Low-value Tests Research Articles

Patient and Physician Attitudes Toward Low-Value Diagnostic Tests.

Patient and Physician Attitudes Toward Low-Value Diagnostic Tests.

Comparing Care Given by Primary Care Physicians and Advanced Practice Clinicians

In a study of data from two national ambulatory care surveys, researchers evaluated quality of primary care by assessing use of low-value and guideline-discordant tests and treatments that were provided during care of patients who had one of three common outpatient conditions (upper respiratory infection, headache, or back …

Educational Intervention Reduces Utilization of Low-Value Testing in Cerebrovascular Inpatients: An Example of Rapidly Implementable Quality Improvement (P2.309)

Educational Intervention Reduces Utilization of Low-Value Testing in Cerebrovascular Inpatients: An Example of Rapidly Implementable Quality Improvement (P2.309)

The Choosing Wisely campaign - don't throw the baby out with the bathwater.

The goal of the Choosing Wisely campaign launched in 2009 by the American Board of Internal Medicine (ABIM) Foundation is to promote dialog on avoiding wasteful or unnecessary medical tests, treatments and procedures. Originating in 2009, the Choosing Wisely initiative involved three primary care specialties in a project aiming to develop "Top Five" lists, which were to be "specialty-specific enumerations of achievable practice changes to improve patient health through better treatment choices, reduced risks and reduced costs. The initiative soon became global, many specialty societies outside the US joining. Some time later, however, data collected demonstrated that a reduction had been achieved only for a few low-value tests and procedures, thus highlighting the need for a more evidence-based approach for identifying low-value practices and for evaluating the efficacy of this initiative over time.

Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial.

Low-value diagnostic tests have been included on primary care specialty societies' "Choosing Wisely" Top Five lists. To evaluate the effectiveness of a standardized patient (SP)-based intervention designed to enhance primary care physician (PCP) patient-centeredness and skill in handling patient requests for low-value diagnostic tests. Randomized clinical trial of 61 general internal medicine or family medicine residents at 2 residency-affiliated primary care clinics at an academic medical center in California. Two simulated visits with SP instructors portraying patients requesting inappropriate spinal magnetic resonance imaging for low back pain or screening dual-energy x-ray absorptiometry. The SP instructors provided personalized feedback to residents regarding use of 6 patient-centered techniques to address patient concerns without ordering low-value tests. Control group physicians received SP visits without feedback and were emailed relevant clinical guidelines. The primary outcome was whether resident PCPs ordered SP-requested low-value tests during up to 3 unannounced SP clinic visits over 3 to 12 months follow-up, with patients requesting spinal magnetic resonance imaging, screening dual-energy x-ray absorptiometry, or headache neuroimaging. Secondary outcomes included PCP patient-centeredness and use of targeted techniques (both coded from visit audiorecordings), and SP satisfaction with the visit (0-10 scale). Of 61 randomized resident PCPs (31 control group and 30 intervention group), 59 had encounters with 155 SPs during follow-up. Compared with control PCPs, intervention PCPs had similar patient-centeredness (Measure of Patient-Centered Communication, 43.9 [95% CI, 42.0 to 45.7] vs 43.7 [95% CI, 41.8 to 45.6], adjusted mean difference, -0.2 [95% CI, -2.9 to 2.5]; P = .90) and used a similar number of targeted techniques (5.4 [95% CI, 4.9 to 5.8] vs 5.4 [95% CI, 4.9 to 5.8] on a 0-9 scale, adjusted mean difference, 0 [95% CI, -0.7 to 0.6]; P = .96). Residents ordered low-value tests in 41 SP encounters (26.5% [95% CI, 19.7%-34.1%]) with no significant difference in the odds of test ordering in intervention PCPs relative to control group PCPs (adjusted odds ratio, 1.07 [95% CI, 0.49-2.32]). Rates of test ordering among intervention and control PCPs were similar for all 3 SP cases. The SPs rated visit satisfaction higher among intervention than control PCPs (8.5 [95% CI, 8.1-8.8] vs 7.8 [95% CI, 7.5-8.2], adjusted mean difference, 0.6 [95% CI, 0.1-1.1]). An SP-based intervention did not improve the patient-centeredness of SP encounters, use of targeted interactional techniques, or rates of low-value test ordering, although SPs were more satisfied with intervention than control residents. clinicaltrials.gov Identifier: NCT01808664.

Coaching Does Not Prevent Low-Value Diagnostic Testing

Coaching Does Not Prevent Low-Value Diagnostic Testing

Do Written Interventions Discourage Inappropriate Screening

Reducing use of low-value screening tests (i.e., those that result in net harm or offer only a small possible benefit) requires effective interventions to change patient behavior. In this study, researchers evaluated four different ways to present evidence-based information to patients on risks and benefits of three such screening tests: prostate cancer screening in middle-aged men (age range, 50–69), …

Choosing Wisely in Emergency Medicine: A National Survey of Emergency Medicine Academic Chairs and Division Chiefs.

The Choosing Wisely campaign was launched in 2011 to promote stewardship of medical resources by encouraging patients and physicians to speak with each other regarding the appropriateness of common tests and procedures. Medical societies including the American College of Emergency Physicians (ACEP) have developed lists of potentially low-value practices for their members to address with patients. No research has described the awareness or attitudes of emergency physicians (EPs) regarding the Choosing Wisely campaign. The study objective was to assess these beliefs among leaders of academic departments of emergency medicine (EM). This was a Web-based survey of emergency department (ED) chairs and division chiefs at institutions with allopathic EM residency programs. The survey examined awareness of Choosing Wisely, anticipated effects of the program, and discussions of Choosing Wisely with patients and professional colleagues. Participants also identified factors they associated with the use of potentially low-value services in the ED. Questions and answer scales were refined using iterative pilot testing with EPs and health services researchers. Seventy-eight percent (105/134) of invited participants responded to the survey. Eighty percent of respondents were aware of Choosing Wisely. A majority of participants anticipate the program will decrease costs of care (72% of respondents) and use of ED diagnostic imaging (69%) but will have no effect on EP salaries (94%) or medical-legal risks (65%). Only 45% of chairs have ever addressed Choosing Wisely with patients, in contrast to 88 and 82% who have discussed it with faculty and residents, respectively. Consultant-requested tests were identified by 97% of residents as a potential contributor to low-value services in the ED. A substantial majority of academic EM leaders in our study were aware of Choosing Wisely, but only slightly more than half could recall any ACEP recommendations for the program. Respondents familiar with Choosing Wisely anticipated generally positive effects, but chairs reported only infrequently discussing Choosing Wisely with patients. Future research should identify potentially low-value tests requested by consultants and objectively measure the utility and cost of these tests among ED patient populations.

KUALITAS BUTIR SOAL UAS BAHASA INGGRIS UNTUK SISWA MTs DI SAMARINDA

This study is aimed at seeing the item quality of English test used for Leaving Exam at SMP Samarinda. Analysis is used to see item difficulty (p), discrimination (D), distracter effectiveness, validity, and reliability. The results of analysis show that of 45 items, 19 (42.2%) must be dropped due to the poor p and 17 (37.8%) receive the low D. Analysis of p and D reveal that of 45 items, only 5 (11.1%) items are applicable, 21 (46.7%) need revision, and 19 (42.2%) should be dropped. The distracters are also poor, as 25 (55.6%) items have very poor distracters. Validity testing under Product Moment formula achieved low value (0.346) and reliability testing under KR-21 shows fair value (0.650).

An Age-Adjusted D-dimer Threshold for Emergency Department Patients With Suspected Pulmonary Embolus: Accuracy and Clinical Implications

We determine the accuracy of an age-adjusted D-dimer threshold to detect pulmonary embolism in emergency department (ED) patients older than 50 years and describe current ED practices when evaluating possible pulmonary embolism. This was a retrospective study of ED encounters for suspected pulmonary embolism from 2008 to 2013. We used structured data to calculate the sensitivity, specificity, negative predictive value, and positive predictive value of different D-dimer thresholds. We describe the incidence of pulmonary embolism, the proportion of patients receiving imaging concordant with D-dimer levels, and the number of "missed" pulmonary embolisms. These findings were used to estimate patient outcomes based on different D-dimer thresholds. Among 31,094 encounters for suspected pulmonary embolism, there were 507 pulmonary embolism diagnoses. The age-adjusted D-dimer threshold was more specific (64% versus 54%) but less sensitive (93% versus 98%) than the standard threshold of 500 ng/dL; 11,999 imaging studies identified 507 pulmonary embolisms (4.2%); of these, 1,323 (10.6%) were performed with a D-dimer result below the standard threshold. Among patient encounters without imaging, 17.6% had D-dimer values above the threshold, including 5 missed pulmonary embolisms. Among patients who received imaging, 10.6% had a negative D-dimer result. Applying an age-adjusted D-dimer threshold to our sample would avert 2,924 low-value imaging tests while resulting in 26 additional cases of missed pulmonary embolism. An age-adjusted D-dimer limit has the potential to reduce chest imaging among older ED patients and is more accurate than a standard threshold of 500 ng/dL. Our findings support the adoption of an age-adjusted D-dimer cutoff in community EDs.

The problem with eliminating ‘low-value care’

‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist...

Shared decision-making: easy to evoke, challenging to implement.

Shared decision-making: easy to evoke, challenging to implement.

Choosing wisely: prevalence and correlates of low-value health care services in the United States.

Specialty societies in the United States identified low-value tests and procedures that contribute to waste and poor health care quality via implementation of the American Board of Internal Medicine Foundation's Choosing Wisely initiative. To develop claims-based algorithms, to use them to estimate the prevalence of select Choosing Wisely services and to examine the demographic, health and health care system correlates of low-value care at a regional level. Using Medicare data from 2006 to 2011, we created claims-based algorithms to measure the prevalence of 11 Choosing Wisely-identified low-value services and examined geographic variation across hospital referral regions (HRRs). We created a composite low-value care score for each HRR and used linear regression to identify regional characteristics associated with more intense use of low-value services. Fee-for-service Medicare beneficiaries over age 65. Prevalence of selected Choosing Wisely low-value services. The national average annual prevalence of the selected Choosing Wisely low-value services ranged from 1.2% (upper urinary tract imaging in men with benign prostatic hyperplasia) to 46.5% (preoperative cardiac testing for low-risk, non-cardiac procedures). Prevalence across HRRs varied significantly. Regional characteristics associated with higher use of low-value services included greater overall per capita spending, a higher specialist to primary care ratio and higher proportion of minority beneficiaries. Identifying and measuring low-value health services is a prerequisite for improving quality and eliminating waste. Our findings suggest that the delivery of wasteful and potentially harmful services may be a fruitful area for further research and policy intervention for HRRs with higher per-capita spending. These findings should inform action by physicians, health systems, policymakers, payers and consumer educators to improve the value of health care by targeting services and areas with greater use of potentially inappropriate care.

Measuring low-value care in Medicare.

Despite the importance of identifying and reducing wasteful health care use, few direct measures of overuse have been developed. Direct measures are appealing because they identify specific services to limit and can characterize low-value care even among the most efficient providers. To develop claims-based measures of low-value services, examine service use (and associated spending) detected by these measures in Medicare, and determine whether patterns of use are related across different types of low-value services. Drawing from evidence-based lists of services that provide minimal clinical benefit, we developed 26 claims-based measures of low-value services. Using 2009 claims for 1,360,908 Medicare beneficiaries, we assessed the proportion of beneficiaries receiving these services, mean per-beneficiary service use, and the proportion of total spending devoted to these services. We compared the amount of use and spending detected by versions of these measures with different sensitivity and specificity. We also estimated correlations between use of different services within geographic areas, adjusting for beneficiaries' sociodemographic and clinical characteristics. Use and spending detected by 26 measures of low-value services in 6 categories: low-value cancer screening, low-value diagnostic and preventive testing, low-value preoperative testing, low-value imaging, low-value cardiovascular testing and procedures, and other low-value surgical procedures. Services detected by more sensitive versions of measures affected 42% of beneficiaries and constituted 2.7% of overall annual spending. Services detected by more specific versions of measures affected 25% of beneficiaries and constituted 0.6% of overall spending. In adjusted analyses, low-value spending detected in geographic regions at the 5th percentile of the regional distribution of low-value spending ($227 per beneficiary) exceeded the difference in detected low-value spending between regions at the 5th and 95th percentiles ($189 per beneficiary). Adjusted regional use was positively correlated among 5 of 6 categories of low-value services (mean r for pairwise, between-category correlations, 0.33; range, 0.14-0.54; P ≤ .01). Services detected by a limited number of measures of low-value care constituted modest proportions of overall spending but affected substantial proportions of beneficiaries and may be reflective of overuse more broadly. Performance of claims-based measures in supporting targeted payment or coverage policies to reduce overuse may depend heavily on how the measures are defined.

"Choosing wisely" in an academic department of medicine.

The "Choosing Wisely" campaign seeks to reduce unnecessary care in the United States through self-published recommendations by professional societies. The research team sought to identify factors related to low-value care in the Department of Medicine at the University of California San Francisco, using a subset of clinical scenarios published by the American College of Physicians. The team further explored respondents' values on cost consciousness. A notable minority disagreed with the identified low-value tests. In 6 of 8 scenarios, faculty were more likely to rate the scenarios as representing low-value testing (P < .05). Level of training was the only predictor of attitudes toward unnecessary care after linear regression analysis (coefficient 3.14, P < .001). Increased postgraduate education about cost of care is recommended.

Patient demand for care: How much does this contribute to inappropriate tests and treatments?

6530 Background: There are many calls for physicians to provide more cost-effective care. Physicians sometimes claim that patients demand high cost or low value tests and treatments. How frequently...

How Should Top-Five Lists Be Developed?

Readers might wonder why the editors of JAMA Internal Medicine decided to publish “A Top-Five List for Emergency Medicine.” Some of our readers might practice emergency medicine (EM), and many provide “urgent” care. However, we decided to publish this article for another reason. We believe that “A Top-Five List for Emergency Medicine” from Schuur et al1 at Partners Healthcare demonstrates a solid methodological approach to developing a list of low-value tests, procedures, and treatments in response to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.Althoughmanyprofessional societies havepublished “top-five” lists,most havenot detailed the methods by which the list was created. In some cases, it is clear that the lists were developed without much input fromfrontlinepractitioners, usingaprocess thatwasnot transparent andwithout clear criteria for inclusionon the list. We hope the article by Schuur et al1 will stimulate other professional societies to adopt clear, transparentmethods for developingand revising top-five listswith substantial input from practicing clinicians. We would like to see a consensus develop around criteria for choosing items on top-five lists. To start this conversation, we suggest that there should be clear evidence that the tests and treatments on a top-five list cause potential harm or provide little benefit to patients, are frequentlymisused in clinical practice, aremeasureable, and are under the control of providers. At least 50 specialty societies have now developed topfive lists for Choosing Wisely, and about 10 more are expected to publish lists in the next fewmonths. This activity is gratifying, butwebelieve it is also time to consider next steps. An important next step is to develop ways to evaluate the effect of the top-five lists onhealth caredelivery andhealth care value. To collect data, it will be important to focus on highimpact activities that can be tracked using electronic databases. Although partnering with specialty societies has been successful, we also believe that another crucial next step is to include other health care providers in the Choosing Wisely campaign so that nurses and pharmacists, among others, are on the same page. The involvement of the American College of Emergency Physicians (ACEP) in theChoosingWiselycampaignbeganwith discussion and a passionate floor debate at the 2012 national ACEP Council meeting. Those in favor of joining the Choosing Wisely campaign believed that identifying 5 good costsaving ideaswouldbe easy and that itwouldbe anembarrassment if EM ended up conspicuously absent from the movement.Thoseagainstnotedthat theACEPalreadyhadconvenedaCost-effectivenessCareTaskForce toaddress thesame issue. This group also believed that other barriers to joining ChoosingWisely are unique to EM, including that emergency department patients are sicker on average thanpatients cared forby someother specialists, thatmalpractice ismoreof a concern, that EMphysiciansmust follow the EmergencyMedical Treatment and Active Labor Act that requires they treat and stabilize anyone with an emergency medical condition, and that reimbursement is alreadyunderattackby third-partypayers who regularly down-code and discount emergency patient care. Furthermore,manyof theexistingChoosingWisely campaign recommendations fromother specialties seemed to be aimedat theEMscopeof practice. Theoutcomeof a closely divided council floor vote that followed was that the ACEP Council recommended against joining the Choosing Wisely campaign. At that time, Dr Schuur and colleagues at Partners Healthcare decided to independently develop a top-five list for EM. After further reflection, the board of directors of ACEP reversed their initial stance and decided to join the Choosing Wisely campaign. They asked Dr Schuur to help lead this effort. They built on his work described in this issue as well as the work of the Cost-effectiveness Care Task Force to create the ACEP’s top-five list. The Task Force had already developed a survey of all ACEP members for “cost-saving measures,” and more than 200 individual suggestions were received. The results of this surveywere grouped intodomains, and an expert panel used amodified Delphi technique to prioritize the recommendations following methods similar to those used by Dr Schuur and colleagues at Partners Healthcare.Multiple roundsofvoting followedto identifyhighly rated strategies that offered cost reductions and benefit to patients and were highly actionable by practicing EM physicians. The development process had a high level of specialty awareness (a floor debate at thenationalmeeting and specialty-wide survey data) and transparency. The final step included a literature review to establish a solid evidence base that specifically sought to include available cost data. Scientific support was assembled by a subcommittee of the Cost-effectiveness Care Task Force for each of the EM proposals for the Choosing Wisely campaign. The strategies that received majority support of the expert subgroup were then forwarded to the ACEP board of directors, who selected the top 5 for submission to the American Board of Internal Medicine Foundation (http://www.choosingwisely Related article page 509 Opinion

Screening for ovarian cancer in BRCA1/BRCA2 mutations carriers

Worldwide screening for early detection of ovarian cancer in both, the general population and the group of women at high risk for ovarian cancer including BRCA genes mutations carriers, has proven to be ineffective. The recommended screening methods, including a pelvic examination, transvaginal ultrasound, and CA125 performed biannually continue to fail due to their relatively low sensitivity specificity and positive predictive value tests, as well as the fact that cancer is still detected in advanced stages (FIGO III/IV). However proteomic techniques and the ongoing search for more sensitive and specific biomarkers to increase effectiveness of screening tests for ovarian cancer bring new hope. We reviewed the current literature on screening for ovarian cancer in BRCA genes mutations carriers.

Use of electronic health record data to evaluate overuse of cervical cancer screening

National organizations historically focused on increasing use of effective services are now attempting to identify and discourage use of low-value services. Electronic health records (EHRs) could be used to measure use of low-value services, but few studies have examined this. The aim of the study was to: (1) determine if EHR data can be used to identify women eligible for an extended Pap testing interval; (2) determine the proportion of these women who received a Pap test sooner than recommended; and (3) assess the consequences of these low-value Pap tests. Electronic query of EHR data identified women aged 30-65 years old who were at low-risk of cervical cancer and therefore eligible for an extended Pap testing interval of 3 years (as per professional society guidelines). Manual chart review assessed query accuracy. The use of low-value Pap tests (ie, those performed sooner than recommended) was measured, and adverse consequences of low-value Pap tests (ie, colposcopies performed as a result of low-value Pap tests) were identified. Manual chart review confirmed query accuracy. Two-thirds (1120/1705) of low-risk women received a Pap test sooner than recommended, and 21 colposcopies were performed as a result of this low-value Pap testing. Secondary analysis of EHR data can accurately measure the use of low-value services such as Pap testing performed sooner than recommended in women at low risk of cervical cancer. Similar application of our methodology could facilitate efforts to simultaneously improve quality and decrease costs, maximizing value in the US healthcare system.