Outpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysis.

BACKGROUND: The COVID-19 pandemic led to a dramatic shift in the delivery of outpatient medicine with reduced in-person visits and a transition to predominantly virtual visits. We sought to understand trends in visit patterns for ambulatory care sensitive conditions (ACSCs) commonly seen in internal medicine clinics. METHODS: We included adult outpatients seen for an ACSC between March 15th, 2017 and March 14th, 2021 at a single-centre in Ontario, Canada. Monthly visits were assessed by visit type (new consultation, follow-up), diagnosis, and clinic. Time series analyses compared visit volumes pre- and post-pandemic. Proportion of virtual visits were compared before and during the pandemic. Patient and visit factors were compared between in-person and virtual visits. RESULTS: 8274 patients with 34,021 visits were included. Monthly visits increased by 15% during the pandemic (p <  0.0001). New consultations decreased by 10% (p = 0.0053) but follow-up visits increased by 21% (p <  0.0001). Monthly heart failure visits increased by 43% (p <  0.0001) whereas atrial fibrillation visits decreased. Pre- pandemic, < 1% of visits were virtual compared to 82% during the pandemic (p <  0.0001). Less than half of heart failure visits were virtual whereas > 95% of diabetes visits were virtual. CONCLUSIONS: We found a significant increase in overall visits to internal medicine clinics driven by increased volumes of follow-up visits, which more than offset decreased new consultations. There was variability in visit trends and uptake of virtual care by visit diagnosis, which may indicate challenges with delivery of virtual care for certain conditions.

Measuring the frequency and variation of unnecessary care across Canada.

BACKGROUND: Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions. METHODS: Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years. RESULTS: Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. CONCLUSIONS: The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.

Knowledge of and Interest in the Copper Intrauterine Device Among Women Seeking Emergency Contraception.

OBJECTIVE: Emergency contraception (EC) includes hormonal pills (levonorgestrel or ulipristal acetate) and the copper IUD (Cu-IUD). The Cu-IUD is more effective for EC than hormonal pills but remains underused, possibly because of lack of knowledge or interest. The objective of this study was to examine knowledge of and interest in the Cu-IUD for EC among Canadian women seeking EC. METHODS: The study used a cross-sectional convenience survey of English-speaking women presenting for EC at two sexual health clinics in Toronto. The anonymous paper-based survey was completed in the waiting room. The main outcome measures were women's knowledge of and interest in the Cu-IUD for EC. Demographic and reproductive health data were also collected. RESULTS: Between January and December 2013, 124 surveys were completed. Mean age of respondents was 26 years (SD ± 6.9). Most were single (85%), and over one half had completed postsecondary education. Overall, 77% had heard of the Cu-IUD, but only 21% were aware of its use for EC. Over 50% were aware that the Cu-IUD is hormone-free and may be used for long-term contraception. Women were less familiar with the window of administration of the Cu-IUD for EC (26%) and its efficacy (6%). In total, 23% (28 of 124) of women were interested in the Cu-IUD, including eight women scheduled to receive one that day. CONCLUSION: Women presenting for EC were unaware of the Cu-IUD but were moderately interested in it once informed. Public education and routine counselling about the Cu-IUD at EC visits may increase the uptake of this method.

Preoperative Laboratory Investigations: Rates and Variability Prior to Low-risk Surgical Procedures.

BACKGROUND: Increasing attention has been focused on low-value healthcare services. Through Choosing Wisely campaigns, routine laboratory testing before low-risk surgery has been discouraged in the absence of clinical indications. The authors investigated rates, determinants, and institutional variation in laboratory testing before low-risk procedures. METHODS: Patients who underwent ophthalmologic surgeries or predefined low-risk surgeries in Ontario, Canada, between April 1, 2008, and March 31, 2013, were identified from population-based administrative databases. Preoperative blood work was defined as a complete blood count, prothrombin time, partial thromboplastin, or basic metabolic panel within 60 days before an index procedure. Adjusted associations between patient and institutional factors and preoperative testing were assessed with hierarchical multivariable logistic regression. Institutional variation was characterized using the median odds ratio. RESULTS: The cohort included 906,902 patients who underwent 1,330,466 procedures (57.1% ophthalmologic and 42.9% low-risk surgery) at 119 institutions. Preoperative blood work preceded 400,058 (30.1%) procedures. The unadjusted institutional rate of preoperative blood work varied widely (0.0 to 98.1%). In regression modeling, significant predictors of preoperative testing included atrial fibrillation (adjusted odds ratio [AOR], 2.58; 95% CI, 2.51 to 2.66), preoperative medical consultation (AOR, 1.68; 95% CI, 1.65 to 1.71), previous mitral valve replacement (AOR, 2.33; 95% CI, 2.10 to 2.58), and liver disease (AOR, 1.69; 95% CI, 1.55 to 1.84). The median odds ratio for interinstitutional variation was 2.43. CONCLUSIONS: Results of this study suggest that testing is associated with a range of clinical covariates. However, an association was similarly identified with preoperative consultation, and significant variation between institutions exists across the jurisdiction.

Preoperative testing before low-risk surgical procedures.

BACKGROUND: There is concern about increasing utilization of low-value health care services, including preoperative testing for low-risk surgical procedures. We investigated temporal trends, explanatory factors, and institutional and regional variation in the utilization of testing before low-risk procedures. METHODS: For this retrospective cohort study, we accessed linked population-based administrative databases from Ontario, Canada. A cohort of 1 546 223 patients 18 years or older underwent a total of 2 224 070 low-risk procedures, including endoscopy and ophthalmologic surgery, from Apr. 1, 2008, to Mar. 31, 2013, at 137 institutions in 14 health regions. We used hierarchical logistic regression models to assess patient- and institution-level factors associated with electrocardiography (ECG), transthoracic echocardiography, cardiac stress test or chest radiography within 60 days before the procedure. RESULTS: Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. ECG and chest radiography were conducted before 31.0% (95% confidence interval [CI] 30.9%-31.1%) and 10.8% (95% CI 10.8%-10.8%) of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% (95% CI 2.9%-2.9%) and 2.1% (95% CI 2.1%-2.1%), respectively. Significant variation was present across institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. Receipt of preoperative ECG and radiography were associated with older age (among patients 66-75 years of age, for ECG, adjusted odds ratio [OR] 18.3, 95% CI 17.6-19.0; for radiography, adjusted OR 2.9, 95% CI 2.8-3.0), preoperative anesthesia consultation (for ECG, adjusted OR 8.7, 95% CI 8.5-8.8; for radiography, adjusted OR 2.2, 95% CI 2.1-2.2) and preoperative medical consultation (for ECG, adjusted OR 6.8, 95% CI 6.7-6.9; for radiography, adjusted OR 3.6, 95% CI 3.5-3.6). The median ORs for receipt of preoperative ECG and radiography were 2.3 and 1.6, respectively. INTERPRETATION: Despite guideline recommendations to limit testing before low-risk surgical procedures, preoperative ECG and chest radiography were performed frequently. Significant variation across institutions remained after adjustment for patient- and institution-level factors.

Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences.

BACKGROUND: The COVID-19 pandemic and the need for physical distancing has led to rapid uptake of virtual visits to deliver ambulatory health care. Despite widespread adoption, there has been limited evaluation of the quality of care being delivered through virtual modalities for ambulatory care sensitive conditions (ACSCs). OBJECTIVE: To characterize patients' and providers' experiences with the quality and sustainability of virtual care for ACSCs. DESIGN: This was a multi-method study utilizing quantitative and qualitative data from patient surveys, provider surveys, and provider focus groups at a large academic ambulatory care hospital between May 2020 and June 2021. We included patients and providers utilizing telephone or video visits for the following ACSCs: hypertension, angina, heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma. MAIN MEASURES: Quantitative and qualitative patient and provider survey responses were mapped to the Six Domains of Healthcare Quality framework. Provider focus groups were coded to identify themes within each quality domain. KEY RESULTS: Surveys were completed by 110/352 (31%) consenting patients and 20/61 (33%) providers. 5 provider focus groups were held with 14 participants. Patients found virtual visits to be generally more convenient than in-person visits for ACSCs. The perceived effectiveness of virtual visits was dependent on the clinical and social complexity of individual encounters. Respondents reported difficulty forming effective patient-provider relationships in the virtual environment. Patients and providers felt that virtual care has potential to both alleviate and exacerbate structural barriers to equitable access to care. CONCLUSIONS: In a large academic ambulatory care hospital, patients and providers experienced the quality of virtual visits for the management of ACSCs to be variable depending on the biopsychosocial complexity of the individual encounter. Our findings in each quality domain highlight key considerations for patients, providers and institutions to uphold the quality of virtual care for ACSCs.

Routine use of chest x-ray for low-risk patients undergoing a periodic health examination: a retrospective cohort study.

BACKGROUND: Many evidence-based recommendations advocate against the use of routine chest x-rays for asymptomatic, low-risk outpatients; however, it is unclear how regularly chest x-rays are ordered in primary care. Our study aims to describe the frequency of, and variation in, routine chest x-ray use in low-risk outpatients among primary care physicians. METHODS: In this retrospective cohort study, Ontario residents aged 18 years and older with a periodic health examination (PHE) between Apr. 1, 2010, and Mar. 31, 2015, were identified via administrative claims data. Patients with a recent history (last 3 years) of any of the following were excluded: cardiac or pulmonary disease, high-risk comorbidity (e.g., diabetes), consultations/visits or procedures involving cardiac or pulmonary specialists, cancer and severe chest trauma. The primary outcome, a routine chest x-ray, was defined as at least 1 chest x-ray claim within 7 days after a PHE. RESULTS: While a routine chest x-ray followed only 2.42% of 2 847 508 PHEs, one-quarter of family physicians (499/2031) ordered chest x-rays for more than 5.0% of their PHEs (interquartile range 1.5%-5.0%) and accounted for 62.9% of all tests observed. Routine chest x-ray use declined by 2.0% per quarter (adjusted rate ratio 0.98, 95% confidence interval [CI] 0.97-0.98). Older age (45-64 yr v. 18-44 yr, adjusted odds ratio [OR] 1.82, 95% CI 1.78-1.86; ≥ 65 yr v. 18-44 yr, adjusted OR 2.48, 95% CI 2.39-2.58) and male sex of the patient (OR 2.19, 95% CI 2.14-2.24) and male sex of the provider (OR 1.55, 95% CI 1.51-1.59) were significantly associated with increased odds of a routine chest x-ray being ordered. INTERPRETATION: It is relatively uncommon for a chest x-ray to be ordered as part of a PHE in Ontario; however, the substantial variation observed among physicians suggests potential for interventions targeted at the most frequent users.

Physician Characteristics Associated With Ordering 4 Low-Value Screening Tests in Primary Care.

Importance: Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently. Objectives: To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care. Design, Setting, and Participants: A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians. Exposures: Physician sex, years since medical school graduation, and primary care model. Main Outcomes and Measures: This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2). Results: The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users. Conclusions and Relevance: This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.

High Prevalence of Inappropriate Benzodiazepine and Sedative Hypnotic Prescriptions among Hospitalized Older Adults.

BACKGROUND: Benzodiazepines and sedative hypnotics are commonly used to treat insomnia and agitation in older adults despite significant risk. A clear understanding of the extent of the problem and its contributors is required to implement effective interventions. OBJECTIVE: To determine the proportion of hospitalized older adults who are inappropriately prescribed benzodiazepines or sedative hypnotics, and to identify patient and prescriber factors associated with increased prescriptions. DESIGN: Single-center retrospective observational study. SETTING: Urban academic medical center. PARTICIPANTS: Medical-surgical inpatients aged 65 or older who were newly prescribed a benzodiazepine or zopiclone. MEASUREMENTS: Our primary outcome was the proportion of patients who were prescribed a potentially inappropriate benzodiazepine or sedative hypnotic. Potentially inappropriate indications included new prescriptions for insomnia or agitation/anxiety. We used a multivariable random-intercept logistic regression model to identify patient- and prescriber-level variables that were associated with potentially inappropriate prescriptions. RESULTS: Of 1308 patients, 208 (15.9%) received a potentially inappropriate prescription. The majority of prescriptions, 254 (77.4%), were potentially inappropriate. Of these, most were prescribed for insomnia (222; 87.4%) and during overnight hours (159; 62.3%). Admission to a surgical or specialty service was associated with significantly increased odds of potentially inappropriate prescription compared to the general internal medicine service (odds ratio [OR], 6.61; 95% confidence interval [CI], 2.70-16.17). Prescription by an attending physician or fellow was associated with significantly fewer prescriptions compared to first-year trainees (OR, 0.28; 95% CI, 0.08-0.93). Nighttime prescriptions did not reach significance in initial bivariate analyses but were associated with increased odds of potentially inappropriate prescription in our regression model (OR, 4.48; 95% CI, 2.21-9.06). CONCLUSIONS: The majority of newly prescribed benzodiazepines and sedative hypnotics were potentially inappropriate and were primarily prescribed as sleep aids. Future interventions should focus on the development of safe sleep protocols and education targeted at first-year trainees.Journal of Hospital Medicine 2017;12:310-316.

Frequency of and variation in low-value care in primary care: a retrospective cohort study.

BACKGROUND: Low-value care, defined as care with a lack of benefit, can lead to higher health care costs, inconvenience to patients and, in some cases, harm to patients. The objectives of this study are to conduct exploratory analyses to understand how frequently selected low-value tests are ordered, to assess the degree of variation in ordering that exists across regions and practices, and to identify services that may warrant further investigation and targeted interventions. METHODS: We conducted a population-based retrospective cohort study using administrative health care databases from Ontario to identify rates of use of the following low-value services between fiscal years 2008/09 and 2012/13: computed tomography (CT) or magnetic resonance imaging (MRI) after a diagnosis of low back pain, Papanicolaou testing in women less than 21 years of age or older than 69 years of age and repeated dual-energy X-ray absorptiometry (DEXA) scanning within 2 years of an index scan. Regional and practice-level rates were calculated. Bivariate analyses were conducted to explore associations between patient factors and repeat DEXA scans. RESULTS: Repeated DEXA scans were the most common service (21.0%), whereas cervical cancer screening among women less than 21 years of age or older than 69 years of age (8.0%) and CT or MRI imaging for low back pain (4.5%) were less common. There was substantial variation across practices with rates of repeated DEXA scans, ranging from 4.0% to 54.9%, and cervical cancer screening, ranging from 0.9% to 35.2%. Patients with a high-risk index DEXA were more likely to receive a repeat scan (28.1%) than those with a baseline (8.9%) or low-risk (8.1%) scan. INTERPRETATION: There is significant, practice-level variation in the frequency of low-value testing for DEXA scans, back imaging and cervical cancer screening. There is a particular need for interventions that aim to reduce unnecessary DEXA scans.

Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination.

Importance: Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown. Objective: To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE. Design, Setting, and Participants: A population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE. Exposures: Receipt of an ECG within 30 days of an AHE. Main Outcomes and Measures: Primary outcome was receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months. Results: A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P < .001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts. Conclusions and Relevance: Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.

Financial Incentives and Cervical Cancer Screening Participation in Ontario's Primary Care Practice Models.

OBJECTIVES: The primary objective of this paper is to compare cervical cancer screening rates of family physicians in Ontario's two dominant reformed practice models, Family Health Group (FHG) and Family Health Organization (FHO), and traditional fee-for-service (FFS) model. Both reformed models formally enrol patients and offer extensive pay-for-performance incentives; however, they differ by remuneration for core services (FHG is FFS; FHO is capitated). The secondary objective is to estimate the average and marginal costs of screening in each model. METHODS: Using administrative data on 7,298 family physicians and their 2,083,633 female patients aged 35-69 eligible for cervical cancer screening in 2011, we assessed screening rates after adjusting for patient and physician characteristics. Predicted screening rates, fees and bonus payments were used to estimate the average and marginal costs of cervical cancer screening. RESULTS: Adjusted screening rates were highest in the FHG (81.9%), followed by the FHO (79.6%), and then the traditional FFS model (74.2%). The cost of a cervical cancer screening was $18.30 in the FFS model. The estimated average cost of screening in the FHGs and FHOs were $29.71 and $35.02, respectively, while the corresponding marginal costs were $33.05 and $39.06. DISCUSSION: We found significant differences in cervical cancer screening rates across Ontario's primary care practice models. Cervical screening rates were significantly higher in practice models eligible for incentives (FHGs and FHOs) than the traditional FFS model. However, the average and marginal cost of screening were lowest in the traditional FFS model and highest in the FHOs.

Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low-value care.

The Choosing Wisely campaign began in the USA in 2012 to encourage physicians and patients to discuss inappropriate and potentially harmful tests, treatments and procedures. Since its inception, the campaign has grown substantially and has been adopted by 12 countries around the world. Of great interest to countries implementing the campaign, is the effectiveness of Choosing Wisely to reduce overutilisation. This article presents an integrated measurement framework that may be used to assess the impact of a Choosing Wisely campaign on physician and provider awareness and attitudes on low-value care, provider practice behaviour and overuse of low-value services.