Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination.

Importance: The association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date. Objective: To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE). Design, Setting, and Participants: This population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019. Exposures: Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE. Main Outcomes and Measures: Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested). Results: Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score-matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age, 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively. Conclusions and Relevance: Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.

Building Bridges to Integrate Care (BRIDGES): Incubating Health Service Innovation across the Continuum of Care for Patients with Multiple Chronic Conditions.

Integrating care for people with complex needs is challenging. Indeed, evidence of solutions is mixed, and therefore, well-designed, shared evaluation approaches are needed to create cumulative learning. The Toronto-based Building Bridges to Integrate Care (BRIDGES) collaborative provided resources to refine and test nine new models linking primary, hospital and community care. It used mixed methods, a cross-project meta-evaluation and shared outcome measures. Given the range of skills required to develop effective interventions, a novel incubator was used to test and spread opportunities for system integration that included operational expertise and support for evaluation and process improvement.

A commitment to high-value care education from the internal medicine community.

The Alliance for Academic Internal Medicine, American Board of Internal Medicine (ABIM), ABIM Foundation, and American College of Physicians are collaborating to enhance the education of physicians in high-value care (HVC) and make its practice an essential competency in undergraduate and postgraduate education by 2017. This article serves as the organizations' formal commitment to providing a foundation of HVC education on which others may build. The 5 key targets for HVC education are experiential learning and curriculum, environment and culture, clinical support, regulatory requirements, and sustainability. The goal is to train future health care professionals for whom HVC is part of normal practice, thus providing patients with improved clinical outcomes at a lower cost.

High utilizers of emergency health services in a population-based cohort of homeless adults.

OBJECTIVES: We identified predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Ontario. METHODS: We assessed ED visit rates using administrative data from the Institute for Clinical Evaluative Sciences (2005-2009). We then used logistic regression to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥ 4.7 visits per person-year). RESULTS: Among 1165 homeless adults, 892 (77%) had at least 1 ED visit during the study. The average rate of ED visits was 2.0 visits per person-year, whereas frequent users averaged 12.1 visits per person-year. Frequent users accounted for 10% of the sample but contributed more than 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner or dependent children had a protective effect on frequent use. CONCLUSIONS: Among homeless adults with universal health insurance, a small subgroup accounted for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors.

Predictors of medical or surgical and psychiatric hospitalizations among a population-based cohort of homeless adults.

OBJECTIVES: We identified factors associated with inpatient hospitalizations among a population-based cohort of homeless adults in Toronto, Ontario. METHODS: We recruited participants from shelters and meal programs. We then linked them to administrative databases to capture hospital admissions during the study (2005-2009). We used logistic regression to identify predictors of medical or surgical and psychiatric hospitalizations. RESULTS: Among 1165 homeless adults, 20% had a medical or surgical hospitalization, and 12% had a psychiatric hospitalization during the study. These individuals had a total of 921 hospitalizations, of which 548 were medical or surgical and 373 were psychiatric. Independent predictors of medical or surgical hospitalization included birth in Canada, having a primary care provider, higher perceived external health locus of control, and lower health status. Independent predictors of psychiatric hospitalization included being a current smoker, having a recent mental health problem, and having a lower perceived internal health locus of control. Being accompanied by a partner or dependent children was protective for hospitalization. CONCLUSIONS: Health care need was a strong predictor of medical or surgical and psychiatric hospitalizations. Some hospitalizations among homeless adults were potentially avoidable, whereas others represented an unavoidable use of health services.

A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance.

OBJECTIVES: We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. METHODS: We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). RESULTS: Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. CONCLUSIONS: In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.

US physician practices versus Canadians: spending nearly four times as much money interacting with payers.

Physician practices, especially the small practices with just one or two physicians that are common in the United States, incur substantial costs in time and labor interacting with multiple insurance plans about claims, coverage, and billing for patient care and prescription drugs. We surveyed physicians and administrators in the province of Ontario, Canada, about time spent interacting with payers and compared the results with a national companion survey in the United States. We estimated physician practices in Ontario spent $22,205 per physician per year interacting with Canada's single-payer agency--just 27 percent of the $82,975 per physician per year spent in the United States. US nursing staff, including medical assistants, spent 20.6 hours per physician per week interacting with health plans--nearly ten times that of their Ontario counterparts. If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year. The results support the opinion shared by many US health care leaders interviewed for this study that interactions between physician practices and health plans could be performed much more efficiently.

Public views on a wait time management initiative: a matter of communication.

BACKGROUND: Many countries have tried to reduce waiting times for health care through formal wait time reduction strategies. Our paper describes views of members of the public about a wait time management initiative--the Ontario Wait Time Strategy (OWTS) (Canada). Scholars and governmental reports have advocated for increased public involvement in wait time management. We provide empirically derived recommendations for public engagement in a wait time management initiative. METHODS: Two qualitative studies: 1) an analysis of all emails sent by the public to the (OWTS) email address; and 2) in-depth interviews with members of the Ontario public. RESULTS: Email correspondents and interview participants supported the intent of the OWTS. However they wanted more information about the Strategy and its actions. Interview participants did not feel they were sufficiently made aware of the Strategy and email correspondents requested additional information beyond what was offered on the Strategy's website. Moreover, the email correspondents believed that some of the information that was provided on the Strategy's website and through the media was inaccurate, misleading, and even dishonest. Interview participants strongly supported public involvement in the OWTS priority setting. CONCLUSIONS: Findings suggest the public wanted increased communication from and with the OWTS. Effective communication can facilitate successful public engagement, and in turn fair and legitimate priority setting. Based on the study's findings we developed concrete recommendations for improving public involvement in wait time management.

Developing physician communication skills for patient-centered care.

Growing enthusiasm about patient-centered medical homes, fueled by the Patient Protection and Affordable Care Act's emphasis on improved primary care, has intensified interest in how to deliver patient-centered care. Essential to the delivery of such care are patient-centered communication skills. These skills have a positive impact on patient satisfaction, treatment adherence, and self-management. They can be effectively taught at all levels of medical education and to practicing physicians. Yet most physicians receive limited training in communication skills. Policy makers and stakeholders can leverage training grants, payment incentives, certification requirements, and other mechanisms to develop and reward effective patient-centered communication.