John N. Mafi

Low-Cost, High-Volume Health Services Contribute The Most To Unnecessary Health Spending

An analysis of data for 2014 about forty-four low-value health services in the Virginia All Payer Claims Database revealed more than

Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States

586 million in unnecessary costs. Among these low-value services, those that were low and very low cost (

Disparities in the Quality of Cardiovascular Care Between HIV‐Infected Versus HIV‐Uninfected Adults in the United States: A Cross‐Sectional Study

538 or less per service) were delivered far more frequently than services that were high and very high cost (

How Can We Improve the Efficiency of Specialty Care

539 or more). The combined costs of the former group were nearly twice those of the latter (65 percent versus 35 percent).

Access to Prescription Opioids-Primum Non Nocere: A Teachable Moment.

Importance Hospital-employed physicians provide primary care within the hospital or within community-based office practices. Yet, little is understood regarding the influence of hospital location and ownership on the delivery of low-value care. Objective To assess the association of hospital location and hospital ownership with the provision of low-value health services. Design, Setting, and Participants This study compared low-value service use after primary care visits at hospital-based outpatient practices from January 1, 1997, to December 31, 2011, vs community-based office practices and at hospital-owned vs physician-owned community-based office practices from January 1, 1997, to December 31, 2013. Logistic regression models adjusted for patient and health care professional characteristics and year, and weighted results were used to reflect population estimates. Results were also stratified by symptom acuity and whether a generalist physician (eg, general internist or family practitioner) was the patient’s primary care provider. This study used nationally representative data from the National Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2013) and the National Hospital Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2011) on outpatient visits to generalist physicians. Participants were patients seen with 3 common primary care conditions, namely, upper respiratory tract infection, back pain, and headache. Main Outcomes and Measures The use of antibiotics (for upper respiratory tract infection), computed tomography or magnetic resonance imaging (for back pain and headache), radiographs (for upper respiratory tract infection and back pain), and specialty referrals (for all 3 conditions). Results This study identified 31 162 visits for upper respiratory tract infection, back pain, and headache, representing an estimated 739 million US primary care visits from 1997 to 2013. Compared with visits with community-based physicians, patients in visits to hospital-based physicians were younger (mean age, 44.5 vs 49.1 years; P < .001) and less frequently saw their primary care provider (52.7% vs 81.9%, P < .001). Although antibiotic use was similar in both settings, hospital-based visits had more orders for computed tomography and magnetic resonance imaging (8.3% vs 6.3%, P = .01), radiographs (12.8% vs 9.9%, P < .001), and specialty referrals (19.0% vs 7.6%, P < .001) than community-based visits. Multivariable adjustment and symptom acuity stratification revealed similar findings. Visits with a generalist other than the patient’s primary care provider were associated with greater provision of low-value care but mainly within hospital-based settings. Practice patterns were similar among hospital-owned vs physician-owned community-based practices with the exception of specialty referrals, which were more frequent in hospital-owned community-based practices. Conclusions and Relevance Visits to US hospital-based practices are associated with greater use of low-value computed tomography and magnetic resonance imaging, radiographs, and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. These findings raise concerns about the provision of low-value care at hospital-associated primary care practices.

Physician Prescribing of Opioids to Patients at Increased Risk of Overdose From Benzodiazepine Use in the United States

Background Cardiovascular disease is emerging as a major cause of morbidity and mortality among patients with HIV. We compared use of national guideline‐recommended cardiovascular care during office visits among HIV‐infected versus HIV‐uninfected adults. Methods and Results We analyzed data from a nationally representative sample of HIV‐infected and HIV‐uninfected patients aged 40 to 79 years in the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2006 to 2013. The outcome was provision of guideline‐recommended cardiovascular care. Logistic regressions with propensity score weighting adjusted for clinical and demographic factors. We identified 1631 visits by HIV‐infected patients and 226 862 visits by HIV‐uninfected patients with cardiovascular risk factors, representing ≈2.2 million and 602 million visits per year in the United States, respectively. The proportion of visits by HIV‐infected versus HIV‐uninfected adults with aspirin/antiplatelet therapy when patients met guideline‐recommended criteria for primary prevention or had cardiovascular disease was 5.1% versus 13.8% (P=0.03); the proportion of visits with statin therapy when patients had diabetes mellitus, cardiovascular disease, or dyslipidemia was 23.6% versus 35.8% (P<0.01). There were no differences in antihypertensive medication therapy (53.4% versus 58.6%), diet/exercise counseling (14.9% versus 16.9%), or smoking cessation advice/pharmacotherapy (18.8% versus 22.4%) between HIV‐infected versus HIV‐uninfected patients, respectively. Conclusions Physicians generally underused guideline‐recommended cardiovascular care and were less likely to prescribe aspirin and statins to HIV‐infected patients at increased risk—findings that may partially explain higher rates of adverse cardiovascular events among patients with HIV. US policymakers and professional societies should focus on improving the quality of cardiovascular care that HIV‐infected patients receive.

Trends in the management of headache.

John N. Mafi, MD, MPH and Samuel T. Edwards, MD, MPH Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA; Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, OR, USA; Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, OR, USA.

Assessment and Management of Back Pain—Reply

Story From the Front Lines A 14-year-old boy found acetaminophen-hydrocodone in his parents’ medicine cabinet and took it out of curiosity. He liked how the pills made him feel and progressed to daily use of prescription opioids. At age 15 years, he was prescribed a short course of acetaminophen-oxycodone for a back injury due to wrestling. After the prescription ended, he continued to seek prescription opioids from illicit sources, taking them almost daily. He was briefly sent to juvenile detention after being caught selling opioids. For the next 3 years he abstained from opioids but drank alcohol socially and smoked cigarettes. At age 19 years, he tried heroin with a friend and began using the drug daily. Today, he describes the experience as “spiritual... when I took the drug, it felt like I had found a deep calling.” He began selling heroin to fund his habit. At age 21 years, he overdosed on heroin. He was initially revived by emergency medical services with intranasal naloxone, but owing to compartment syndrome of the right thigh, he developed hyperkalemia and experienced cardiac arrest. After 18 minutes of advanced cardiac life support, a pulse returned. He was intubated and admitted to the intensive care unit. His course was complicated by renal failure requiring renal replacement therapy, stress cardiomyopathy, deep venous thrombosis, and anoxic brain injury. His cardiac and renal function normalized. Although his left-sided motor function is now normal, he still has spastic movements, weakness, and limited range of motion in the right upper and lower extremities. He can now ambulate without a walker or cane, and he has normal thought and speech. Since leaving the hospital, he has been attending weekly Alcoholics Anonymous, Heroin Anonymous, and Narcotics Anonymous meetings. Unfortunately, he has had several relapses, and contracted hepatitis C after sharing injection paraphernalia.

Worsening Trends in the Management and Treatment of Back Pain

Importance Recent increases in US opioid-related deaths underscore the need to understand drivers of fatal overdose. The initial prescription of opioids represents a critical juncture because it increases the risk of future opioid use disorder and is preventable. Objective To examine new opioid prescribing patterns in US patients at increased risk of overdose from benzodiazepine use. Design, Setting, and Participants This study used publicly available data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from January 1, 2005, through December 31, 2015, to identify adults 20 years or older receiving new opioid prescriptions and concurrently using a benzodiazepine. Main Outcomes and Measures Population-based rates of new opioid prescriptions stratified by use of benzodiazepines. Results This study analyzed 13 146 visits, representing 214 million visits nationally, with a new opioid prescription. Rates of new opioid prescriptions among adults using a benzodiazepine increased from 189 to 351 per 1000 persons between 2005 and 2010 (rate difference, 162; 95% CI, 29-295; P = .02) and decreased to 172 per 1000 persons by 2015 (rate difference, −179; 95% CI, −310 to −48; P = .008). New opioid prescriptions in the general population not using benzodiazepines increased nonsignificantly from 78 to 93 per 1000 US persons between 2005 and 2010 (rate difference, 15; 95% CI, −3 to 33; P = .10) and decreased nonsignificantly to 79 per 1000 persons by 2015 (rate difference, −14; 95% CI, −38 to 11; P = .28). The likelihood of receiving a new opioid prescription during an ambulatory visit remained higher for patients concurrently using benzodiazepines compared with the general population after adjusting for demographic characteristics, comorbidities, and diagnoses associated with pain (adjusted relative risk, 1.83; 95% CI, 1.56-2.15; P < .001). Naloxone was coprescribed in less than 1% of visits when a patient concurrently used a benzodiazepine. Conclusions and Relevance In 2010, new opioid prescriptions for US adults stopped increasing and began to decrease among higher-risk patients who used benzodiazepines. These patterns suggest that the recent increase in opioid-related deaths may be associated with factors other than physicians writing new opioid prescriptions. Nevertheless, prescribing among higher-risk patients still occurred at rates higher than rates in the general population, representing an important opportunity to improve quality of care for patients experiencing pain.

Trends in the Ambulatory Management of Headache: Analysis of NAMCS and NHAMCS Data 1999–2010

The Authors’ Reply—We thank Dr. Solomon for his interest in our study assessing national trends in headache management and for raising important questions about the usefulness of lifestyle modification counseling. As noted, we found a decline in first-line recommended lifestyle modification counseling for headache over the past decade, contrary to prominent headache guidelines.1 For instance, guidelines from the American College of Physicians suggest that physicians encourage their patients to identify and avoid specific dietary, behavioral, and environmental triggers for migraine headache.2 While he is correct in pointing out that generic advice on improving diet and exercise habits may lack rigorous scientific evidence showing reduced headache frequency, the dietary and lifestyle counseling provided during a headache visit would likely be targeted towards specific factors that trigger headache. Moreover, we do not agree that “increased stress, dehydration, lack of sleep, sedentary lifestyle, and poor diet… have not been scientifically linked to increased migraine frequency.” In fact, evidence suggests the opposite: migraine headaches are frequently triggered by stress, sleep deprivation, or dietary choice, in addition to a wide array of lifestyle and environmental factors.3 Finally, as we discuss in our paper, our measure of counseling is not limited to diet and exercise counseling. Another important component of our variable includes mental health counseling and stress management therapy, which as Dr. Solomon notes has been shown in various forms to improve headache symptoms in systematic reviews and randomized controlled trials.4,5