study confirms previous research hypothesizing that systematic regional variation in overuse exists and is measurable. Addition research is needed to validate index and to test its predictive and concurrent validity in panel data.

Factors associated with having a usual source of care in an ethnically diverse sample of Asian American adults.

Background:Despite significant population increases, how Asian Americans ethnic subgroups vary in having a usual source of care (USC) is poorly understood. Objectives:To examine how having a USC varies among Asian American ethnic subgroups (Chinese, Filipinos, Japanese, Koreans, Vietnamese, and South Asians), and the potential factors influencing variation in having a USC. Research Design:Data were from 2005 and 2009 California Health Interview Survey. Logistic regressions and pair-wise comparisons were used to compare odds of having a USC among Asian ethnic adults (18–64 y) and to examine ethnicity-specific associations with immigration-related factors (English proficiency, length of residence, and living in an ethnically concordant neighborhood) and key enabling (employment, income, insurance), predisposing (education), and need (health status) factors. Models also adjusted for other sociodemographic factors. Results:Significant differences in the magnitude of the variation and factors influencing having a USC were found across Asian subgroups. Korean and Japanese adults had 52%–69% lower adjusted odds of having a USC compared with Chinese. Among all Asian subgroups, uninsured adults had 85%–94% lower adjusted odds of having a USC. Patterns of associations with USC and key factors varied by specific Asian subgroup. Conclusions:Patterns of associations for USC varied by Asian subgroup, although uninsurance persisted significantly across all subgroups. Persistent variation and heterogenous associations suggest that targeted, ethnicity-specific policies and outreach are needed to improve having a USC for Asian American ethnic adults.

Understanding Pathways to Usual Source of Care among Asian Americans

Although the prevailing conceptual model for health care access is the Andersen Behavioral Model of Health Service Use, researchers have not evaluated empirically whether model pathways are appropriate for Asian Americans (AAs). Using path analysis with 2009 California Health Interview Survey data, we tested pathways among predisposing, enabling, and need factors and acculturation factors for having a usual source of care (USC) among AA adults. Pathway differences among ethnic subgroups (Chinese, Koreans, and Vietnamese) were also examined. The model adequately predicted USC among AAs. As expected, insurance was the key predictor but higher education levels were associated with lower income and lower income with having a USC. English proficiency also contributed significantly to the AA model. Ethnic subgroup models varied significantly. Findings suggest that the Andersen behavioral model is appropriate for studying USC among AAs though pathways vary by ethnicity. Pathways for education and English proficiency must be better understood.

Medication Related Self- efficacy among Linguistically Diverse Patients with Chronic Illnesses

Abstract:This study examines medication-related self-efficacy in a linguistically diverse group of patients with diabetes, hypertension, and elevated cholesterol. A telephone survey of 509 adults conducted in six languages (English, Spanish, Korean, Vietnamese, Mandarin, and Cantonese) was analyzed. Self-efficacy was assessed with the overall Medication Understanding and Use Self-Efficacy (MUSE) score and its two subscale scores on taking medication and learning about medications. Compared with English proficient (EP) patients, patients with limited English proficiency (LEP) had a lower mean learning self-efficacy subscale score (LEP: 14.5, EP: 15.4; p<.001) and no difference in the mean taking self-efficacy subscale score (LEP: 14.4, EP: 14.6; p=.40). Receiving verbal medication information (VMI) from providers modified the relationship between LEP status and learning self-efficacy. In conclusion, among patients with chronic illnesses, LEP patients had lower medication-related self-efficacy scores than EP patients, which may put them at greater risk for medication taking errors and lower adherence.