Salomeh Keyhani

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.

Gender Disparities in Blood Pressure Control and Cardiovascular Care in a National Sample of Ambulatory Care Visits

The purpose of this study was to provide an analysis of gender-based disparities in hypertension and cardiovascular disease care in ambulatory practices across the United States. Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of patient visits with their primary care providers and examined the association between gender and blood pressure control, use of any antihypertensive medication or initiation of new therapy for patients with uncontrolled hypertension, and receipt of recommended therapy for select cardiovascular conditions. Multivariable models were estimated to examine the association between gender and each outcome controlling for other variables. A total of 12 064 patient visits were identified (7786 women and 4278 men). Among patients with hypertension, women were less likely than men to meet blood pressure control targets (54.0% versus 58.7%; P<0.02). In multivariate analyses, women aged 65 to 80 years were less likely than men to have controlled hypertension (odds ratio: 0.62; 95% CI: 0.45 to 0.85). There was no association between gender and use of any antihypertensive medication or initiating a new therapy among patients with uncontrolled hypertension. In multivariate analyses, women were less likely than men to receive aspirin (odds ratio: 0.43; 95% CI: 0.27 to 0.67) and &bgr;-blockers (odds ratio: 0.60; 95% CI: 0.36 to 0.99) for secondary prevention of cardiovascular disease. Our study highlights the persistent gender disparities in blood pressure control and cardiovascular disease management and also reveals the inadequate delivery of cardiovascular care to all patients.

“Top 5” Lists Top

1. Fried TR, Tinetti ME, Towle V, O’Leary JR, Iannone L. Effects of benefits and harms on older persons’ willingness to take medication for primary cardiovascular prevention. Arch Intern Med. 2011;171(10):923-928. 2. Leipzig RM, Whitlock EP, Wolff TA, et al; US Preventive Services Task Force Geriatric Workgroup. Reconsidering the approach to prevention recommendations for older adults. Ann Intern Med. 2010;153(12):809-814. 3. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference. New York, NY: 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. 4. Fried TR, Tinetti M, Agostini J, Iannone L, Towle V. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns. 2011;83(2):278-282. 5. Nease RF Jr, Kneeland T, O’Connor GT, et al; Ischemic Heart Disease Patient Outcomes Research Team. Variation in patient utilities for outcomes of the management of chronic stable angina: implications for clinical practice guidelines. JAMA. 1995;273(15):1185-1190. 6. Man-Son-Hing M, Gage BF, Montgomery AA, et al. Preference-based antithrombotic therapy in atrial fibrillation: implications for clinical decision making. Med Decis Making. 2005;25(5):548-559. 7. Rosenfeld KE, Wenger NS, Kagawa-Singer M. End-of-life decision making: a qualitative study of elderly individuals. J Gen Intern Med. 2000;15(9):620-625. 8. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066. 9. Ditto PH, Druley JA, Moore KA, Danks JH, Smucker WD. Fates worse than death: the role of valued life activities in health-state evaluations. Health Psychol. 1996;15(5):332-343.

5 Billion

Background:Electronic health records (EHRs) have been promoted as an important tool to improve quality of care. We examined the association between EHR components, a complete EHR, and the quality of care. Methods:Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of all visits with an established primary care provider and examined the association between presence of EHR components and: (1) blood pressure control; and (2) receipt of appropriate therapy for chronic conditions. We examined similar associations for complete EHRs which we defined as one that includes physician and nursing notes, electronic reminder system, computerized prescription order entry, test results, and computerized test order entry. We constructed multivariate models to examine the association between EHR components and each outcome controlling for patient sociodemographic, health, physician practice, and geographic factors. Results:We found no association between electronic physician notes and blood pressure control or receipt of appropriate therapies, with the exception of inhaled steroids among asthmatics (adjusted odds ratio 2.86; 95% confidence interval, 1.12–7.32). We found no association between electronic reminder systems and blood pressure control or receipt of appropriate therapies, with the exception of angiotensin converting enzyme inhibitors or angiotensin receptor blockers in patients with diabetes with hypertension (odds ratio 2.58; 95% confidence interval, 1.22–5.42). We found no association between electronic physician notes and any measure of quality. We found no relationship between having a complete EHR and any of the quality measures investigated. Conclusions:We found no consistent association between blood pressure control, management of chronic conditions, and specific EHR components. Future research focusing on how an EHR is implemented and used and how care is integrated through an EHR will improve our understanding of the impact of EHRs on the quality of care.

Electronic Health Record Components and the Quality of Care

BACKGROUND Given the rising costs of health care, policymakers are increasingly interested in identifying the inefficiencies in our health care system. The objective of this study was to determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade. METHODS Cross-sectional analysis of the 1999 and 2009 National Ambulatory Medical Care Survey and the outpatient department component of the National Hospital Ambulatory Medical Care Survey, which are nationally representative annual surveys of visits to non-federally funded ambulatory care practices. We applied 22 quality indicators using a combination of current quality measures and guideline recommendations. The main outcome measures were the rates of underuse, overuse, and misuse and their 95% CIs. RESULTS We observed a statistically significant improvement in 6 of 9 underuse quality indicators. There was an improvement in the use of antithrombotic therapy for atrial fibrillation; the use of aspirin, β-blockers, and statins in coronary artery disease; the use of β-blockers in congestive heart failure; and the use of statins in diabetes mellitus. We observed an improvement in only 2 of 11 overuse quality indicators, 1 indicator became worse, and 8 did not change. There was a statistically significant decrease in the overuse of cervical cancer screening in visits for women older than 65 years and in the overuse of antibiotics in asthma exacerbations. However, there was an increase in the overuse of prostate cancer screening in men older than 74 years. Of the 2 misuse indicators, there was a decrease in the proportion of patients with a urinary tract infection who were prescribed an inappropriate antibiotic. CONCLUSIONS We found significant improvement in the delivery of underused care but more limited changes in the reduction of inappropriate care. With the high cost of health care, these results are concerning.

Trends in the Overuse of Ambulatory Health Care Services in the United States

OBJECTIVES To explore attitudes of physicians from all specialties toward gifts from and interactions with the pharmaceutical and medical device industries. DESIGN Anonymous, cross-sectional survey distributed and collected between June 1 and September 1, 2008. SETTING Hospitals in the Mount Sinai School of Medicine consortium in the New York, New York, metropolitan area. PARTICIPANTS Faculty and trainee physicians from all clinical departments. MAIN OUTCOME MEASURES Attitudes toward industry interactions and gifts and their appropriateness measured on 4-point Likert scales. RESULTS A total of 590 physicians and medical students completed the survey (response rate, 67.0%); 351 (59.5%) were male, 230 (39.0%) were attending physicians, and 131 (23.7%) of 553 (excluding medical students) were from surgical specialties. Attitudes toward industry and gifts were generally positive: 72.2% found sponsored lunches appropriate, whereas 25.4% considered large gifts appropriate. Surgeons, trainees, and those unfamiliar with institutional policies on industry interactions held more positive attitudes than others and were more likely to deem some gifts appropriate, including industry funding of residency programs and, among surgeons, receiving meals, travel expenses, and payments for attending lectures. Nonattending physicians held more positive attitudes toward receiving meals in clinical settings, textbooks, and samples. CONCLUSIONS Physicians continue to hold positive attitudes toward marketing-oriented activities of the pharmaceutical and device industries. Changes in medical culture and physician education focused on surgeons and trainees may align physician attitudes with current policy trends.

Physician Attitudes Toward Industry: A View Across the Specialties

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.

Overuse and Systems of Care 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.

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

Objective To examine the association between the presence of individual principal investigators’ financial ties to the manufacturer of the study drug and the trial’s outcomes after accounting for source of research funding. Design Cross sectional study of randomized controlled trials (RCTs). Setting Studies published in “core clinical” journals, as identified by Medline, between 1 January 2013 and 31 December 2013. Participants Random sample of RCTs focused on drug efficacy. Main outcome measure Association between financial ties of principal investigators and study outcome. Results A total of 190 papers describing 195 studies met inclusion criteria. Financial ties between principal investigators and the pharmaceutical industry were present in 132 (67.7%) studies. Of 397 principal investigators, 231 (58%) had financial ties and 166 (42%) did not. Of all principal investigators, 156 (39%) reported advisor/consultancy payments, 81 (20%) reported speakers’ fees, 81 (20%) reported unspecified financial ties, 52 (13%) reported honorariums, 52 (13%) reported employee relationships, 52 (13%) reported travel fees, 41 (10%) reported stock ownership, and 20 (5%) reported having a patent related to the study drug. The prevalence of financial ties of principal investigators was 76% (103/136) among positive studies and 49% (29/59) among negative studies. In unadjusted analyses, the presence of a financial tie was associated with a positive study outcome (odds ratio 3.23, 95% confidence interval 1.7 to 6.1). In the primary multivariate analysis, a financial tie was significantly associated with positive RCT outcome after adjustment for the study funding source (odds ratio 3.57 (1.7 to 7.7). The secondary analysis controlled for additional RCT characteristics such as study phase, sample size, country of first authors, specialty, trial registration, study design, type of analysis, comparator, and outcome measure. These characteristics did not appreciably affect the relation between financial ties and study outcomes (odds ratio 3.37, 1.4 to 7.9). Conclusions Financial ties of principal investigators were independently associated with positive clinical trial results. These findings may be suggestive of bias in the evidence base.

Financial ties of principal investigators and randomized controlled trial outcomes: cross sectional study

Objectives To compare tympanostomy tube insertion for children with otitis media in 2002 with the recommendations of two sets of expert guidelines. Design Retrospective cohort study. Setting New York metropolitan area practices associated with five diverse hospitals. Participants 682 of 1046 children who received tympanostomy tubes in the five hospitals for whom charts from the hospital, primary care physician, and otolaryngologist could be accessed. Results The mean age was 3.8 years. On average, children with acute otitis media had fewer than four infections in the year before surgery. Children with otitis media with effusion had less than 30 consecutive days of effusion at the time of surgery. Concordance with recommendations was very low: 30.3% (n=207) of all tympanostomies were concordant with the explicit criteria developed for this study and 7.5% (n=13) with the 1994 guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology—Head and Neck Surgery. Children who had previously had tympanostomy tube surgery, who were having a concomitant procedure, or who had “at risk conditions” were more likely to be discordant. Conclusions A significant majority of tympanostomy tube insertions in the largest and most populous metropolitan area in the United States were inappropriate according to the explicit criteria and not recommended according to both guidelines. Regardless of whether current practice represents a substantial overuse of surgery or the guidelines are overly restrictive, the persistent discrepancy between guidelines and practice cannot be good for children or for people interested in improving their health care.