Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018.

Importance: Low-value care, defined as care offering no net benefit in specific clinical scenarios, is associated with harmful outcomes in patients and wasteful spending. Despite a national education campaign and increasing attention on reducing health care waste, recent trends in low-value care delivery remain unknown. Objective: To assess national trends in low-value care use and spending. Design, Setting, and Participants: In this cross-sectional study, analyses of low-value care use and spending from 2014 to 2018 were conducted using 100% Medicare fee-for-service enrollment and claims data. Included individuals were aged 65 years or older and continuously enrolled in Medicare parts A, B, and D during each measurement year and the previous year. Data were analyzed from September 2019 through December 2020. Exposure: Being enrolled in fee-for-service Medicare for a period of time, in years. Main Outcomes and Measures: The Milliman MedInsight Health Waste Calculator was used to assess 32 claims-based measures of low-value care associated with Choosing Wisely recommendations and other professional guidelines. The calculator designates services as wasteful, likely wasteful, or not wasteful based on an absence of indication of appropriate use in the claims history; calculator-designated wasteful services were defined as low-value care. Spending was calculated as claim-line level (ie, spending on the low-value service) and claim level (ie, spending on the low-value service plus associated services), adjusting for inflation. Results: Among 21 045 759 individuals with fee-for-service Medicare (mean [SD] age, 77.4 [7.9] years; 12 515 915 [59.5%] women), the percentage receiving any of 32 low-value services decreased from 36.3% (95% CI, 36.3%-36.4%) to 33.6% (95% CI, 33.6%-33.6%) from 2014 to 2018. Uses of low-value services per 1000 individuals decreased from 677.8 (95% CI, 676.2-679.5) to 632.7 (95% CI, 632.6-632.8) from 2014 to 2018. Three services comprised approximately two-thirds of uses among 32 low-value services per 1000 individuals: preoperative laboratory testing decreased from 213.8 (95% CI, 213.4-214.2) to 166.2 (95% CI, 166.2-166.2), while opioids for back pain increased from 154.4 (95% CI, 153.6-155.2) to 182.1 (95% CI, 182.1-182.1) and antibiotics for upper respiratory infections increased from 75.0 (95% CI, 75.0-75.1) to 82 (95% CI, 82.0-82.0). Spending per 1000 individuals on low-value care also decreased, from $52 765.5 (95% CI, $51 952.3-$53 578.6) to $46 921.7 (95% CI, $46 593.7-$47 249.7) at the claim-line level and from $160 070.4 (95% CI, $158 999.8-$161 141.0) to $144 741.1 (95% CI, $144 287.5-$145 194.7) at the claim level. Conclusions and Relevance: This cross-sectional study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign in collaboration with clinician specialty societies and increased attention on low-value care. While most use of low-value care came from 3 services, 1 of these was opioid prescriptions, which increased over time despite the harms associated with their use. These findings may represent several opportunities to prevent patient harm and lower spending.

Health Sector Reform in the Kurdistan Region-Iraq: Primary Care Management Information System, Physician Dual Practice Finance Reform, and Quality of Care Training.

Since 2010, the RAND Corporation has worked with the Ministry of Health and Ministry of Planning of the Kurdistan Regional Government to develop and implement initiatives for improving the region's health care system through analysis, planning, and development of analytical tools. This third phase of the project (reflecting work completed in 2013-2015) focused on development and use of a primary care management information system; health financing reform, focusing on policy reform options to solve the problem of physician dual practice, in which physicians practice in both public and private settings; and hospital patient safety training within the context of health quality improvement. Most main primary health care centers serve too many people, and most sub-centers serve too few people. Staffing by physicians, nurses, dentists, and pharmacists is uneven across the region. The data also identified centers where laboratory, X-ray, and/or other equipment should be repaired or replaced and where users should be trained. Though the required workweek is 35 hours, and all physicians are paid for these 35 hours, most physicians spent only three or four hours per day working in the public sector. The remainder of the time was often spent working in the private sector, where pay is much higher. The vast majority of physicians (over 80 percent) indicated that if pay were higher and public-sector resources were increased, they would prefer to work only in the public sector. To resolve the problems associated with dual practice, the authors recommend full separation between public- and private-sector practice.

Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial.

BACKGROUND: The effectiveness of collaborative care of mental health problems is clear for depression and growing but mixed for anxiety disorders, including posttraumatic stress disorder (PTSD). We know little about whether collaborative care can be effective in settings that serve low-income patients such as Federally Qualified Health Centers (FQHCs). OBJECTIVE: We compared the effectiveness of minimally enhanced usual care (MEU) versus collaborative care for PTSD with a care manager (PCM). DESIGN: This was a multi-site patient randomized controlled trial of PTSD care improvement over 1 year. PARTICIPANTS: We recruited and enrolled 404 patients in six FQHCs from June 2010 to October 2012. Patients were eligible if they had a primary care appointment, no obvious physical or cognitive obstacles to participation, were age 18-65 years, planned to continue care at the study location for 1 year, and met criteria for a past month diagnosis of PTSD. MAIN MEASURES: The main outcomes were PTSD diagnosis and symptom severity (range, 0-136) based on the Clinician-Administered PTSD Scale (CAPS). Secondary outcomes were medication and counseling for mental health problems, and health-related quality of life assessed at baseline, 6 months, and 12 months. KEY RESULTS: Patients in both conditions improved similarly over the 1-year evaluation period. At 12 months, PTSD diagnoses had an absolute decrease of 56.7% for PCM patients and 60.6% for MEU patients. PTSD symptoms decreased by 26.8 and 24.2 points, respectively. MEU and PCM patients also did not differ in process of care outcomes or health-related quality of life. Patients who actually engaged in care management had mental health care visits that were 14% higher (p < 0.01) and mental health medication prescription rates that were 15.2% higher (p < 0.01) than patients with no engagement. CONCLUSIONS: A minimally enhanced usual care intervention was similarly effective as collaborative care for patients in FQHCs.

Impact of teen depression on academic, social, and physical functioning.

OBJECTIVE: This study aimed to determine the impact of teen depression on peer, family, school, and physical functioning and the burden on parents. METHODS: Patients participated in a longitudinal study of teens with and without probable depression, drawn from 11 primary care offices in Los Angeles, California, and Washington, DC. A total of 4856 teens completed full screening assessments; 4713 were eligible for the study, and 187 (4.0%) met the criteria for probable depression and were invited to participate, as were teens who were not depressed. A total of 184 baseline assessments for teens with probable depression and 184 for nondepressed teens were completed, as were 339 (90%) parent interviews. Follow-up interviews were conducted with 328 teens (89%) and 302 parents (82%). Measures included teen reports of peer and parent support, 2 measures of school functioning, grades, physical health, and days of impairment. Parent reports included peer, school, and family functioning and subjective and objective burdens on parents. RESULTS: Teens with depression and their parents reported more impairment in all areas, compared with teens without depression at baseline, and reported more coexisting emotional and behavioral problems. Both depression and coexisting problems were related to impairment. There was a lasting impact of depressive symptoms on most measures of peer, family, and school functioning 6 months later, but controlling for coexisting baseline emotional and behavioral problems attenuated this relationship for some measures. CONCLUSION: Improvements in teen depression might have benefits that extend beyond clinical symptoms, improving peer, family, and school functioning over time.

The effect of adherence to practice guidelines on depression outcomes.

BACKGROUND: Few studies have assessed clinician adherence to depression practice guidelines and the relationship between clinician adherence and depression outcomes. OBJECTIVE: To estimate how frequently specific guideline recommendations are followed and to assess whether following guideline recommendations is linked to improved depression outcomes. DESIGN: Observational analysis of data collected from 1996 to 1998 in 3 randomized clinical trials. SETTING: 45 primary care practices in 13 U.S. states. PATIENTS: 1131 primary care patients with depression. MEASUREMENTS: Expert panel methods were used to develop a patient survey-based index that measured adherence to clinical practice guidelines on depression. Rates of adherence to the 20 indicators that form the index were evaluated. Multivariable regression that controlled for case mix was used to assess how index scores predicted continuous and dichotomous depression measures at 12, 18, and 24 months. RESULTS: Quality of care was high (clinician adherence > or =79%) for 6 indicators, including primary care clinician detection of depression. Quality of care was low (adherence, 20% to 38%) for 8 indicators, including management of suicide risk (3 indicators), alcohol abuse (2 indicators), and elderly patients; assessment of symptoms and history of depression; and treatment adjustment for patients who did not respond to initial treatment. Greater adherence to practice guidelines significantly predicted fewer depressive symptoms on continuous measures (P < 0.001 for 12 months, P < 0.01 for 18 months, and P < 0.001 for 24 months) and dichotomous measures (P < 0.05 for 18 and 24 months). LIMITATIONS: Data are based on patient self-report. Possible changes in practice since 1998 may limit the generalizability of the findings. CONCLUSIONS: Adherence to guidelines was high for one third of the recommendations that were measured but was very low for nearly half of the measures, pointing to specific needs for quality improvement. Guideline-concordant depression care appears to be linked to improved outcomes in primary care patients with depression.

Factors associated with primary care clinicians' choice of a watchful waiting approach to managing depression.

OBJECTIVES: Watchful waiting to manage depression in primary care may be an appropriate management approach for some patients who present with less severe depression. This study examined factors associated with primary care clinicians' choice of a watchful waiting approach to care management for depression. METHODS: Secondary data were analyzed from Partners in Care, which examined dissemination of best practices for depression in primary care. Primary care clinicians' decisions regarding watchful waiting were examined by using the baseline survey data from Partners in Care completed by clinicians and patients from February 1996 to March 1997. Participants were 167 primary care clinicians from 46 practices of seven managed care organizations across the United States and their 1,187 patients with depression. Primary care clinicians' proclivity for watchful waiting was examined by using a brief scenario describing a patient with major depressive disorder. RESULTS: Thirty-four clinicians (20 percent) reported a strong proclivity to use watchful waiting for the patient in the scenario. The proclivity was significantly associated with clinicians' reports of the proportion of their actual patients with whom they used this approach. Clinicians were significantly more likely to choose watchful waiting for their actual patients if they had more psychotherapy knowledge (p=.035) or perceived that the need to treat the patient's medical illness was more important than the need to treat his or her mental illness (p=.046) and were less likely to choose a watchful waiting approach if they perceived the lack of availability of mental health professionals as a barrier (p=.050). CONCLUSIONS: Primary care clinicians' knowledge of treatment and perception of barriers influence their proclivity for watchful waiting. Clinician education to promote appropriate use of watchful waiting on the basis of clinical need is recommended.

Influence of patient preference and primary care clinician proclivity for watchful waiting on receipt of depression treatment.

OBJECTIVE: We examined whether patients' preference for watchful waiting and their primary care clinician's proclivity for watchful waiting were associated with decreased likelihood of receiving depression treatment. METHODS: In a quality improvement intervention for depression in primary care, patients with depressive symptoms were identified through screening in 46 clinics from June 1996 to March 1997. We analyzed baseline survey data completed by clinicians and patients using logistic regression models. RESULTS: Of 1140 patients, 179 (16%) preferred watchful waiting over active treatment. After controlling for covariates, patients with depressive disorders who preferred watchful waiting were less likely to report use of antidepressants (OR=0.86, 95% CI=0.77-0.95). Among patients with depressive symptoms only, those who preferred watchful waiting were less likely to report antidepressant use (OR=0.84, 95% CI=0.76-0.93) or counseling (OR=0.84, 95% CI=0.77-0.95). Patients with less knowledge about depression were less likely to receive depression treatment. Clinician proclivity for watchful waiting was not associated with the likelihood that patients received depression treatment. CONCLUSIONS: Patient preference for watchful waiting is associated with lower rates of some depression treatments, especially among patients with subsyndromal depression. Addressing patient preference for watchful waiting in primary care may include active symptom monitoring and patient education.

Impacts of evidence-based quality improvement on depression in primary care: a randomized experiment.

CONTEXT: Previous studies testing continuous quality improvement (CQI) for depression showed no effects. Methods for practices to self-improve depression care performance are needed. We assessed the impacts of evidence-based quality improvement (EBQI), a modification of CQI, as carried out by 2 different health care systems, and collected qualitative data on the design and implementation process. OBJECTIVE: Evaluate impacts of EBQI on practice-wide depression care and outcomes. DESIGN: Practice-level randomized experiment comparing EBQI with usual care. SETTING: Six Kaiser Permanente of Northern California and 3 Veterans Administration primary care practices randomly assigned to EBQI teams (6 practices) or usual care (3 practices). Practices included 245 primary care clinicians and 250,000 patients. INTERVENTION: Researchers assisted system senior leaders to identify priorities for EBQI teams; initiated the manual-based EBQI process; and provided references and tools. EVALUATION PARTICIPANTS: Five hundred and sixty-seven representative patients with major depression. MAIN OUTCOME MEASURES: Appropriate treatment, depression, functional status, and satisfaction. RESULTS: Depressed patients in EBQI practices showed a trend toward more appropriate treatment compared with those in usual care (46.0% vs 39.9% at 6 months, P = .07), but no significant improvement in 12-month depression symptom outcomes (27.0% vs 36.1% poor depression outcome, P = .18). Social functioning improved significantly (mean score 65.0 vs 56.8 at 12 months, P = .02); physical functioning did not. CONCLUSION: Evidence-based quality improvement had perceptible, but modest, effects on practice performance for patients with depression. The modest improvements, along with qualitative data, identify potential future directions for improving CQI research and practice.

Differences in individual-level terrorism preparedness in Los Angeles County.

BACKGROUND: Increasing individual preparedness for disasters, including large-scale terrorist attacks, is a significant concern of public health planners. As with natural disasters, individuals can help protect their health and safety by preparing for the emergency situation that may follow a terrorist event. Our study describes variations in preparedness among the population of Los Angeles County after the September 11, 2001 and subsequent anthrax attacks. METHODS: In 2004, the data were analyzed from the Los Angeles County Health Survey, a random-digit-dialed telephone survey of the non-institutionalized population in Los Angeles County fielded October 2002 through February 2003. RESULTS: Overall, 28.0% of respondents had emergency supplies, and 17.1% developed an emergency plan in the past year in response to the possibility of terrorism. Factors associated with having emergency supplies included African American (adjusted odds ratio [AOR] 1.8, 95% confidence interval [CI]=1.1-3.1) and Latino (AOR=1.5, 95% CI=1.0-2.4) race/ethnicity; having a household dependent aged

Primary care provider attitudes are associated with smoking cessation counseling and referral.

OBJECTIVE: Most primary care providers (PCPs) endorse the importance of smoking cessation, but counseling rates are low. We evaluated the consistency of PCP's attitudes toward smoking cessation counseling and corresponding smoking-cessation behaviors. DESIGN: This was a postintervention analysis of a population-based sample from a group randomized controlled trial to improve adherence to smoking cessation guidelines. SETTING: A total of 18 VA sites in Southwestern and Western United States participated. PARTICIPANTS: A total of 280 PCPs completed a survey at 12 months after the implementation of a smoking-cessation quality improvement (QI) program. Their patients also completed 12- (n = 1080) and 18-month (n = 924) follow-up surveys. INTERVENTION: The quality improvement intervention included local priority setting, quality improvement plan development, implementation, and monitoring. MEASUREMENTS AND MAIN RESULTS: PCPs at intervention sites were more likely to report counseling patients about smoking cessation (P = 0.04) but not referral. PCP attitude toward smoking-cessation counseling was strongly associated with reported counseling (P < 0.001) and with referral (P = 0.01). Other associations with counseling were the perceived barrier "patients are not interested in quitting" (P = 0.01) and fewer years in practice (P = 0.03); other associations with referral were specialty consultation (P < 0.0001) and the perceived barrier "referral not convenient" (P = 0.001) (negative association). PCP attitudes were associated with higher rates of counseling, referral, and program attendance. CONCLUSIONS: PCPs, regardless of intervention participation, had attitudes consistent with their reported smoking-cessation behaviors and more favorable attitudes were associated with higher rates of patient-reported smoking cessation behavior. Findings suggest that PCPs who endorse smoking-cessation counseling and referral may provide more treatment recommendations and have higher patient quit rates.

Will public health's response to terrorism be fair? Racial/ethnic variations in perceived fairness during a bioterrorist event.

OBJECTIVES: Public health departments' effectiveness during catastrophic bioterrorism will require trust on the part of diverse communities. This study describes variations in perceptions that the public health system will respond fairly to one's needs in a bioterrorist event, regardless of race/ethnicity, income, or other characteristics. METHODS: Using the Los Angeles County Health Survey, a random-digit, population-based, telephone survey, we conducted multivariate logistic regression of race/ethnicity on perceived fairness, adjusting for demographic factors and perceived neighborhood safety. We performed similar analyses stratified by race/ethnicity subgroup. RESULTS: Overall, 72.7% of respondents perceived that the public health system will respond fairly in a bioterrorist event. African Americans (AA) and Asian/Pacific Islanders (API) reported the lowest perceived fairness (AA 63.0%, API 68.2%, Latino 73.1%, White 76.6%, p = 0.005 for group differences). Adjusting for demographic factors and neighborhood safety, African Americans had lower perceived fairness compared to whites (adjusted odds ratio, aOR 0.45; 95% confidence intervals, CI 0.26-0.79; p < 0.005). Other factors associated with lower perceived fairness included Asian-language compared to English-language interview (aOR 0.29; 95% CI 0.11-0.76; p < 0.05) and lower compared to higher neighborhood safety (aOR 0.48; 95% CI 0.31-0.74; p < 0.005). Among African Americans, participants aged 18-29 years were less likely to report perceived fairness (aOR 0.06; 95% CI 0.01-0.59) compared to participants older than 60 years of age. Among Asian/Pacific Islanders, Asian-language interview (aOR 0.07; 95% CI 0.01-0.48) and lower perceived neighborhood safety (aOR 0.01; 95% CI <0.01-0.13) were associated with perceived fairness. CONCLUSIONS: To strengthen bioterrorism preparedness, public health officials must continue to improve perceived fairness among African American and Asian/Pacific Islander communities.