Evaluation of Socioeconomic Disparities in Follow-Up Completion for Incidental Pulmonary Nodules.

PURPOSE: The aim of this study was to evaluate the association between census tract-level measures of social vulnerability and residential segregation and incidental pulmonary nodule (IPN) follow-up. METHODS: This retrospective cohort study included patients with IPNs ≥6 mm in size or multiple subsolid or ground-glass IPNs <6 mm (with nonoptional follow-up recommendations) diagnosed between January 1, 2018, and December 30, 2019, at a large urban tertiary center and followed for ≥2 years. Geographic sociodemographic context was characterized by the 2018 Centers for Disease Control and Prevention Social Vulnerability Index (SVI) and the index of concentration at the extremes (ICE), categorized in quartiles. Multivariable binomial regression models were used, with a primary outcome of inappropriate IPN follow-up (late or no follow-up). Models were also stratified by nodule risk. RESULTS: The study consisted of 2,492 patients (mean age, 65.6 ± 12.6 years; 1,361 women). Top-quartile SVI patients were more likely to have inappropriate follow-up (risk ratio [RR], 1.24; 95% confidence interval [CI], 1.12-1.36) compared with the bottom quartile; risk was also elevated in top-quartile SVI subcategories of socioeconomic status (RR, 1.23; 95% CI, 1.13-1.34), Minority status and language (RR, 1.24; 95% CI, 1.03-1.48), housing and transportation (RR, 1.13; 95% CI, 1.02-1.26), and ICE (RR, 1.20; 95% CI, 1.11-1.30). Furthermore, top-quartile ICE was associated with greater risk for inappropriate follow-up among high-risk versus lower risk IPNs (RR, 1.33 [95% CI, 1.18-1.50] versus 1.13 [95% CI, 1.02-1.25]), respectively; P for interaction = .017). CONCLUSIONS: Local social vulnerability and residential segregation are associated with inappropriate IPN follow-up and may inform policy or interventions tailored for neighborhoods.

Downstream Mammary and Extramammary Cascade Services and Spending Following Screening Breast Magnetic Resonance Imaging vs Mammography Among Commercially Insured Women.

Importance: Increasing use of screening breast magnetic resonance imaging (MRI), including among women at low or average risk of breast cancer, raises concerns about resulting mammary and extramammary cascades (downstream services and new diagnoses) of uncertain value. Objective: To estimate rates of cascade events (ie, laboratory tests, imaging tests, procedures, visits, hospitalizations, and new diagnoses) and associated spending following screening breast MRI vs mammography among commercially insured US women. Design, Setting, and Participants: This cohort study used 2016 to 2018 data from the MarketScan research database (IBM Corporation), which includes claims and administrative data from large US employers and commercial payers. Participants included commercially insured women aged 40 to 64 years without prior breast cancer who received an index bilateral screening breast MRI or mammogram between January 1, 2017, and June 30, 2018. We used propensity scores based on sociodemographic, clinical, and utilization variables to match MRI recipients to mammogram recipients in each month of index service use. Data were analyzed from October 8, 2020, to October 28, 2021. Exposures: Breast MRI vs mammography. Main Outcomes and Measures: Mammary and extramammary cascade event rates and associated total and patient out-of-pocket spending in the 6 months following the index test. Results: In this study, 9208 women receiving breast MRI were matched with 9208 women receiving mammography (mean [SD] age, 51.4 [6.7] years). Compared with mammogram recipients, breast MRI recipients had 39.0 additional mammary cascade events per 100 women (95% CI, 33.7-44.2), including 5.0 additional imaging tests (95% CI, 3.8-6.2), 17.3 additional procedures (95% CI, 15.5-19.0), 13.0 additional visits (95% CI, 9.4-17.2), 0.34 additional hospitalizations (95% CI, 0.18-0.50), and 3.0 additional new diagnoses (95% CI, 2.5-3.6). For extramammary cascades, breast MRI recipients had 19.6 additional events per 100 women (95% CI, 8.6-30.7) including 15.8 additional visits (95% CI, 10.2-21.4) and no statistically significant differences in other events. Breast MRI recipients had higher total spending for mammary events ($564 more per woman; 95% CI, $532-$596), extramammary events ($42 more per woman; 95% CI, $16-$69), and overall ($1404 more per woman; 95% CI, $1172-$1636). They also had higher overall out-of-pocket spending ($31 more per woman; 95% CI, $6-$55). Conclusions and Relevance: In this cohort study of commercially insured women, breast MRI was associated with more mammary and extramammary cascade events and spending relative to mammography. These findings can inform cost-benefit assessments and coverage policies to ensure breast MRI is reserved for patients for whom benefits outweigh harms.

Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication.

BACKGROUND: Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise. METHODS: Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention. RESULTS: Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse. CONCLUSION: Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.

Longitudinal Content Analysis of the Characteristics and Expected Impact of Low-Value Services Identified in US Choosing Wisely Recommendations.

IMPORTANCE: The US Choosing Wisely campaign has had substantial reach in mobilizing efforts to reduce low-value care, achieved largely by engaging physician specialty societies in stewardship. While some early recommendations were criticized for avoiding revenue-generating services, there is limited evidence of how the composition of recommendations shifted as more societies contributed. OBJECTIVE: To analyze the characteristics and expected impact of Choosing Wisely recommendations. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study included content and trend analyses of all 626 Choosing Wisely recommendations by US physician societies as of March 1, 2021. Data were analyzed between March and May 2021. MAIN OUTCOMES AND MEASURES: Primary outcomes were proportions of identified low-value services by characteristics (society type, service type, indication, do vs avoid, and clinical context) and expected impact (effect on the revenue of society members, cost, number of individuals at risk, direct harm potential, and cascade potential). RESULTS: Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging (168 [26.8%]) and laboratory studies (156 [24.9%]) in the context of chronic conditions (169 [27.0%]) and healthy patients with risk factors alone (126 [20.1%]). Most of the identified low-value services were revenue neutral for the recommending society (402 [64.2%]) and the plurality were low cost (<$200; 284 [45.4%]); low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations (1.2 percentage points per year; P = .001). Nearly half (280 [44.7%]) of recommendations identified services with high direct harm potential, and 388 (62.0%) identified those with high potential for cascades (ie, triggering downstream services). CONCLUSIONS AND RELEVANCE: The results of this qualitative study suggest that the Choosing Wisely recommendations identified services with a range of expected impacts. Stakeholders could explicitly set priorities for future recommendations, while clinical leaders and payers might target intervention efforts on recommendations with the greatest potential for impact based on spending across populations, direct harms, and cascades.

Association of Social Vulnerability, COVID-19 vaccine site density, and vaccination rates in the United States.

The COVID-19 pandemic has disproportionately impacted Americans in socially vulnerable areas. Unfortunately, these groups are also experiencing lower vaccination rates. To understand how strategic vaccine site placement may benefit high vulnerability populations, we extracted vaccine site locations for 26 U.S. states and linked these data to county-level adult vaccination rates and the CDC 2018 Social Vulnerability Index rankings. We fit quasi-Poisson regression models to compare vaccine site density between the highest and lowest SVI domain quartiles, and assessed whether greater vaccine site density mediated or modified the relationship between social vulnerability and vaccination rates. We found that high vulnerability counties by socioeconomic status had more vaccine sites per 10,000 residents, yet this higher vaccine site density did not reduce socioeconomic disparities in vaccination rates. Persistent vaccination inequities may reflect other structural barriers to access. Our results suggest that targeted vaccine site placement in high vulnerability counties may be necessary but insufficient for the goal of widespread, equitable vaccination.

Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation.

BACKGROUND: Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value. OBJECTIVES: This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events. METHODS: Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services. RESULTS: Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending. CONCLUSIONS: Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.

Primary Care Access During the COVID-19 Pandemic: a Simulated Patient Study.

BACKGROUND: Primary care practices have experienced major strains during the COVID-19 pandemic, such that patients newly seeking care may face potential barriers to timely visits. OBJECTIVE: To quantify availability and wait times for new patient appointments in primary care and to describe how primary care practices are guiding patients with suspected COVID-19. DESIGN: Trained callers conducted simulated patient calls to 800 randomly sampled primary care practices between September 14, 2020, and September 28, 2020. PARTICIPANTS: We extracted complete primary care physician listings from large commercial insurance networks in four geographically dispersed states between September 10 and 14, 2020 (n=11,521). After excluding non-physician providers and removing duplicate phone numbers, we identified 2705 unique primary care physician practices from which we randomly sampled 200 practices in each region. MAIN MEASURES: Primary care appointment availability, median wait time in days, and practice guidance to patients suspecting COVID-19 infection. KEY RESULTS: Among 56% of listed practices that had accurate contact information listed in the directory, 84% offered a new patient in-person or virtual appointment. Median wait time was 10 days (IQR 3-26 days). The most common guidance in case of suspected COVID-19 was clinician consultation, which was offered in 41% of completed calls. Callers were otherwise directed to on-site testing (14%), off-site testing (24%), a COVID-19 hotline (8%), or an urgent care/emergency department (12%), while 2% of practices had no guidance to offer. CONCLUSIONS: Despite resource constraints, most reachable primary care practices offered timely new patient appointments as well as direct COVID-19 care. Pandemic mitigation strategies should account for and support the central role of primary care practices in the community-based pandemic response.

Sensitivity and specificity of patient-entered red flags for lower back pain.

BACKGROUND CONTEXT: Red flags are questions typically ascertained by providers to screen for serious underlying spinal pathologies. The utility of patient-reported red flags in guiding clinical decision-making for spine care, however, has not been studied. PURPOSE: The aim of this study was to quantify the sensitivity and specificity of patient-reported red flags in predicting the presence of serious spinal pathologies. STUDY DESIGN: This was a retrospective nested case-control study. PATIENT SAMPLE: This study consisted of 120 patients with International Classification of Diseases, Ninth Revision, Clinical Modification codes for spinal pathologies and 380 randomly selected patients, from a population of 4,313 patients seen at a large tertiary care spine clinic between October 9, 2013 and June 30, 2014. OUTCOME MEASURES: The presence of patient-reported red flags and red flags obtained from medical records was verified for chart review. The spinal pathology (ie, malignancy, fractures, infections, or cauda equina syndrome) was noted for each patient. METHODS: The sensitivity and specificity of patient-reported red flags for detecting serious spinal pathologies were calculated from data obtained from the 500 patients. Youden's J was used to rank performance. Agreement between patient-reported red flags and those obtained from medical record review was assessed via Cohen's kappa statistic. RESULTS: "History of cancer" was the best performing patient-reported red flag to identify malignancy (sensitivity=0.75 [95% confidence intervals, CI 0.53-0.90], specificity=0.79 [95% CI 0.75-0.82]). The best performing patient-reported red flag for fractures was the presence of at least one of the following: "Osteoporosis," "Steroid use," and "Trauma" (sensitivity=0.59 [95% CI 0.44-0.72], specificity=0.65 [95% CI 0.60-0.69]). The prevalence of infection and cauda equina diagnoses was insufficient to gauge sensitivity and specificity. Red flags from medical records had better performance than patient-reported red flags. There was poor agreement between patient red flags and those obtained from medical record review. CONCLUSIONS: Patient-reported red flags had low sensitivity and specificity for identification of serious pathologies. They should not be used in insolation to make treatment decisions, although they may be useful to prompt further probing to determine if additional investigation is warranted.