Importance There has been insufficient research on the patient harms and costs associated with po... more Importance There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population. Objective To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. Design, Setting, and Participants This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020. Main Outcomes and Measures For inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs),...
The preceding papers in this Series have outlined how underuse and overuse of health-care service... more The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective-ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
Supplemental Digital Content is available in the text. Background: The Risk Stratification Index ... more Supplemental Digital Content is available in the text. Background: The Risk Stratification Index (RSI) is superior to Hierarchical Conditions Categories (HCC) in patient-level regressions but has not been applied to assess hospital effects. Objective: The objective of this study was to measure the accuracy of RSI in modeling 30-day hospital mortality across all conditions using multilevel logistic regression. Subjects and Data Sources: A 100% sample of Medicare inpatient stays from 2009 to 2014, restricted to patients greater than 65 years of age in general hospitals, resulting in 64 million stays at 3504 hospitals. Research Design: We calculated RSI and HCC scores for patient stays using multilevel logistic regression in 3 populations: all inpatients, surgical, and nonsurgical. Correlations of risk-standardized mortality rates with rates of specific case types assessed case-mix balance. Patient stay volume was included to assess smaller hospitals. Results: We found a negligible cor...
This work compares deaths for confirmed COVID-19 cases in China to eight other countries, Italy, ... more This work compares deaths for confirmed COVID-19 cases in China to eight other countries, Italy, Spain, France, USA, UK, Germany, Netherlands and South Korea. After implementing varying intensities and timing of social distancing measures, several appear to be converging onto the decline in the daily growth rate of deaths, or relative second derivative of total deaths, seen in China after the implementation an aggressive social distancing policy. By calculating future trajectories in these countries based on the observed Chinese fatality statistics, an estimate of the total deaths and maximum daily death rates over a defined period of time is made. Our lower bound estimate for the United Kingdom based on the real data approximates the lower bound estimate of the recent modelling study of Ferguson et al. [1]. These results suggest there may be a threshold of effective public health intervention. Our method of viewing the data may be helpful in monitoring the course of the epidemic, j...
With the aim of better understanding what the public (as opposed to "patients")... more With the aim of better understanding what the public (as opposed to "patients") wants from health care, this study asked people on the street, "What does the right health care mean to you?" Responses ranged from "Caring about me more than just in the appointment" to "That everyone should see exactly what medical treatment costs." A qualitative analysis revealed that all responses fell into 2 overarching categories: health care at the interpersonal level and health care at the system level. Approximately 66.7% of responses included system-level factors, whereas 59% of responses included interpersonal-level factors. We conclude that the public is cognizant of and concerned about issues that also concern patients and others working to improve health care and, thus, should be engaged in the process to design care in a way that meets their needs and preferences before they become ill or interact with the delivery system.
Underuse-the failure to use effective and affordable medical interventions-is common and responsi... more Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.
The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting... more The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.
Overuse, which is defined as the provision of medical services that are more likely to cause harm... more Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
Importance There has been insufficient research on the patient harms and costs associated with po... more Importance There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population. Objective To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. Design, Setting, and Participants This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020. Main Outcomes and Measures For inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs),...
The preceding papers in this Series have outlined how underuse and overuse of health-care service... more The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective-ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
Supplemental Digital Content is available in the text. Background: The Risk Stratification Index ... more Supplemental Digital Content is available in the text. Background: The Risk Stratification Index (RSI) is superior to Hierarchical Conditions Categories (HCC) in patient-level regressions but has not been applied to assess hospital effects. Objective: The objective of this study was to measure the accuracy of RSI in modeling 30-day hospital mortality across all conditions using multilevel logistic regression. Subjects and Data Sources: A 100% sample of Medicare inpatient stays from 2009 to 2014, restricted to patients greater than 65 years of age in general hospitals, resulting in 64 million stays at 3504 hospitals. Research Design: We calculated RSI and HCC scores for patient stays using multilevel logistic regression in 3 populations: all inpatients, surgical, and nonsurgical. Correlations of risk-standardized mortality rates with rates of specific case types assessed case-mix balance. Patient stay volume was included to assess smaller hospitals. Results: We found a negligible cor...
This work compares deaths for confirmed COVID-19 cases in China to eight other countries, Italy, ... more This work compares deaths for confirmed COVID-19 cases in China to eight other countries, Italy, Spain, France, USA, UK, Germany, Netherlands and South Korea. After implementing varying intensities and timing of social distancing measures, several appear to be converging onto the decline in the daily growth rate of deaths, or relative second derivative of total deaths, seen in China after the implementation an aggressive social distancing policy. By calculating future trajectories in these countries based on the observed Chinese fatality statistics, an estimate of the total deaths and maximum daily death rates over a defined period of time is made. Our lower bound estimate for the United Kingdom based on the real data approximates the lower bound estimate of the recent modelling study of Ferguson et al. [1]. These results suggest there may be a threshold of effective public health intervention. Our method of viewing the data may be helpful in monitoring the course of the epidemic, j...
With the aim of better understanding what the public (as opposed to "patients")... more With the aim of better understanding what the public (as opposed to "patients") wants from health care, this study asked people on the street, "What does the right health care mean to you?" Responses ranged from "Caring about me more than just in the appointment" to "That everyone should see exactly what medical treatment costs." A qualitative analysis revealed that all responses fell into 2 overarching categories: health care at the interpersonal level and health care at the system level. Approximately 66.7% of responses included system-level factors, whereas 59% of responses included interpersonal-level factors. We conclude that the public is cognizant of and concerned about issues that also concern patients and others working to improve health care and, thus, should be engaged in the process to design care in a way that meets their needs and preferences before they become ill or interact with the delivery system.
Underuse-the failure to use effective and affordable medical interventions-is common and responsi... more Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.
The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting... more The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.
Overuse, which is defined as the provision of medical services that are more likely to cause harm... more Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Papers by Vikas Saini