Dataset Information

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

ABSTRACT:

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.

SUBMITTER: Pendrith C

PROVIDER: S-EPMC5378544 | biostudies-literature | 2017 Jan-Mar

REPOSITORIES: biostudies-literature

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Publications

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

Pendrith Ciara C Bhatia Meghan M Ivers Noah M NM Mecredy Graham G Tu Karen K Hawker Gillian A GA Jaglal Susan B SB Wilson Lynn L Wintemute Kimberly K Glazier Richard H RH Levinson Wendy W Bhatia R Sacha RS

CMAJ open 20170120 1

<h4>Background</h4>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.<h4>Methods< ...[more]

PMID: 28401118

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Project description:BackgroundSeveral studies showed that during the pandemic patients have refrained from visiting their general practitioner (GP). This resulted in medical care being delayed, postponed or completely forgone. The provision of low-value care, i.e. care which offers no net benefit for the patient, also could have been affected. We therefore assessed the impact of the COVID-19 restrictions on three types of low-value GP care: 1) imaging for back or knee problems, 2) antibiotics for otitis media acuta (OMA), and 3) repeated opioid prescriptions, without a prior GP visit.MethodsWe performed a retrospective cohort study using registration data from GPs part of an academic GP network over the period 2017-2022. The COVID-19 period was defined as the period between April 2020 to December 2021. The periods before (January 2017 to April 2020) and after the COVID-19 period (January 2022 to December 2022) are the pre- and post-restrictions periods. The three clinical practices examined were selected by two practicing GPs from a top 30 of recommendations originating from the Dutch GP guidelines, based on their perceived prevalence and relevance in practice (van Dulmen et al., BMC Primary Care 23:141, 2022). Multilevel Poisson regression models were built to examine changes in the incidence rates (IR) of both registered episodes and episodes receiving low-value treatment.ResultsDuring the COVID-19 restrictions period, the IRs of episodes of all three types of GP care decreased significantly. The IR of episodes of back or knee pain decreased by 12%, OMA episodes by 54% and opioid prescription rate by 13%. Only the IR of OMA episodes remained significantly lower (22%) during the post-restrictions period. The provision of low-value care also changed. The IR of imaging for back or knee pain and low-value prescription of antibiotics for OMA both decreased significantly during the COVID-restrictions period (by 21% and 78%), but only the low-value prescription rate of antibiotics for OMA remained significantly lower (by 63%) during the post-restrictions period. The IR of inappropriately repeated opioid prescriptions remained unchanged over all three periods.ConclusionsThis study shows that both the rate of episodes as well as the rate at which low-value care was provided have generally been affected by the COVID-19 restrictions. Furthermore, it shows that the magnitude of the impact of the restrictions varies depending on the type of low-value care. This indicates that deimplementation of low-value care requires tailored (multiple) interventions and may not be achieved through a single disruption or intervention alone.

Project description:BackgroundWhether patients receive low-value hospital care (care that is not expected to provide a net benefit) may be influenced by unmeasured factors at the hospital they attend or the hospital's Local Health District (LHD), or the patients' areas of residence. Multilevel modelling presents a method to examine the effects of these different levels simultaneously and assess their relative importance to the outcome. Knowing which of these levels has the greatest contextual effects can help target further investigation or initiatives to reduce low-value care.MethodsWe conducted multilevel logistic regression modelling for nine low-value hospital procedures. We fit a series of six models for each procedure. The baseline model included only episode-level variables with no multilevel structure. We then added each level (hospital, LHD, Statistical Local Area [SLA] of residence) separately and used the change in the c statistic from the baseline model as a measure of the contribution of the level to the outcome. We then examined the variance partition coefficients (VPCs) and median odds ratios for a model including all three levels. Finally, we added level-specific covariates to examine if they were associated with the outcome.ResultsAnalysis of the c statistics showed that hospital was more important than LHD or SLA in explaining whether patients receive low-value care. The greatest increases were 0.16 for endoscopy for dyspepsia, 0.13 for colonoscopy for constipation, and 0.14 for sentinel lymph node biopsy for early melanoma. SLA gave a small increase in c compared with the baseline model, but no increase over the model with hospital. The VPCs indicated that hospital accounted for most of the variation not explained by the episode-level variables, reaching 36.8% (95% CI, 31.9-39.0) for knee arthroscopy. ERCP (8.5%; 95% CI, 3.9-14.7) and EVAR (7.8%; 95% CI, 2.9-15.8) had the lowest residual variation at the hospital level. The variables at the hospital, LHD and SLA levels that were available for this study generally showed no significant effect.ConclusionsInvestigations into the causes of low-value care and initiatives to reduce low-value care might best be targeted at the hospital level, as the high variation at this level suggests the greatest potential to reduce low-value care.

Project description:ObjectivesTo determine the extent to which referral for defined symptoms from primary care varies by age, sex, and social deprivation and whether any sociodemographic variations in referral differ according to the presence of national referral guidance and the potential of the symptoms to be life threatening.DesignCohort study using individual patient data from the health improvement network database in primary care.SettingUnited Kingdom.Participants5492 patients with postmenopausal bleeding, 23 121 with hip pain, and 101 212 with dyspepsia from 326 general practices, 2001-7.Main outcome measuresMultivariable associations between odds of immediate referral for postmenopausal bleeding and age and social deprivation; hazard rates of referral for hip pain or dyspepsia and age, sex, and social deprivation. Analyses for dyspepsia were stratified for people aged less than and more than 55 years because referral guidance differs by age.Results61.4% (3374/5492) of patients with postmenopausal bleeding, 17.4% (4019/23 121) with hip pain, and 13.8% (13 944/101 212) with dyspepsia were referred. The likelihood of referral for postmenopausal bleeding declined with increasing age: the adjusted odds ratio for patients aged 85 or more compared with those aged 55-64 was 0.39 (95% confidence interval 0.31 to 0.49). Patients aged 85 or more with hip pain were also less likely to be referred than those aged 55-64 (0.68, 0.57 to 0.81). Women were less likely than men to be referred for hip pain (hazard ratio 0.90, 95% confidence interval 0.84 to 0.96). More deprived patients with hip pain or dyspepsia (if aged <55) were less likely to be referred. Adjusted hazard ratios for those in the most deprived Townsend fifth compared with the least deprived were 0.72 (95% confidence interval 0.62 to 0.82) and 0.76 (0.68 to 0.85), respectively. No socioeconomic gradient was evident in referral for postmenopausal bleeding.ConclusionsInequalities in referral associated with socioeconomic circumstances were more likely to occur in the absence of both explicit guidance and potentially life threatening conditions, whereas inequalities with age were evident for all conditions.

Project description:Background Antenatal care (ANC) plays an important role in preventing low birthweight (LBW). Whereas the government of Lao People’s Democratic Republic (Lao PDR) has committed to increasing the usage of ANC, little attention has been given to the early initiation of ANC. The present study assessed the influence of delayed and fewer ANC visits on LBW in the country. Methods This is a retrospective cohort study conducted at Salavan Provincial Hospital. Study participants were all pregnant women who gave birth at the hospital between 1 August 2016 and 31 July 31 2017. Data were collected from medical records. Logistic regression analyses were performed to quantify the relationship between ANC visits and LBW. We also investigated factors associated with inadequate ANC visits: first ANC visit after the first trimester or < 4 ANC visits. Results The mean birth weight was 2808.7 g [standard deviation: SD 455.6]. Among 1804 participants, 350 (19.4%) had babies with LBW, and 147 (8.2%) had inadequate ANC visits. In multivariate analyses, compared to participants with adequate ANC visits, those with ≥ 4 ANC visits and the first ANC visit after the second trimester, those with < 4 ANC visits, and those with no ANC visits had higher odds ratios (ORs) of LBW: 3.77 (95% confidence interval: CI = 1.66–8.57), 2.39 (95% CI = 1.18–4.83) and 2.22 (95% CI = 1.08–4.56), respectively. Younger maternal age (OR 1.42; 95% CI = 1.07–1.89), government subsidisation (OR 2.69; 95% CI = 1.97–3.68) and ethnic minority (OR 1.88; 95% CI = 1.50–2.34) were associated with increased risk of insufficient number of ANC visits after adjusting for covariates. Conclusions Frequent and early initiation of ANC was associated with a reduction in LBW in Lao PDR. Encouraging childbearing-aged women to receive sufficient ANC at proper timing may lead to a reduction in LBW and improvement in short- and long-term health outcomes of neonates. Special attention will be needed for ethnic minorities and women in lower socioeconomic classes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-023-05442-7.

Dataset Information

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

Background

Methods

Results

Interpretation

Publications

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

Similar Datasets

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