Shared decision-making for lung cancer screening: more straw for the camel's back.

This editorial describes the need for a system that helps primary care physicians prioritize shared decision-making for preventive services.

Stewardship decisions among internal medicine residents: responses to common challenges using vignettes.

BACKGROUND: Stewardship is an important aspect of medical care to which little formal attention is paid during training. PURPOSE: The goal is to evaluate stewardship practices of internal medicine residents and the relationship of resident refusal to provide requested nonindicated care with levels of confidence and bother. METHODS: Cross-sectional survey of residents in one training program, containing four hypothetical clinical scenarios asking residents whether they would provide nonindicated tests and treatments, and to report confidence in the decision and bother. RESULTS: Sixty-seven of 105 residents completed the survey. Most residents prescribed a requested brand-name expensive medication when a generic was available and hospitalized a patient with no expected clinical benefit, but few were willing to repeat imaging for quicker availability or perform an unnecessary diagnostic evaluation. Residents ordering nonindicated tests and treatments reported lower confidence in their decision and more bother. PGY level was not associated with clinical decision or bother. CONCLUSIONS: Internal medicine residents, at least on hypothetical scenarios, demonstrate inconsistent stewardship practices. Findings support room for improvement in confidence when faced with requests for nonindicated care and suggest the need for greater curricular emphasis on stewardship.

Changes in Blood Pressure Outcomes Among Hypertensive Individuals During the COVID-19 Pandemic: A Time Series Analysis in Three US Healthcare Organizations.

BACKGROUND: The COVID-19 pandemic may have negatively affected medical care for and self-management of chronic hypertension. We sought to examine the impact of the pandemic on blood pressure (BP) among individuals with hypertension. METHODS: Using an interrupted time series analysis, we compared the level and trend (slope) of BP outcomes before the public health emergency declaration (prepandemic period: August 2018 through January 2020) versus after the stay-at-home orders (pandemic period: April 2020 through November 2020) among adults with hypertension followed at 3 large health systems (n=137 593). Outcomes include systolic and diastolic BP recorded in electronic health records and the proportion of individuals with BP <140/90 mm Hg. RESULTS: The number of BP measurements substantially dropped early in the pandemic and then gradually increased. During the pandemic period, systolic and diastolic BP increased by 1.79 mm Hg (95% CI, 1.57-2.01; P<0.001) and 1.30 mm Hg (95% CI, 1.18-1.42; P<0.001), respectively, compared with the prepandemic period. Similarly, the proportion of patients with controlled BP decreased by 3.43 percentage points (95% CI, -3.97 to -2.90; P<0.001). A trend showing increasing control in the prepandemic period (+3.19 percentage points per year [95% CI, +2.96 to +3.42]; P<0.001) flattened during the pandemic period (+0.27 percentage points per year [95% CI, -0.81 to -1.37]; P=0.62). CONCLUSIONS: The first 8 months of the pandemic were associated with worsening BP outcomes among individuals with hypertension. Opportunities to ensure ongoing access to health care with telemedicine and home BP monitoring may mitigate adverse impacts on BP control for future disasters/emergencies.

Validity of Physician and Administrator Peer Review for Selecting Specialist Narrow Network Participants.

Increasingly, insurers control costs by selectively contracting with high-performing, low-cost providers through "narrow networks." Health care systems are faced with selecting specialists for inclusion in these shared-risk contracts. One approach is to use peer ratings, but it remains uncertain whether physicians can identify which of their peers are quantitatively high-quality, highly efficient care providers. If the results of administrator and physician peer ratings were a reliable stand-in for empirical scores, then they might substitute for the resource- and time-intensive task of quantitative performance ratings. This study examines whether peer ratings correlate with empirical ratings from a multisource, quantitative performance score derived from electronic health record (EHR) data. The authors evaluated 74 specialists' quantitative performance using a composite of metrics derived from EHR data. A single-item survey was administered separately that asked 32 primary care physicians (PCPs) to rate the specialists on their orientation to value-based health care. Bivariate and multivariate relationships were assessed between mean PCP ratings and quantitative performance scores, and logistic regression with receiver operating characteristic curve analysis was employed to evaluate the accuracy of peer review in classifying specialists scoring in the top quartile of quantitative performance. Correlations between PCP ratings and quantitative scores were positive and significant (r = 0.70; P < 0.0001). Multivariable linear regression explained 52% of the variance in quantitative scores. Peer ratings predicted top-quartile performance with an accuracy of 82%. Physician and administrator peer ratings identified top-performing specialists fairly accurately, suggesting that PCPs are well positioned as both stewards and assessors of specialist efficiency and quality.

Economic Evaluation of Quality Improvement Interventions Designed to Improve Glycemic Control in Diabetes: A Systematic Review and Weighted Regression Analysis.

OBJECTIVE: Quality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control among adults with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS: We used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLit, Centre for Reviews and Dissemination, New York Academy of Medicine's Grey Literature Report, and WorldCat (January 2004 to August 2016). We extracted data regarding intervention, study design, change in HbA1c, time horizon, perspective, incremental net cost (studies lasting ≤3 years), incremental cost-effectiveness ratio (ICER) (studies lasting ≥20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA1c and incremental net cost. RESULTS: Of 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA1c declined by 0.26% (95% CI 0.17-0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting ≤3 years, incremental net costs were $116 (95% CI -$612 to $843) per patient annually. Long-term ICERs were $100,000-$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000-$99,999/QALY in 1 RCT, $0-$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias. CONCLUSIONS: Diverse multifaceted QI interventions that lower HbA1c appear to be a fair-to-good value relative to usual care, depending on society's willingness to pay for improvements in health.

Physician variation in lung cancer treatment at the end of life.

OBJECTIVES: To determine whether a treating oncologist's characteristics are associated with variation in use of chemotherapy for patients with advanced non-small cell lung cancer (aNSCLC) at the end of life. STUDY DESIGN: Retrospective cohort. METHODS: Using the 2009 Surveillance, Epidemiology, and End Results-Medicare database, we studied chemotherapy receipt within 30 days of death among Medicare enrollees who were diagnosed with aNSCLC between 1999 and 2006, received chemotherapy, and died within 3 years of diagnosis. A multilevel model was constructed to assess the contribution of patient and physician characteristics and geography to receiving chemotherapy within 30 days of death. RESULTS: Among 21,894 patients meeting eligibility criteria, 43.1% received chemotherapy within 30 days of death. In unadjusted bivariate analyses, female sex, Asian or black race, older age, and a greater number of comorbid diagnoses predicted lower likelihood of receiving chemotherapy at the end of life (P ≤.038 for all comparisons). Adjusting for patient and physician characteristics, physicians in small independent practices were substantially more likely than those employed in other practice models, particularly academic practices or nongovernment hospitals, to order chemotherapy for a patient in the last 30 days of life (P <.001 for all comparisons); female physicians were less likely than males to prescribe such treatment (P = .04). CONCLUSIONS: Patients receiving care for aNSCLC in small independent oncology practices are more likely to receive chemotherapy in the last 30 days of life.

When choosing statin therapy: the case for generics.

The development of "Top 5" lists across specialties and at regular intervals can help to remind physicians that optimal care is often possible at a lower cost. For purposes of cardiovascular risk reduction, generic statins, or their brand equivalents if priced similarly, remain the appropriate choice for dyslipidemic patients initiating statin therapy. In this article, we review the evidence supporting the choice of generic statins.