Low-value Tests Research Articles

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

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. 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. 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. 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.

Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis

IntroductionOveruse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system...

PoCUS: Just because we can doesn't mean we should.

PoCUS: Just because we can doesn't mean we should.

Low-value prostate cancer screening among young men with private insurance.

240 Background: Debate remains about the value of Prostate-specific antigen (PSA) based prostate cancer screening among men aged 55-69 (USPSTF Grade C). However, no professional society or guideline recommends PSA based prostate cancer screening in men younger than age 40. This study aims to understand the risk of PSA testing exposure in young men, and we hypothesize that substantial low-value testing occurs in this population. Methods: We performed a retrospective analysis of claims data from the MarketScan database to identify men aged 18 to 39 without prostate cancer who received a PSA test from 2008 to 2017. For the primary analysis, men were required to be continuously in the database for least 5 years. Age groups were stratified to include: men less than 25, 25-29, 30-34, and 35-39 years. Secondary analysis did not limit subjects to those with 5 years of continuous data and explored the association of Charlson Comorbidity Index (CCI), lower urinary tract symptoms, erectile dysfunction, depression/anxiety, prostate cancer screening, infertility, and hypogonadism with PSA testing in young men. We used logistic regression to determine which of the factors were associated with PSA testing in young men. Results: We identified claims for 40,164,773 adult men who met study criteria. Of these men, 3,230,748 were continuously in the Marketscan database for at least 5 years. The cumulative risk for receiving a PSA over 5 years for men under 40 is 2.5%. Stratified by age, men aged 35-39 are at highest risk (Table). Logistic multivariable regression showed that, relative to all men between 18 and 40, patients in this age group who received a PSA were more likely to be diagnosed with hypogonadism (OR 20.55, 95% CI 20.39-20.71) or lower urinary tract symptoms (OR 9.34, 95% CI 9.26-9.41). Higher CCIs appeared to correlate with a decreased rate of PSA testing. This population was not significantly more likely to be diagnosed with infertility, depression, or anxiety. Conclusions: PSA screening for men under 40 is not uncommon, especially when associated with concomitant genitourinary symptoms. At a population level, this represents substantial low-value testing. Interventions aimed at clarifying the relationship between common urologic conditions and prostate cancer, the extremely low incidence of prostate cancer in this age group, and the lack of guidelines supporting this practice may help decrease low-value PSA testing. Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number K08CA234431. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.[Table: see text]

Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration

Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. To understand rates and factors associated with outpatient low-value cancer screenings. This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. Receipt of cancer screening test. Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.

Deimplementation in Bronchiolitis: How Low Can We Go?

Achievable benchmarks of care (ABCs) provide a goal for deimplementation initiatives by defining attainable performance. ABCs have previously been defined for bronchiolitis.1 It is unclear, however, whether these previously defined ABCs have an expiration date. Are ABCs a static benchmark, or do they require modification over time?Bronchiolitis is an ideal target for deimplementation initiatives to reduce the use of low-value tests and treatments because no interventions improve its course.2,3 In this issue of Pediatrics, Ralston et al4 examine the evolution of ABCs for bronchiolitis over time using data from the Pediatric Health Information System (PHIS). Ralston et al4 calculated both ABCs and performance gaps for 6 nonrecommended tests and treatments for 2 cohorts of patients diagnosed with bronchiolitis: those evaluated in and discharged from the emergency department (ED) and those admitted as either inpatient or observation status. Children evaluated between 2006 and 2019 were included and divided into 2 time periods separated by the updated 2014 American Academy of Pediatrics bronchiolitis guideline. In the ED cohort, they found improvements in ABCs for chest radiography and bronchodilator use, whereas, in the admitted cohort, they found improvements in ABCs for chest radiography, viral testing, and antibiotic use. The authors also found performance gaps, defined as the difference between the benchmark and median performance, to be largest for viral testing and bronchodilator use in both cohorts. The large performance gaps demonstrate that much of the cohort lags far behind optimal performers for these two measures.The results of Ralston et al,4 although important, suffer from limitations in their approach and those inherent in their use of administrative data. The PHIS database represents only 20% of pediatric hospitalizations in the United States and is limited to hospitals with the resources to participate. It is not clear whether community hospitals warrant different ABCs. Additionally, given the lack of clinical details available through the PHIS, the authors could not distinguish whether testing at a referring institution affected disposition or, for patients requiring hospitalization, whether a particular test or treatment performed early in the visit was performed by the ED or inpatient team. With the amount of evidence showing no benefit of additional testing and treatments for bronchiolitis,2 assessing the rationale behind a particular intervention and not just improvement efforts should be considered but cannot be with administrative data alone. For example, an imaging study performed at presentation versus with an unexpected clinical deterioration requires a different improvement target. The PHIS database includes the timing of tests and treatments by day. The study would have been strengthened if the authors had differentiated between tests obtained and treatments provided early versus late in the hospitalization.When it comes to bronchiolitis, the initiatives to address its management, most of which fall under the category of medical overuse, are too numerous to count.5 From the American Academy of Pediatrics bronchiolitis guideline2 to the American Board of Internal Medicine’s Choosing Wisely campaign6 to the multitude of local and national quality improvement initiatives,3,5 it is disappointing that ongoing performance gaps exist. Part of the challenge comes from the difficulty inherent to deimplementation work7 and the variability in the clinical course of bronchiolitis. As clinicians, it can be difficult to minimize interventions because providing supportive care is often perceived as “doing nothing,” which runs contrary to our desire to help.8,9 Additionally, simplification of quality improvement initiatives for bronchiolitis neglects the consideration of many other conditions presenting with respiratory distress in an infant (eg, myocarditis or sepsis) that often require diagnostic testing to differentiate them from bronchiolitis. One consideration to address such diagnostic challenges is to systematically approach the communication of contingency planning around diagnostic uncertainty so that providers can decide the ideal time, if any, to rule out a nonbronchiolitis etiology via testing.Sharp declines in hospitalizations for bronchiolitis and other childhood respiratory illnesses have occurred during the coronavirus disease 2019 pandemic.10 Clinicians, including trainees, have seen scant cases of respiratory illness during their core rotations, and although the decline in hospitalizations for viral respiratory infections is certainly good for children and their families, the return of bronchiolitis is likely to result in a steep learning curve. This curve includes what tests and treatments are considered low value (all of them) because their unfamiliarity with the clinical findings and management of bronchiolitis and its differentiation from other similarly presenting conditions may lead to increased use of nonrecommended tests and treatments.Regardless of what the postpandemic future of bronchiolitis holds, Ralston et al4 found improvements in ABCs for not ordering several nonrecommended tests over the last decade. Despite this encouraging improvement, performance gaps remain, and the study by Ralston et al4 offers suggestions for further closing that gap. Perhaps more importantly, in their work, Ralston et al4 highlight the need to revisit ABCs over time as baseline performance improves.

The role of electronic versus written order sets in inappropriate laboratory testing among hospitalized medical patients

ImportanceReducing inappropriate blood tests has been highlighted by Choosing Wisely as a key area of focus. Computer physician order entry is one modifiable contributor, but little is known about how computer ordering compares to paper methods when it comes to low-value laboratory testing. ObjectiveTo determine which method of order entry is associated with a greater amount of appropriate lab testing. Furthermore, to identify ordering patterns for more targeted interventions in future. DesignWe conducted a retrospective observational cohort study of inpatients discharged at two hospitals (one site uses paper order sets, while the other uses electronic order sets). SettingGeneral internal medicine wards at two Canadian teaching hospitals. ParticipantsAt site 1 (electronic orders), all general internal medicine discharges from May 2015 and February 2016. At site 2 (paper orders), all general internal medicine discharges from April 15, 2015 to May 26, 2015. Main Outcome(s) and Measure(s)Main outcome was the percentage of inpatient discharges at each site with orders for daily laboratory tests for three days on admission. Secondary measures include proportion of tests with appropriate indications and rates of discontinuation of daily laboratory tests. ResultsWe reviewed 395 discharges with a mean patient age of 69.5 ± 18.9 years and mean length of stay of 12.1 days. Daily laboratory tests were more common with paper orders (site 2) compared to electronic order sets (site 1) for complete blood count (CBC) (90.8% vs. 68.5%, p < 0.001), electrolytes (93.8% vs 71.5%, p < 0.001), and creatinine (93.8% vs 70.0%, p < 0.001) testing. However, paper orders for daily laboratory tests were more often appropriate, both in CBC (76.3% vs. 38.9%, p < 0.001) and electrolyte/creatinine (80.3% vs 44.2%, p < 0.001) testing. Discontinuation of daily labs occurred more often with paper orders (35.4% vs. 6.7%, p < 0.001). Conclusions and RelevanceCompared to written orders, daily laboratory testing using electronic ordering was associated with higher rates of inappropriate indications and lower rates of discontinuation. Our results support interventions aimed at ensuring electronic order sets incorporate appropriate indications and a mechanism for discontinuation of daily lab orders. Further studies aimed at understanding how the process of completing paper or electronic orders influence appropriateness of daily laboratory orders are needed to further minimize inappropriate testing.

Decision fatigue in low-value prostate cancer screening.

Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue. Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00am and 4:59pm, with noon omitted. Urologists were examined separately from other clinicians. In 1,581,826 outpatient appointments identified, the median patient age was 54years (interquartile range, 37-66years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00am (reference group). PSA testing declined through 11:00am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00pm (P<.001). Low-value testing was overall less likely (P<.001) and followed a similar trend, declining steadily from 8:00am (OR, 0.48; 95% CI, 0.42-0.56) through 4:00pm (P<.001; OR, 0.23; 95% CI, 0.18-0.30). Testing patterns in urologists were noticeably different. Among most clinicians, outpatient PSA testing behaviors appear to be consistent with decision fatigue. These findings establish decision fatigue as a promising, actionable target for reducing wasteful and low-value practices in routine urologic care. Decision fatigue causes poorer choices to be made with repetitive decision making. This study used medical records to investigate whether decision fatigue influenced clinicians' likelihood of ordering a low-value screening test (prostate-specific antigen [PSA]) for prostate cancer. In more than 1.5 million outpatient appointments by adult men without prostate cancer, the chances of both appropriate and low-value PSA testing declined as the clinic day progressed, with a larger decline for appropriate testing. Testing patterns in urologists were different from those reported by other clinicians. The authors conclude that outpatient PSA testing behaviors appear to be consistent with decision fatigue among most clinicians, and interventions may reduce wasteful testing and downstream patient harms.

Patterns and Determinants of Low-Value Preoperative Testing in Michigan

This cohort study examines use of preoperative testing before 3 low-risk ambulatory surgical procedures across diverse practice settings in Michigan.

Using Health Care Resources Wisely After the COVID-19 Pandemic: Recommendations to Reduce Low-Value Care

&#x0D; Low-value tests, treatments, and procedures are an important health care quality problem in Canada and across the world because they provide little clinical benefit, may be harmful for patients, and waste limited resources.&#x0D; Due to the COVID-19 pandemic, health care systems face increased challenges of limited resources, reduced capacity, and a growing backlog of surgeries and other procedures. The pandemic has compelled health care professionals to make challenging decisions to prioritize health care services while coping with increased demand.&#x0D; As Canada emerges from the pandemic and health care systems rebuild and begin to address the backlog of delayed or cancelled services, there is an imperative to introduce lasting changes to reduce low-value care and ensure high-quality care is available to everyone.&#x0D; To help inform efforts for using health care resources wisely and to support decision-making, CADTH and Choosing Wisely Canada convened a 10-member multi-disciplinary panel of clinicians, patient representatives, and health policy experts to review areas of low-value care that can be reduced or limited. This panel reviewed, deliberated, and prioritized 19 recommendations of the more than 400 Choosing Wisely Canada recommendations, the implementation of which can help ensure high-value care after the pandemic.&#x0D; &#x0D; Examples of the 19 recommendations include:&#x0D; &#x0D; Avoiding unnecessary transfers for patients in long-term care to hospitals unless there is an urgent medical need.&#x0D; Limiting blood tests and imaging unless required to answer a specific clinical question or guide treatment.&#x0D; Not transfusing red blood cells for hemodynamically stable patients in the intensive care unit.&#x0D; Not delaying palliative care for patients with serious illness because they are pursuing disease-directed treatment.&#x0D; &#x0D; Moreover, the panel’s discussion highlighted how the selected recommendations can advance key priorities, including improving health equity and access to care, appropriately using limited resources, emphasizing patient-focused care, and addressing challenges the pandemic has presented for long-term care.

Using Health Care Resources Wisely During and Following the COVID-19 Pandemic

In the pandemic era, the Choosing Wisely Canada campaign has taken on new meanings and urgency. There are drops in utilization for necessary health care services and procedures during the pandemic; however, there is growing literature suggesting that some decreases in utilization have been driven by declines in low-value tests and treatments. As resources have shifted to pandemic priorities and essential care needs, these unnecessary tests and treatments have also declined. Choosing Wisely Canada and CADTH are proactively working to highlight key recommendations from evidence-based lists of recommendations to inform priorities for rebuilding, which include avoiding low-value care. Rebuilding the health care system in the post-pandemic era needs to take into account a diversity of perspectives on how to prioritize high-value care for those who need it most, including clinician, patient, and policy expert perspectives.

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration

The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

Test Volume Ratio Benchmarking to Identify and Reduce Low-Value Laboratory Utilization.

We analyzed test volume data to identify low-value test utilization. We subsequently tracked the efficacy of interventions to improve test utilization by decreasing low-value testing. Test volume data for analytes included in the Choosing Wisely guidelines were analyzed to identify population outliers. Outliers were defined by test volume ratios of either analyte to sodium or paired analytes to correct for variation in patient volumes at each site. Interventions to improve test utilization were targeted to outlier sites. Relative efficacy in reducing low-value testing was tracked at those sites. After appropriate data cleaning, test volume ratios for 17 analytes paired with sodium and 8 pairs of analytes were acquired from 108 national sites. A site with abnormally high Clostridium difficile/sodium ratio was selected for intervention, leading to a 71% decrease in C difficile tests. Two different interventions to decrease creatine kinase MB isoform (CKMB) testing were performed at two unique sites with abnormally high CKMB/troponin ratios. These interventions decreased CKMB by 11% and 98% at the different sites, showing the efficacy of the different kinds of interventions. Test volume ratio analysis and benchmarking enable identification of low-value test utilization.

Prostate-specific antigen testing among young men: an opportunity to improve value.

IntroductionProstate cancer screening using prostate‐specific antigen (PSA) testing remains widespread. The prevalence of PSA testing in young men is unknown and may be an appropriate target for improving health care by decreasing low‐value testing in this age group. The purpose of this study was to determine PSA testing rates in men younger than current guidelines support.Materials and MethodsHealth Informational National Trends Surveys (HINTS) from 2011 to 2014 and 2017 were analyzed to establish the prevalence of PSA testing in young men and to evaluate the differences in testing rates based on race.ResultsThe combined survey data included 5178 men, with 2393 reporting previous PSA screening. Of men ages 18–39, 7% recalled receipt of PSA testing. Twenty‐two percent of men between the ages of 40 and 44 had been tested. Among men under age 40, PSA testing was more common among black men (14%) compared to white men (7%), Hispanics (6%), and men of Asian descent (8%). Logistic regression modeling demonstrates that black men under the age of 40 were more likely to undergo PSA testing than other racial or ethnic groups (odds ratio 2.14; 95% CI 1.17, 3.93).ConclusionsCurrent guidelines do not recommend routine PSA testing in average‐risk men under the age of 40. This study found that a significant number of young men are exposed to testing, with the greatest risk among black men. This suggests that there is an opportunity to improve the value of PSA testing by decreasing testing in young men.

Patterns of Left-Ventricular Function Assessment in Patients With Acute Coronary Syndromes

BackgroundIn patients with acute coronary syndromes (ACS), guidelines recommend the assessment of left-ventricular ejection fraction (LVEF). Many patients with ACS undergo multiple assessments of LVEF, the clinical value of which is unknown. MethodsPatients with ACS undergoing cardiac catheterization between 2012 and 2016 were evaluated and assessments of LV function identified. To evaluate changes in LVEF over time, available echocardiograms were reviewed in a subsample of patients with LVEF data available (n = 3221). Patients with ACS were classified into 3 groups: group 1 (LVEF > 50%), group 2 (LVEF 35% to 50%), and group 3 (LVEF < 35%). ResultsOur cohort consisted of 8327 patients with ACS (76% men), presenting with a mean age of 62.4 ± 12.4 years. At index presentation, 66% of patients had an LVEF > 50%, 27% had an LVEF between 35% and 50%, and 7% had severely reduced LVEF of < 35%. More than half of the cohort (n = 4600) had follow-up assessment of LV function, performed over an average of 2.71 ± 1.31 years. In the subsample of 3221 patients, only 1.1% of those in group 1, and 5.1% of those in group 2, deteriorated to an LVEF < 35%. ConclusionsPatients with ACS often undergo multiple assessments of LV function. Those with initially preserved EF rarely demonstrate a decline in EF to < 35%. A reduction in low-value cardiac tests may be an important first step in improving the quality of care for patients with ACS.

Strategies to reduce the use of low-value medical tests in primary care: a systematic review.

It is recognised that medical tests are overused in primary care; however, it is unclear how best to reduce their use. To identify which strategies are effective in reducing the use of low-value medical tests in primary care settings. Systematic review. The databases MEDLINE, EMBASE, and Rx for Change were searched (January 1990 to November 2019) for randomised controlled trials (RCTs) that evaluated strategies to reduce the use of low-value medical tests in primary care settings. Two reviewers selected eligible RCTs, extracted data, and assessed their risk of bias. Of the 16 RCTs included in the review, 11 reported a statistically significant reduction in the use of low-value medical tests. The median of the differences between the relative reductions in the intervention and control arms was 17% (interquartile range 12% to 24%). Strategies using reminders or audit/feedback showed larger reduction than those without these components (22% versus 14%, and 22% versus 13%, respectively) and patient-targeted strategies showed larger reductions than those not targeted at patients (51% versus 17%). Very few studies investigated the sustainability of the effect, adverse events, cost-effectiveness, or patient-reported outcomes related to reducing the use of low-value tests. This review indicates that it is possible to reduce the use of low-value medical tests in primary care, especially by using multiple components including reminders, audit/feedback, and patient-targeted interventions. To implement these strategies widely in primary care settings, more research is needed not only to investigate their effectiveness, but also to examine adverse events, cost-effectiveness, and patient-reported outcomes.

IMPACT OF APPROPRIATE ECHOCARDIOGRAPHY USE ON UTILIZATION OF CARDIAC SERVICES AND OUTCOMES IN PATIENTS WITH HEART FAILURE OR CORONARY ARTERY DISEASE: A RETROSPECTIVE COHORT STUDY OF THE ECHO WISELY RANDOMIZED CONTROLLED TRIAL

Interventions aimed at reducing low-value care and testing may be effective in changing physician practice. While important, such interventions may also lead to unintended consequences. These include under- or over-utilization of ancillary testing or adverse clinical outcomes. Our objective was to determine the impact of an intervention aimed at reducing the proportion of rarely appropriate transthoracic echocardiography (TTE) on utilization of ancillary services and clinical outcomes for patients with a previous diagnosis of coronary artery disease (CAD) and/or congestive heart failure (HF).

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration

Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration. To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition. This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020. Continuous enrollment in Veterans Health Administration during fiscal year 2015. Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level. Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001). In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.

Delta Studies: Expanding the Concept of Deviance Studies to Design More Effective Improvement Interventions.

The effects of improvement (implementation and de-implementation) interventions are often modest. Although positive and negative deviance studies have been extensively used in improvement science and quality improvement efforts, conceptual and methodological innovations are needed to improve our ability to use information about variation in quality to design more effective interventions. We describe a novel mixed methods extension of the deviance study we term "delta studies." Delta studies seek to quantitatively identify sites that have recently changed from low performers to high performers, or vice versa, in order to qualitatively learn about active strategies that produced recent change, challenges change agents faced and how they overcame them, and where applicable, the causes of recent deterioration in performance-information intended to inform the design of improvement interventions for deployment in low performing sites. We provide examples of lessons learned from this method that may have been missed with traditional positive or negative deviance designs. Considerations for quantitatively identifying delta sites are described including which quality metrics to track, over what timeframe to observe change, how to account for reliability of observed change, consideration of patient volume and initial performance as implementation context factors, and how to define clinically meaningful change. Methods to adapt qualitative protocols by integrating quantitative information about change in performance are also presented. We provide sample data and R code that can be used to graphically display distributions of initial status, change, and volume that are essential to delta studies. Patients and facilities of the US Veterans Health Administration. As an example, we discuss what decisions we made regarding the delta study design considerations in a funded study of low-value preoperative testing. The method helped us find sites that had recently reduced the burden of low-value testing, and learn about the strategies they employed and challenges they faced. The delta study concept is a promising mixed methods innovation to efficiently and effectively identify improvement strategies and other factors that have actually produced change in real-world settings.

Trends in Low-Value Carotid Imaging in the Veterans Health Administration From 2007 to 2016

As part of the Choosing Wisely campaign, primary care, surgery, and neurology societies have identified carotid imaging ordered for screening, preoperative evaluation, and syncope as frequently low value. To determine the changes in overall and indication-specific rates of carotid imaging following Choosing Wisely recommendations. This serial cross-sectional study compared annual rates of carotid imaging before Choosing Wisely recommendations (ie, 2007 to 2012) and after (ie, 2013 to 2016) among adults receiving care in the Veterans Health Administration (VHA) national health system. Data analysis was performed from April 10, 2019, to November 27, 2019. Release of the Choosing Wisely recommendations. Annual rates of overall imaging, imaging ordered for stroke workup, imaging ordered for low-value indications (ie, screening owing to carotid bruit, preoperative evaluation, and syncope). Indications were identified using a text lexicon algorithm based on electronic health record review of a stratified random sample of 1000 free-text imaging orders. The subsequent performance of carotid procedures within 6 months after carotid imaging was assessed. Between 2007 and 2016, 809 071 carotid imaging examinations were identified (mean [SD] age of patients undergoing imaging, 69 [10] years; 776 632 [96%] men), of which 201 467 images (24.9%) were ordered for low-value indications (67 064 [8.2%] for carotid bruit, 25 032 [3.1%] for preoperative evaluation, and 109 400 [13.5%] for syncope), 257 369 (31.8%) for stroke workup, and 350 235 (43.3%) for other indications. Imaging for carotid bruits declined across the study period while there was no significant change in imaging for syncope or preoperative evaluation. Compared with the 6 years before, during the 4 years following Choosing Wisely recommendations, there was no change in the trend for syncope, a small decline in preoperative imaging (post-Choosing Wisely trend, -0.1 [95% CI, -0.1 to <-0.1] images per 10 000 veterans), and a continued but less steep decline in imaging for carotid bruits (post-Choosing Wisely trend, -0.3 [95% CI, -0.3 to -0.2] images per 10 000 veterans). During the study period, 17 689 carotid procedures were identified, of which 3232 (18.3%) were preceded by carotid imaging ordered for low-value indications. These findings suggest that Choosing Wisely recommendations were not associated with a meaningful change in low-value carotid imaging in a national integrated health system. To reduce low-value testing and utilization cascades, interventions targeting ordering clinicians are needed to augment the impact of public awareness campaigns.