Grace A. Lin

Frequency of Stress Testing to Document Ischemia Prior to Elective Percutaneous Coronary Intervention

CONTEXT Guidelines call for documenting ischemia in patients with stable coronary artery disease prior to elective percutaneous coronary intervention (PCI). OBJECTIVE To determine the frequency and predictors of stress testing prior to elective PCI in a Medicare population. DESIGN, SETTING, AND PATIENTS Retrospective, observational cohort study using claims data from a 20% random sample of 2004 Medicare fee-for-service beneficiaries aged 65 years or older who had an elective PCI (N = 23 887). MAIN OUTCOME MEASURES Percentage of patients who underwent stress testing within 90 days prior to elective PCI; variation in stress testing prior to PCI across 306 hospital referral regions; patient, physician, and hospital characteristics that predicted the appropriate use of stress testing prior to elective PCI. RESULTS In the United States, 44.5% (n = 10 629) of patients underwent stress testing within the 90 days prior to elective PCI. There was wide regional variation among the hospital referral regions with stress test rates ranging from 22.1% to 70.6% (national mean, 44.5%; interquartile range, 39.0%-50.9%). Female sex (adjusted odds ratio [AOR], 0.91; 95% confidence interval [CI], 0.86-0.97), age of 85 years or older (AOR, 0.83; 95% CI, 0.72-0.95), a history of congestive heart failure (AOR, 0.85; 95% CI, 0.79-0.92), and prior cardiac catheterization (AOR, 0.45; 95% CI, 0.38-0.54) were associated with a decreased likelihood of prior stress testing. A history of chest pain (AOR, 1.28; 95% CI, 1.09-1.54) and black race (AOR, 1.26; 95% CI, 1.09-1.46) increased the likelihood of stress testing prior to PCI. Patients treated by physicians performing 150 or more PCIs per year were less likely to have stress testing prior to PCI (AOR, 0.84; 95% CI, 0.77-0.93). No hospital characteristics were associated with receipt of stress testing. CONCLUSION The majority of Medicare patients with stable coronary artery disease do not have documentation of ischemia by noninvasive testing prior to elective PCI.

Preoperative Medical Testing in Medicare Patients Undergoing Cataract Surgery

BACKGROUND Routine preoperative testing is not recommended for patients undergoing cataract surgery, because testing neither decreases adverse events nor improves outcomes. We sought to assess adherence to this guideline, estimate expenditures from potentially unnecessary testing, and identify patient and health care system characteristics associated with potentially unnecessary testing. METHODS Using an observational cohort of Medicare beneficiaries undergoing cataract surgery in 2011, we determined the prevalence and cost of preoperative testing in the month before surgery. We compared the prevalence of preoperative testing and office visits with the mean percentage of beneficiaries who underwent tests and had office visits during the preceding 11 months. Using multivariate hierarchical analyses, we examined the relationship between preoperative testing and characteristics of patients, health system characteristics, surgical setting, care team, and occurrence of a preoperative office visit. RESULTS Of 440,857 patients, 53% had at least one preoperative test in the month before surgery. Expenditures on testing during that month were

Shared Decision Making State of the Science

4.8 million higher and expenditures on office visits

Resident Perceptions of the Impact of Work Hour Limitations

12.4 million higher (42% and 78% higher, respectively) than the mean monthly expenditures during the preceding 11 months. Testing varied widely among ophthalmologists; 36% of ophthalmologists ordered preoperative tests for more than 75% of their patients. A patients probability of undergoing testing was associated mainly with the ophthalmologist who managed the preoperative evaluation. CONCLUSIONS Preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics. (Funded by the Foundation for Anesthesia Education and Research and the Grove Foundation.).

Why Physicians Favor Use of Percutaneous Coronary Intervention to Medical Therapy: A Focus Group Study

Patients have traditionally entrusted decision making to physicians. However, during the past several decades, patients have been encouraged to become more activated and involved in their health decisions. These situations abound in cardiology, for example, therapy for stable coronary artery disease, anticoagulation for atrial fibrillation, and placement of implantable cardioverter-defibrillators. Each condition demands patient participation in the decision-making process because patients live with the consequences of medical decisions in their day-to-day lives. Unfortunately, research has also shown that patients often are misinformed about the risks and benefits associated with treatments and have little involvement in the decision-making process.1,2 Thus, 1 of the great challenges of increasing patient engagement is ensuring that patients make informed, evidence-based decisions that are consistent with their values and preferences. Shared decision making (SDM) has come to the forefront as a way to improve clinical care for patients by encouraging the production and dissemination of accurate, balanced, understandable health information and increasing patient participation in care. SDM interventions have been shown to improve patients’ understanding of the available treatment options, increase the proportion of patients with realistic expectations of benefits and harms, stimulate patients’ involvement in decision making, and improve agreement between patients’ values and treatment choices.3 Incorporating patient preferences into the decision-making process may also lead to improved patient well-being through better adherence to treatment, fewer concerns about illness, and higher satisfaction with health outcomes.4,5 In this article, we review the state of the science in the field of SDM. We discuss models of SDM, as well as methods for providing decision support to patients, including best practices for risk communication, efficacy of decision aids (DAs) for decision support, and use of decision coaches to facilitate shared decision making. SDM was first invoked by the President’s Commission for …

Revisit Rates and Associated Costs After an Emergency Department Encounter: A Multistate Analysis

BACKGROUNDMandatory work hour limitations for residents began in July 2003. There has been little evaluation of the impact of the new limitations on Internal Medicine residency training.OBJECTIVETo assess Internal Medicine residents’ perceptions of the impact of work hour limitations on clinical experiences, patient care, resident education, and well-being, and their compliance with the limitations.DESIGN AND PARTICIPANTSCross-sectional survey administered to Internal Medicine residents at 1 large U.S. teaching hospital.MEASUREMENTSResident perceptions using 5-point Likert scales, and self-reported compliance. Exploratory factor analysis was used to identify underlying domains and develop scales.RESULTSThe survey response rate was 85%. Five domains were identified by factor analysis: 1) clinical experience, 2) patient care and safety, 3) communication, 4) satisfaction with training, and 5) work–rest balance. Residents perceived work hour limitations to have a negative impact on clinical experience (mean scale score 1.84, 1 = negative, 5 = positive), patient care and safety (2.64), and communication domains (1.98). Effects on satisfaction (3.12) and work–rest balance domains (2.95) were more positive. Senior residents perceived more negative effects of work hour limitations than interns. Compliance was difficult; 94% interns and 70% residents reported violating work hour limits. Patient care and teaching duties were the main reasons for work hour violations.CONCLUSIONSThis study suggests that the current work hour limitations may be having unintended negative consequences on residency training. Ongoing monitoring to evaluate the impact of program changes as a result of work hour regulation is crucial to improving residency training.

Consequences of Not Respecting Patient Preferences for Cancer Screening: Opportunity Lost

BACKGROUNDPercutaneous coronary intervention (PCI) is performed in many patients with stable coronary artery disease, despite evidence of little clinical benefit over optimal medical therapy.OBJECTIVETo examine physicians’ beliefs, practices, and decision-making regarding elective PCI.DESIGNSix focus groups, three with primary care physicians and three with cardiologists. Participants discussed PCI using hypothetical case scenarios. Transcripts were analyzed using grounded theory, and commonly expressed themes regarding the decision-making pathway to PCI were identified.PARTICIPANTSTwenty-eight primary care physicians and 20 interventional and non-interventional cardiologists in Butte County, Orange County, and San Francisco Bay Area, California, in 2006.RESULTSA number of factors led primary care physicians to evaluate non-symptomatic or minimally symptomatic patients for coronary artery disease and refer them to a cardiologist. The use of screening tests often led to additional testing and referral, as well as fear of missing a coronary stenosis, perceived patient expectations, and medicolegal concerns. The end result was a cascade such that any positive test would generally lead to the catheterization lab, where an “oculostenotic reflex” made PCI a virtual certainty.CONCLUSIONSThe widespread use of PCI in patients with stable coronary artery disease—despite evidence of little benefit in outcomes over medical therapy—may in part be due to psychological and emotional factors leading to a cascade effect wherein testing leads inevitably to PCI. Determining how to help physicians better incorporate evidence-based medicine into decision-making has important implications for patient outcomes and the optimal use of new technologies.

From the closest observers of patient care: a thematic analysis of online narrative reviews of hospitals

Context Information is lacking about what happens to patients after discharge from the emergency department (ED). Contribution These researchers found that 1 of every 5 patients discharged from an ED had at least 1 revisit within 30 days. One third of revisits that took place within 3 days of the index ED visit were to a different ED, and the total cost of all revisits was more than the total cost of all initial visits. Caution The study was limited to 6 states, and only 1 state provided cost data. Implication Return visits are more frequent than previously recognized and may be more costly. Return visits to an emergency department (ED) or hospital after an index ED visit strain already overburdened EDs and the broader health care system (1, 2). These revisits may be planned follow-ups for progression of symptoms or disease, but they also may reflect failures of ambulatory follow-up (3, 4) or poor-quality care in the ED (58) or may be unrelated to the index ED visit. Concern over high costs, ED crowding, and waste of resources has led some organizations to consider prioritizing the reduction of preventable revisits (9, 10). But little is known at the population level about the rates at which ED patients return for care, whether revisit rates are higher for some diagnoses, or the costs associated with revisits. Without this information, creating effective and efficient interventions to reduce ED revisits with minimal unintended consequences will be difficult. Research on revisit rates has included studies that have examined revisits to a single institution (58, 11) or within a single state or insurance plan (12, 13) or have used data at multiple unaffiliated EDs, with returns to other EDs or admissions directly to inpatient care not captured (14). In addition, we are not aware of prior estimates of the costs associated with revisits. Therefore, the magnitude of the resource burden of revisits on the health care system is unknown. To address this, we examined acute care revisits after an index ED treat-and-discharge visit by using newly available multistate, longitudinal data that link encounters and allow identification of returns to any ED (not just the index ED) or admission to any acute care hospital after the index ED visit. We assessed the frequency of and costs associated with revisits within 30 days. Because most research has focused on 3-day revisit rates, we also calculated such rates overall and by whether the patient returned to or was admitted to the index or a different ED or hospital. Lastly, we examined the variation in 3-day revisit rates among the most common ED diagnoses and by state. Methods Data Sources Encounter data were obtained from the Healthcare Cost and Utilization Project (HCUP), which is maintained by the Agency for Healthcare Research and Quality. Data from 2006 to 2010 were abstracted for states for which the State Emergency Department Databases (SEDD) (15), State Inpatient Databases (SID) (16), and files linking these databases were available. The SEDD includes all ED treat-and-discharge visits and transfers to an ED (that is, all ED visits that did not result in an admission). The SID includes a variable identifying patients admitted from the ED. The discharge and visit records from these databases contain patient demographics; International Classification of Diseases, Ninth Revision, diagnoses; expected payer, admission, and discharge dates; and patient disposition. For some states, HCUP also provides linkage files (17) that enable identification of any subsequent ED visits or admissions to any ED or hospital within the state for an individual patient. Because our interest was in ED visits or admissions after an index ED visit, we included only states and years for which SEDD, SID, and linkage files were available with verified patient identifiers for more than 85% of index ED visits. This included Arizona, California, Florida, Nebraska, Utah, and Hawaii, with the following exceptions: We were able to include Arizona for 2006 and 2007 only because no revisit linkage files were available for the other years; data from 2010 for Hawaii and Utah were not available at the time of analysis and were excluded. Identifying Eligible Index Visits We included only index ED visits for adults who were discharged back to their home or place of residence. We excluded visits for pediatric (aged 17 years) patients. Assessment of Revisits To understand when revisits are most common and how they contribute to cost overall, we examined revisit rates and associated costs over the first 30 days after index ED visits. In addition, because most research has focused on 3-day revisit rates (5, 7, 14), we calculated revisit rates and costs for this period. The primary outcomes in this study were daily and cumulative revisit rates and costs over the first 30 days after an index ED treat-and-discharge visit and 3-day revisit rates and cumulative costs in the first 3 days after an index ED visit. If more than 1 revisit occurred in either the 3- or 30-day window, only the first revisit was included. We also examined revisit rates by place of revisit (to either the same or a different ED or hospital). We could not link index ED and subsequent ED visits or inpatient admissions by diagnosis for this analysis. Assessment of Cost Costs were estimated by assigning Medicare reimbursement rates in 2008 to Current Procedural Terminology codes for ED visits and diagnosis-related group codes for inpatient admissions. Florida was the only state with nearly complete (97%) capture of Current Procedural Terminology codes in SEDD; therefore, cost data are presented for Florida only. To reduce the effect of Floridas historical status as a high-utilization state (18), we express the costs as a percentage of index visits so that typical Florida utilization patterns are in both the numerator and the denominator. For calculating cumulative costs for the first 30 days after an index ED visit, we included only the first revisit. Costs were extrapolated for the other states by using the most common Current Procedural Terminology and diagnosis-related group codes from Florida for age and diagnosis combinations and by applying state-specific Medicare rates. These results are presented in the Appendix Table and Appendix Figures 1 and 2). Appendix Table. Costs in 6 States* of Revisits Within 3 Days, as a Percentage of Index ED Visit Costs, for the 10 Most Common Diagnoses Among Index ED Visits Appendix Figure 1. Cumulative revisit costs in Florida as a percentage of total index ED visit costs for revisits that ended with discharge versus revisits ending with admission. At day 30, costs for all revisits after which the patient was discharged home were 18% of total index ED visit costs. However, the costs for revisits that led to admission were 100% of total index ED visit costs. ED = emergency department. * Percentage of costs of all index ED visits. Appendix Figure 2. Cumulative revisit costs as a percentage of total index ED visit costs in 6 states. The 6 states include Arizona, California, Florida, Hawaii, Nebraska, and Utah. Revisit costs were 9% of total index ED visit costs at day 0, and revisit costs were at 100% of total index ED visit costs at day 16. At day 30, revisit costs were 145% of total index ED visit costs. ED = emergency department. * Percentage of costs of all index ED visits. Descriptive Variables Available patient characteristics included age, sex, race, primary insurance status, and diagnoses. Hospital variables included the number of beds, teaching and urban status, and type of ownership. Diagnosis categories were determined using Clinical Classification Software (19), which groups all International Classification of Diseases, Ninth Revision, diagnosis codes into clinically meaningful and mutually exclusive diagnosis categories. Statistical Analysis We calculated diagnosis-specific, 3-day revisit rates and 95% CIs. All rates are expressed as the total number of revisits within 3 days per 100 initial ED treat-and-discharge visits. Costs are reported as percentages of total index ED visit costs along with 95% CIs. To simultaneously account for the sampling weights and the clustering by hospital, we used survey-weighted analyses with hospital defined as the primary sampling unit (20, 21). Although most states had 5 years of data, there were a few exceptions (Arizona had 2 and Utah and Hawaii had 4 years of data). To produce approximate population-level estimates for the 5-year period in all of our analyses, we used a sampling weight equal to the maximum number of years (5 years) divided by the actual number of years in a particular state (that is, all observations were given a sampling weight of 1 except for those from Arizona, Utah, and Hawaii, which were given sampling weights of 2.5, 1.25, and 1.25, respectively). Of note, we used the surveylogistic procedure in SAS software (SAS Institute) for the risk-adjusted rates, surveyfreq for the diagnosis-specific revisit rates, and surveymeans with the ratio option for the cost analyses. To examine whether risk-adjusted revisit rates varied by state, we standardized the state rates using a logistic regression model that included patient-level factors of age, sex, insurance status, and Charlson comorbidity index (22). By including state as a fixed effect in these models, we were able to estimate predicted probabilities of revisit for each state and standardize to the mean values of covariates. These analyses were done by using the SAS procedure surveylogistic and the lsmeans command. To control for differences among states in the pattern of admission during initial ED visits, we included state-specific, risk-adjusted rates of admission during initial ED visits as a predictor when examining variation in risk-adjusted revisit rate by state. Analyses were conducted using SAS, version 9.3. Role of the Funding Source The Agency for Healthcare Research and Quality had no role

Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits.

A 60-YEAR-OLD WOMAN PRESENTED TO HER physician for an annual physical examination. As part of the examination, she and her physician discussed colorectal cancer screening, which her physician had discussed with her at her last yearly physical. The decision at that time had been for colonoscopy, and the patient was referred to the gastroenterologist. Since the patient never followed through with the colonoscopy, the topic was broached again. As part of a quality improvement initiative designed to promote shared decisionmaking, the patient was given a decision support intervention (DESI) to review the options (fecal occult blood testing [FOBT], flexible sigmoidoscopy, or colonoscopy, described in a booklet and DVD) and was told to let her physician know about her decision. The patient reviewed the DESI, decided that she wanted to pursue FOBT, and informed her physician about her choice. The physician responded that FOBT was not appropriate, and that the patient should consider only flexible sigmoidoscopy or colonoscopy. The patient was confused and upset that the very physician who had provided her the decision support material was not honoring her informed choice. To date, she has not followed through with colon cancer screening. Routine screening for colorectal cancer is recommended in patients older than 50 years, and therefore discussion of colorectal cancer screening was an important and appropriate part of the primary care preventive care visit for this patient. Major clinical practice guidelines list several acceptable options for colorectal cancer screening, including the options discussed in the DESI. Guidelines also recommend incorporation of patient preferences into care, practicing shared decision-making, and focusing on strategies that maximize the number of individuals who get screening. However, studies suggest that shared decisionmaking is not routinely occurring in primary care, especially for colorectal cancer screening. In addition, over half of adults preferred FOBT to colonoscopy when given time to consider detailed information about colorectal cancer screening tests. Despite the data indicating patient preferences for less invasive testing, colonoscopy rates are increasing, and evidence suggests that the test may be overused, particularly in the Medicare population. Decision support interventions, like the one given to this patient, are a way to facilitate shared decision-making and have been associated with greater knowledge, more accurate risk perceptions, and increased participation in the decision-making process. However, decision support is most effective as part of a shared decision-making process, in which physician and patient discussion leads to a mutual decision that is both evidence based and incorporates the patient’s preferences. The physician had good intentions in terms of recommending that the patient be screened for colorectal cancer and helping the patient make an informed choice by providing high-quality information and decision support. The patient also did her part to become an active and informed participant in the decision-making process. However, although the evidence base supported use of FOBT as a screening modality and the patient stated her preference for the less invasive test, the physician’s preference for a more invasive and technologically advanced procedure precluded a full shared decision-making conversation, ultimately resulting in a missed opportunity to screen the patient for colorectal cancer.

Addressing Overuse of Medical Services One Decision at a Time

Objective Patient-centred care has become a priority in many countries. It is unknown whether current tools capture aspects of care patients and their surrogates consider important. We investigated whether online narrative reviews from patients and surrogates reflect domains in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and we described additional potential domains. Design We used thematic analysis to assess online narrative reviews for reference to HCAHPS domains and salient non-HCAHPS domains and compared results by reviewer type (patient vs surrogate). Setting We identified hospitals for review from the American Hospital Association database using a stratified random sampling approach. This approach ensured inclusion of reviews of a diverse set of hospitals. We searched online in February 2013 for narrative reviews from any source for each hospital. Participants We included up to two narrative reviews for each hospital. Exclusions: Outpatient or emergency department reviews, reviews from self-identified hospital employees, or reviews of <10 words. Results 50.0% (n=122) of reviews (N=244) were from patients and 38.1% (n=93) from friends or family members. Only 57.0% (n=139) of reviews mentioned any HCAHPS domain. Additional salient domains were: Financing, including unexpected out-of-pocket costs and difficult interactions with billing departments; system-centred care; and perceptions of safety. These domains were mentioned in 51.2% (n=125) of reviews. Friends and family members commented on perceptions of safety more frequently than patients. Conclusions A substantial proportion of consumer reviews do not mention HCAHPS domains. Surrogates appear to observe care differently than patients, particularly around safety.