Low-Value Care at the Actionable Level of Individual Health Systems.
Low-Value Care at the Actionable Level of Individual Health Systems.
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DOI：
10.1001/jamainternmed.2021.5531
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发表时间：
2021-11-01
影响因子：
39
通讯作者：
Colla CH
中科院分区：
文献类型：
--
作者：
Ganguli I;Morden NE;Yang CW;Crawford M;Colla CH
低价值护理的使用在不同卫生系统中有何不同？这项队列研究测量并报告了 556 个卫生系统对 41 项个人低价值服务的使用情况以及 28 项服务的综合测量情况，为全美总共 11637763 名医疗保险受益人提供服务。提供低价值护理的系统差异很大；那些初级保健医生比例较小、没有大型教学医院、为非白人患者比例较大、总部位于南部和西部以及医疗保健支出较高的地区提供更多低价值护理的机构。这项研究表明，基于索赔的定义可用于衡量系统内的低价值护理，提供精细的、可操作的反馈，以提高医疗保健质量和可负担性。尽管几十年来一直致力于衡量和减少低价值医疗保健，但低价值医疗保健在美国仍然普遍存在。这些努力收效甚微，部分原因是低价值护理的衡量在很大程度上仅限于国家或地区层面，限制了可操作性。衡量和报告个人卫生系统之间和内部的低价值护理使用情况，并使用医疗保险管理数据确定与较高使用量相关的系统特征。这项针对卫生系统归属的医疗保险受益人的回顾性队列研究是在美国卫生系统医疗保健研究和质量纲要中的 556 个卫生系统中进行的，其中包括年龄超过 65 岁、在 2016 年或 2017 年连续参加医疗保险 A 和 B 部分至少 12 个月、并且有资格获得特定低价值服务的系统归属受益人。统计分析于2021年1月26日至7月15日进行。使用41项个人低价值服务以及系统归属受益人中28项最常见服务的综合衡量标准，并根据与平均值的距离进行标准化。措施基于 Milliman MedInsight 健康废物计算器和已发布的基于索赔的定义。在为总共 11 637 763 名受益人提供服务的 556 个卫生系统中，41 项低价值服务中每一项的平均 (SD) 使用范围为合格受益人的 0% (0.01%) 到 28% (4%)。最常见的低价值服务是术前实验室检测（平均 [SD] 发生率，28% [4%] 合格受益人）、70 岁以上男性的前列腺特异性抗原检测（平均 [SD] 发生率，27% [8%]），以及痴呆患者使用抗精神病药物（平均 [SD] 发生率，24% [8%]）。在多变量分析中，与更多使用低价值护理相关的卫生系统特征是初级保健医生比例较小（调整后的综合评分，对于初级保健医生比例低于中位数的系统，为 0.15 [95% CI，0.04-0.26]，而对于初级保健医生比例高于中位数的系统，调整后的综合评分为 -0.16 [95% CI，–0.27 至 –0.05]； P < .001），没有主要教学医院（调整后综合，0.10 [95% CI，–0.01 至 0.20]，没有教学医院 vs -0.18 [95% CI，–0.34 至 –0.02] 有教学医院；P = .01），非白人患者比例较大（调整后综合，0.15 [95% CI，对于非白人受益人 >20% 的系统，为 –0.02 至 0.32；对于非白人受益人 ≤20% 的系统，为 -0.06 [95% CI，–0.16 至 0.03]；P = .04），总部位于南部或西部（调整后的综合结果，0.28 [95% CI，0.14-0.43]）南部地区为 0.22 [95% CI, 0.02-0.42]，而东北部地区为 -0.09 [95% CI, –0.26 至 0.08]，中西部地区为 -0.44 [95% CI, –0.60 至 –0.28]；P < .001），以及医疗保健支出较多的地区（调整后的综合数据，支出中位数水平以上的地区为 0.23 [95% CI, 0.11-0.35]，支出中位数水平以下的地区为 -0.24 [95% CI, –0.36 至 –0.12]（P < .001）。这项大型队列研究的结果表明，对特定低价值服务进行系统级测量和报告是可行的，可以进行跨系统比较，并揭示广泛的低价值护理用途。这项队列研究使用医疗保险数据来衡量和报告个人卫生系统之间和内部的低价值护理使用情况，并确定与较高使用量相关的系统特征。
How does low-value care use vary across health systems? This cohort study measured and reported the use of 41 individual low-value services and a composite measure of 28 services for 556 health systems serving a total of 11 637 763 Medicare beneficiaries across the US. Systems varied widely in the provision of low-value care; those with a smaller proportion of primary care physicians, without a major teaching hospital, serving a larger proportion of non-White patients, headquartered in the South and West, and serving areas with higher health care spending delivered more low-value care. This study suggests that claims-based definitions can be used to measure low-value care within systems, providing granular, actionable feedback to promote health care quality and affordability. Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability. To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. This retrospective cohort study of health system–attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. Use of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions. Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs −0.16 [95% CI, –0.27 to –0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, –0.01 to 0.20] without a teaching hospital vs −0.18 [95% CI, –0.34 to –0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, –0.02 to 0.32] for systems with >20% of non-White beneficiaries vs −0.06 [95% CI, –0.16 to 0.03] for systems with ≤20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with −0.09 [95% CI, –0.26 to 0.08] for the Northeast and −0.44 [95% CI, –0.60 to –0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs −0.24 [95% CI, –0.36 to –0.12] for areas below the median level of spending; P < .001). The findings of this large cohort study suggest that system-level measurement and reporting of specific low-value services is feasible, enables cross-system comparisons, and reveals a broad range of low-value care use. This cohort study uses Medicare data to measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use.
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影响因子：
7.2
作者：
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通讯作者：
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