identifying systematic overuse in the medicare fee for service population

1

Identifying Systematic Overuse in the Medicare Fee for Service Population

Jodi B. Segal, MD, MPH,1,2 John FP Bridges, PhD,2 Hsien-yen Chang, PhD,2 Eva Chang, MPH,2

Najlla Nassery, MD,MPH, 1 Jonathan P. Weiner, DrPH,2 Kitty S. Chan, PhD2

1Johns Hopkins University School of Medicine, Department of Medicine; Johns Hopkins

2University Bloomberg School of Public Health, Department of Health Policy and Management

Corresponding Author:

Jodi Segal, MD, MPH

624 N. Broadway, Room 644

Baltimore, MD 21205

410-955-9866

FAX 410-955-0825

Abstract count – 352

Word count – 2977

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Context: Policies targeting regional variation in use of healthcare services might not improve costs and

outcomes, because regional variation may reflect underuse, overuse and, potentially, appropriate

variations in practices. A more appropriate alternative may be to target “systematic overuse” of

healthcare services; however, this requires a measure of overuse.

Objective: To identify a set of potentially overused procedures (POPs) that can be operationalized with

Medicare claims and to test whether aggregating these into a single measure of overuse is associated

with higher costs and poorer outcomes and how this measure of overuse relate to traditional measures

of regional variation in utilization.

Design: Observational study using 5% of Medicare claims from 2008 (Parts A and B)

Setting: Older patients in the U.S. receiving healthcare services in hospital or outpatient settings

Main Measure(s): We identified POPs from the literature. Each POP was assessed for relevance to the

Medicare population and feasibility for measurement with claims data. Algorithms to count the POPs

were developed and applied. We aggregated the operationalized POPs into a single indicator identifying

whether an individual was subjected to any POP during the calendar year, and summed these counts

across individuals within Hospital Referral Regions (HRR). With Spearman’s correlation, we assessed the

correlation of this regional measure, presumptively a measure of systematic overuse, with regional

measures of total costs, risk-adjusted mortality, 30-day mortality, and an aggregate of four procedures

commonly used indicators of variation in utilization.

3

Results: Of the 613 POPs identified, 35 were relevant to the Medicare population and could be

operationalized with claims and; 22 related to diagnostics, 7 to screening, and 6 to interventions. Among

1,451,142 Medicare beneficiaries, 28 % had at least one POP, and this rate varied across the HRRs (20.7-

44.3%). Systematic overuse was positively correlated with total payments (r=0.34, p<0.001) and was not

correlated with mortality (r=-0.087, p=0.13). This indicator is distinct from utilization with weak (and

negative) correlation between it and the aggregated four utilization indicators. (r=-0.13 p=0.022).

Conclusions: This study provides proof of principle that systematic overuse exists and negatively affects

costs and outcomes. Furthermore, this measure describes a pattern distinct from variation in utilization.

4

Spending on healthcare in the United States (U.S.) continues to exceed the growth in the overall

economy. Medicare spending is expected to continue to grow as the baby-boom generation becomes

eligible for federal healthcare coverage.[1] This unsustainable level of spending was a driving force for

the passage of the Patient Protection and Affordable Care Act of 2010. [2] With the provisions in this law

that encourage adoption of medical practices with proven effectiveness, spending might be curtailed.

However, this is unlikely without both a better understanding of the complex determinants of

healthcare spending and tools for tracking the impact of interventions to limit spending with limited

benefit.

An important contributor to the high costs and inefficiencies of the U.S. health care system is

overuse of health care services and products.[3-6] The Institute of Medicine recently suggested that

much of health care spending in the U.S. is wasteful and could be eliminated with negligible loss to

population health. [9] These included elimination of redundant testing, clinical process reengineering

with standardized care pathways to improve the efficiency of care delivery, and reduction in avoidable

emergency department visits, with duplicative and unnecessary drugs and medical services. A recent

campaign by a consortium of professional societies , the “Choosing Wisely campaign, seeks to reduce

the use services that these organizations have deemed to be of low value”.[8]

Overuse of resources may be considered the mirror-image of the traditional quality of care

paradigm, which has largely focused on procedural omissions where necessary care is not delivered and

patients can be harmed from the lack of a service (like vaccination or aspirin). In contrast, health service

overuse is primarily a matter of commission where health care services are provided without sufficient

likelihood of benefit to the patient.

Overuse of healthcare services has been defined as a service used in the absence of a clear

medical basis for its use, when the risk of harm exceeds its likely benefit; [10] or more expansively, when

the added costs do not provide proportional benefits.[11] We define benefits to be those experienced

5

by an individual or a community, such as reduced death rates or improved functioning, and costs to be

the resultant morbidity or mortality associated with use of the interventions, as well as monetary and

opportunity losses experienced at an individual or societal level.[12]

To advance the identification and measurement of overuse, we aimed to identify a set of

procedures that we have termed “potentially overused procedures (POPs)” that can be operationalized

in Medicare Parts A and B claims, and to test whether the use of this set of procedures, in aggregate, is

positively correlated with regional costs and not correlated with regional clinical benefits. We propose

that there may be procedures which are bellwethers for tracking systematic overuse within a region or

health system. Further, we aimed to demonstrate that regional variation in systematic overuse is

distinct from more general variation in utilization (which is not specified as overuse or underuse of

resources).

METHODS

To generate and test an indicator of overuse, we: 1) identified POPs, 2) selected data with which to test

the indicator; 3) operationalized select POPs in this data; 4) aggregated the POPs into a single

standardized and risk-adjusted indicator for each U.S. Hospital Referral Region (HRR), 5) tested the

correlation of the indicator with Medicare payments and with risk-adjusted death rate and 30-day death

rate, across HRRs; 6) tested correlation of the indicator with an aggregate measure of overall utilization;

and 7) plotted results. Our study protocol was approved by the Institutional Review Board from the

Johns Hopkins Bloomberg School of Public Health.

Identification of Potentially Overused Procedures

We identified key national organizations, including professional societies and consumer groups, with

interests in quality improvement or cost-containment. We reviewed publications describing medical

6

procedures considered to be overused by these organizations. We extracted from these articles lists of

procedures deemed as overused, which we termed “potentially overused procedures”. We made no

attempt to review the process by which these procedures were designated as overused. We classified

the procedures as to whether they could be operationalized for measurement with only administrative

claims data. For example, we did not further operationalize overused procedures requiring

symptomatology or clinical information not readily available in claims data. We also excluded measures

requiring information about a pharmacy dispensed medication, for this stage of our effort did not have

access to pharmacy claims. Finally, given that it was our intent to test this process using Medicare data,

the procedure needed to be relevant to the care of older people.

Data

We acquired a 5-percent national sample of fee-for-service patients insured by Medicare in 2008. We

used data from the MedPar, Carrier, and Outpatient files. We required that all included individuals had

12 months of complete enrollment in Medicare Part A and Medicare Part B or death during 2008, were

over the age of 65 years, and were never enrolled in a Medicare Health Maintenance Organization

(HMO) during that year. We linked zip codes in the Medicare data to Hospital Referral Regions (HRRs) as

defined by the Dartmouth Atlas.[13]

Operationalization in Medicare Claims

For each of the POPS, we defined a denominator of individuals for whom use of a particular procedure

was likely to be an overuse event, and a numerator which identified those individuals who received the

procedure. Depending on the procedure, the denominator population may be defined by age, gender,

diagnoses or receipt of other services. For most POPs that we operationalized, the denominator was

individuals with a given diagnosis. We used existing algorithms when possible. For some of the POPs,

the denominator was counts of eligible episodes if individuals could have undergone the intervention

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multiple times during the year. One clinician on the team (J.S.) generated all of the algorithms which

were then reviewed by a second clinician (N.N). Coding software was used to identify relevant

codes.(FlashCode, Medical Coding & Compliance Solutions, LLC (MCCS); Turlock, CA) We did not

validate the algorithms further since the degree of case finding accuracy (i.e. predictive value) was not

essential for our purpose and was not expected to vary non-differentially across regions.

Aggregation of POPs into a Single Indicator

We calculated the unadjusted mean and median counts of use of each potentially overused procedure

for each HRR, as well as measures of variability. We then generated a binary indicator of use of any

potentially overused procedures by an individual. We then aggregated across all individuals within an

HRR and then generated a Z-score for this variable which was calculated as the (actual count – expected

count)/standard error where the expected count was an age, race, sex, and case-mix adjusted count for

that HRR. Case-mix adjustment was done with the ACG software which takes all diagnoses found in the

claims file into consideration (The Johns Hopkins ACG system, Baltimore, MD). The Z-score represents a

standardized, risk-adjusted indicator of overuse for the HRR. To describe overuse variation across HRRs

in the U.S., we used template files from the Dartmouth Atlas and plotted the quartile of Z-score for

overuse for each HRR using the ArcGIS 10.1 software (Esri, Redland, CA). We also plotted a histogram of

the rates of POP use across HRRs to illustrate the variation in rates across HRRs.

Testing the Correlation of the Indicator with Costs and Death

With Spearman’s rank correlation coefficient, we tested for associations between the z-score indicator

of overuse and total costs, as well as 30-day post-discharge mortality and total morality, as a function of

the indicator. Total costs were calculated as the average per person Medicare payments summed over

the HRR. We tested whether the correlation between the standardized, risk adjusted POP indicator and

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total costs was positive and significantly different than zero (indicating that more unnecessary

procedures are related to higher overall costs to Medicare) and that the correlation between the

indicator and mortality was not negative (negative correlations could suggest these procedures were

actually be beneficial).

Tested Correlation with Utilization

We hypothesized that overuse of resources and utilization of resources are distinct. Therefore, we

tested this with four indicators of utilization that have been widely used in literature about small area

variation. These are area prevalences of knee arthroplasty, hip arthroplasty, coronary artery bypass

graft, and percutaneous transluminal coronary angioplasty. We operationalized these four measures

and, as above, generated a count of individuals having any of these procedures within the HRR and

standardized and risk-adjusted this count. We plotted our standardized and risk adjusted indicator of

overuse against the more generalized utilization variable. Substantial scatter around the 45-degree line

of agreement would indicate that these measure different activities. Our null hypothesis was that the

correlation coefficient describing the relationship between overuse and variation would be one.

Statistical analyses were performed using SAS software (version 9.2, SAS Institute Inc, Cary, NC) and

Stata software (version 12; Stata Corporation, College Station, TX).

RESULTS

The Medicare data included information about 551,028 men and 900,114 women after removal of 8,391

individuals with Zip Codes which could not be matched to an HRR. Eighty-eight percent of the enrollees

were white and 7.3% were Black. As required, beneficiaries had a full 12 months of coverage in 2008

unless they died during that year; 5.4% died during 2008. Thirty-nine percent of the beneficiaries

resided in the South, 19% in the Northeast, 25% in the Midwest, and 17% in the West.

9

Potentially Overused Procedures

We found lists of measures and proposed overused procedures through existing measurement

databases and a diverse group of professional societies and quality improvement organizations. These

included the National Quality Forum, National Priorities Partnership, Institute of Medicine, Choosing

Wisely Campaign, Agency for Healthcare Quality and Research, National Quality Measures

Clearinghouse, The Good Stewardship Working Group, the U.K. National Health Service, the American

College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of

Echocardiography; American Heart Association, American Society of Nuclear Cardiology, Heart Failure

Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions,

Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography; Society for

Cardiovascular Magnetic Resonance, and the American College of Chest Physicians.

Upon reviewing these lists, we identified more than 613 unique procedures. The procedures

spanned clinical categories and included radiological procedures, cardiac imaging, invasive diagnostic

procedures, and therapeutics. As anticipated, many of the procedures required knowledge of patient

symptoms or medication use and were therefore excluded.

We selected 35 procedures that could be specified with only claims. (Table and Appendix) Some

were deemed too rare to develop (e.g. hyperbaric oxygen for treatment of multiple sclerosis) and others

were primarily utilization measures and set aside for use in our validation analyses. Twenty-two related

to diagnostics, seven to screening or monitoring, and six to therapeutics. They crossed clinical areas with

six applicable to cardiology, six to cancer screening or treatment, six to radiology, five to allergy or

otolaryngology, four to general medical practice, three to orthopedics, two to emergency medicine,

and one each to neurology, gynecology, and gastroenterology.

The mean and median rates of these procedures across HRRs differed markedly by procedure.

(Table) Among 1,451,142 Medicare beneficiaries, 28% had experienced at least one POP during 2008,

10

and this rate varied substantially across the 306 HRRs (21% to 44%). For many POPs, most HRRs had low

frequencies of use. The standardized, risk adjusted indicator showed marked variation in use of POPs

across the HRRs in the U.S. (Figure 1 and Figure 2)

Testing Indicator as an Overuse Indicator

The composite indicator that included all 35 POPs met our predictions for a measure of overuse. It was

correlated positively with aggregated costs in the HRR (r=0.34, p<.0001) and it was not correlated with

probability of death in the HRR (r=-0.09, p=0.13). Additionally, the indicator was positively correlated

with the 30-day probability of death after discharge within HRRs (r=0.12, p=0.038). (Figure 3)

Relationship between Indicator and Utilization Measure

The median counts of use across the HRRs of the five utilization indicators were between 7 and 11 per

1000 beneficiaries. The aggregate indicator of utilization ranged from 12.7 per 1000 to 42.2 per 1000.

Whereas our null hypothesis was a correlation of 1 between these indications, we saw a slight negative

correlation between the indicator of overuse and the indicator of utilization, across HRRs (r=-0.13,

p=0.02). The absence of a positive correlation suggests that HRRs utilization patterns and overutilization

patterns are distinct. (Figure 4)

COMMENT

This study provides a proof of concept for a practical composite measurement approach to systematic

overuse measurable with a diverse set of interventions. We demonstrated that this metric is correlated

with costs but not with increased longevity. We have also applied this measure to provide preliminary

empirical evidence of the degree of variation of this composite indicator across the nation for Medicare

beneficiaries. Furthermore, we demonstrated that systematic overuse appears to be discrete from

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variation overall health care utilization; a region may not be a high utilizing region but be a region that

highly overuses, or the converse. The use of simple correlations, specified a priori, as well as graphical

presentations was a useful starting point for this new research. We know of no other comparable

measures of overuse in the literature. Traditional measures of small area variation assess only variation

in overall utilization. Although measures of inappropriate end-of-life utilization address a similar

concept, our measure is reflective of a broader set of services that may be given to the general Medicare

beneficiary population.

For this proof of principle analysis, we did not perform extensive explanatory multivariate

modeling to demonstrate the relationship between the indicator and the outcomes of interest. Before

this indicator can be used for the purpose of comparisons across states or across health systems, or to

test interventions targeting overuse, we would want to better understand these relationships. We

intentionally have not focused our discussion on the POPs that we used in this indicator as we do not

think that this is final set that should be broadly used as a measure of overuse. We propose that there is

the need for identifying the best combination of POPs that is most predictive of costs, preferably in costs

in subsequent years, and at the same time correlated or predictive of the absence of clinical benefit.

Additionally, we recommend a highly parsimonious set of POPs that can be most easily operationalized

in different sets of claims.

We anticipate that some clinicians will not agree with all of the POPs included in the indicator.

However, it is precisely because these POPs were identified as POPs by other bodies, through consensus

processes, that we felt supported in including them in an index. We stress that we certainly do not

believe that these are “never procedures” –these procedures are sometimes indicated even in the

populations that comprise the denominators – the patients in whom these procedures are commonly

overused. Determining the appropriateness of these procedures for individual cases is beyond the

scope of this measure. However, assessment of overuse at a system level or state level can be telling as

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we begin to identify factors that drive the health care overuse problem. We do not know yet the level at

which the indicator can be validly applied – future research will investigate the performance of the

indicator at larger levels than HRRs (such as states) and at smaller levels (such as individual health

systems or hospitals).

We also anticipate the criticism that there is no reason to expect that the POPs would be

correlated with death, as most of the indicators are for treatment of conditions that are unexpected to

result in death. We think, however, that death is an appropriate outcome against which to test the

indicator: it is a health outcome of critical importance at the societal level and one that is reliably

available in claims. Furthermore, if we found the relationship to be in the opposite direction, that is, the

use of these procedures prevents death; we would know that this is a poorly functioning indicator. In

the future, other outcomes should be tested such as measures of function and quality of life.

Given the cross-sectional associational study design, we do not make any causal inferences

based on our findings, nor do we want to. Specifically, we do not claim that use of this set of procedures

led to high costs, nor that use of these procedures failed to prevent to death. We are simply

demonstrating that there are underlying differences across HRRs that make some of them high spending

regions without observable global benefits. Having a measure of this will then allow investigations as to

why this is so --- is it due to supply of physician specialists or technologies? Is it due to a culture of

overuse driven by patients within a region and expectations? Is it due to fear of suits within a region that

is prone to lawsuits? We are intrigued by our U.S. map that suggests pockets of overuse surrounding Las

Vegas, Nevada and the southern Texas, and pockets of Florida. Case studies of these regions, as Atul

Gawande did for McAllen, Texas, may be informative;[13] as would case studies that look at high

overuse regions that border on low overuse regions.

Future research should identify the best combination of POPs to serve as an indicator. It should

test the indicator against other health outcomes besides death. The indicator should be expanded for

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use in populations besides the elderly – which will likely require incorporation of additional POPs that

are relevant to younger adults and children. The indicator might, in time, be expanded for use to

include pharmacy claims, or even be expanded for use in electronic medical records data in which case

claims that require knowledge of clinical information, such as symptoms, could be included. The

indicator will need to be tested for its responsiveness to interventions within a region or health system,

which includes understanding the smallest unit to which the indicator can be applied.

We are optimistic that we have defined a new measure that may have very broad application in

time. The ability to identify with a measure those regions or health systems that are overusing and

therefore potentially harming individuals and populations, and exacerbating the national health care

spending problem, is vital. Ultimately, this will allow further study of the determinants of overuse and

the development of interventions to fix it for the benefit of patients.

14

Reference List

[1] General Accounting Office. The Federal Government’s Long-Term Fiscal Outlook Spring 2012 Update. URL: http://www.gao.gov/assets/590/589835.pdf. Accessed October, 2012

[2] Thorpe KE, Ogden LL: Analysis & commentary. The foundation that health reform lays for

improved payment, care coordination, and prevention. Health Aff (Millwood) 2010;29:1183-1187.

[3] Zuckerman S, Waidman, T, Berenson R, Hadly J. Clarifying Sources of Geographic Differences in

Medicare Spending. NEJM 2010 363(1): 54-62. 2011.

[4] Song Y, Skinner J, Bynum J, Sutherland J, Wennberg JE, Fisher ES, Regional Variations in Diagnostic

Practices NEJM 2010 363(1): 45-53. 2011.

[5] Epstein AM. Geographic Variation in Medicare Spending. NEJM 2010 363(1): 85-6. 2011.

[6] Fuchs VR: Eliminating "waste" in health care. JAMA 12-9-2009;302:2481-2482.

[7] Wennberg JE, Fisher ES, Skinner JS: Geography and the debate over Medicare reform. Health Aff

(Millwood) 2002;Suppl Web Exclusives:W96-114.

[8] Choosing Wisely. http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx . (Accessed

Sept 10, 2012.

[9] Agency for Healthcare Research and Quality. Improving Health Care Quality: Fact Sheet. (Accessed

from: http://www.ahrq.gov/news/qualfact.pdf, ). Rockville, MD: Agency for Healthcare Research

and Quality. Pub. No. 02-P032, September 2002

[10] Chassin MR, Mccue SM: A Randomized Trial of Medical Quality Assurance - Improving Physicians

Use of Pelvimetry. Jama-Journal of the American Medical Association 1986;256:1012-1016.

[11] Orzag PR. The overuse, underuse and misuse of health care. Testimony before the Committee of

Finance, United States Senate. July 17, 2008. Washington, DC: Congressional Budget Office. 2011.

http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx�

http://www.ahrq.gov/news/qualfact.pdf�

15

[12] Nassery N, Bridges JFP, Chan KC, Segal JB. A framework for defining the systematic overuse of

diagnostic and therapeutic procedures. Academy Health, National Meeting . 2012.

[13] The Dartmouth Institute for Health Policy and Clinical Practice. The Dartmouth Atlas of Health

Care. www.dartmouthatlas.org . 2012. (Accessed Sept-31-2012)

[14] Gawande, A. The Cost Condundrum. The New Yorker. June 1, 2009

http://www.dartmouthatlas.org/�

16

Table. Mean and Median Counts of Potentially Overuse Procedures (POPs)

Across Hospital Referral Regions (n=306 regions)

Potentially Overused Procedure Mean Median Interquartile Range

Per 1000 Per 1000 Per 1000 Per 1000

P 01

Stress echocardiography for detection of

CAD/risk assessment in symptomatic or

ischemic equivalent acute chest pain *

33.0 22.7 2.7 45.5

P 02

Stress echocardiography for risk assessment

within months of an ACS and prior to

initiation of cardiac rehabilitation*

10.5 0.0 0.0 0.0

P 03

Stress echocardiography for risk assessment

after revascularization and prior to initiation

of cardiac rehabilitation*

6.4 0.0 0.0 0.0

P 08

Cardiac Radionuclide Imaging for risk

assessment within months of an ACS and

prior to initiation of cardiac rehabilitation *

10.3 0.0 0.0 9.9

P 09

Cardiac Radionuclide Imaging for risk

assessment after revascularization and prior

to initiation of cardiac rehabilitation *

1.5 0.0 0.0 1.9

P 10 Laminectomy or spinal fusion 2.2 1.9 1.2 2.9

P 11 Hysterectomy for benign disease 2.8 2.7 1.5 3.9

P 19

Broad spectrum allergy testing in patients

with a diagnosis of sinusitis * 3.9 2.4 0.0 5.3

17

P 20

Fiberoptic laryngoscopy for sinusitis

diagnosis* 7.0 5.2 2.2 9.5

P 21 Nasal endoscopy for sinusitis diagnosis* 34.9 24.8 12.1 45.8

P 22

Cervical cancer screening in older women

(over 65 years) 68.0 66.0 51.0 82.0

P 23

Prostate cancer screening in men over 75

years. 664 658 592 718

P 24

More than one emergency department visit

in last 30 days of life 146 147 121 168

P 25 Knee MRI prior to knee arthoplasty 29.3 23.8 0.0 41.7

P 26

Routine monitoring of digoxin in patients

with congestive heart failure 3.6 3.5 2.8 4.2

P 27

EEG monitoring in individuals presenting with

syncope* 22.8 21.2 13.3 29.4

P 28

MRI in individuals with lung cancer except

those with superior sulcus tumors 2.6 0.0 0.0 0.0

P 29

Hyperbaric oxygen for individuals with foot

ulcers* 24.4 0.0 0.0 28.4

P 32 Serological tests for helicobacter pylori 9.3 8.2 5.5 11.2

P 34

Appropriate Head CT Imaging in Adults with

Mild Traumatic Brain Injury* 14.7 12.7 6.1 21.1

P 35

MRI in individuals with Ductal Carcinoma in

Situ 67.1 33.3 0.0 100.0

18

P 36

PET, CT, and radionuclide bone scan in

individuals with prostate CA at low risk for

metastasis

20.7 19.4 9.3 28.4

P 37 Traction for low back pain* 115 106 77.8 137

P 39

Screening for colorectal cancer in adults older

than age 85 years. 24.4 22.6 16.5 30.9

P 40

Routine screening for abdominal aortic

aneurysm in women. 0.3 0.0 0.0 0.3

P 41

Screening for asymptomatic carotid artery

stenosis in the general adult population 12.5 11.0 8.4 14.9

P 43

Preoperative chest radiography in the

absence of a clinical suspicion for

intrathoracic pathology*

219 213 168 259

P 45

In asymptomatic women with previously

treated breast cancer, performing follow-up

tumor marker studies

732 672 464 984

P 46

Diagnostic tests, such as immunoglobulin G

testing or an indiscriminate battery of

immunoglobulin E tests, in the evaluation of

allergy*

4.5 3.7 1.7 5.8

P 47

Sinus CT or indiscriminately prescribe

antibiotics for uncomplicated acute

rhinosinusitis *

14.0 12.4 6.9 19.1

P 48

Routine cancer screening for dialysis patients

with limited life expectancies without signs or 343 183 0.0 625

19

symptom *

P 49 MRI Lumbar Spine for Low Back Pain * 395 395 356 441

P 50 Thorax CT Use of Contrast Material* 64.9 47.5 26.8 79.7

P 51 Abdomen CT use of contrast material* 222 187 133 288

P 52

Simultaneous Use of Brain Computed

Tomography and Sinus Computed

Tomography *

0.4 0.0 0.0 0.0

20

Figure 1. Distribution of Aggregated Potentially Overused Procedures, across Hospital Referral Regions (n=306 regions)

0

10

20

30

40

50

60

70

80

90

0.213 0.238 0.263 0.288 0.313 0.338 0.363 0.388 0.413 0.438

Count of HRRs

0.21 0.24 0.26 0.29 0.31 0.34 0.36 0.39 0.41 0.44

Rates of Potentially Overuse Procedures in Hospital Referral Regions

21

Figure 2. Quartiles of Overuse as Indicated by Full Indicator, across Hospital Referral Regions

22

Figure 3a and 3b. Correlation between Overuse Indicator and Total Medicare

Payments and Probability of Death across Health Resource Regions

Spearman r = 0.341p<0.001

6000

8000

1000

012

000

Tota

l pay

men

t ($)

-10 0 10 20Z-score - All potentially overused procedures

Spearman r = -0.087p=0.128

4050

6070

80Pr

obab

ility

of d

eath


23

Figure 4. Correlation between Overuse Indicator and an Aggregate Measure of

Utilization by Hospital Referral Region

Spearman r = -0.131p=0.022

-50

510

Z-sc

ore

- Util

izat

ion

indi

cato

rs


y y

24

Appendix I. Potentially Overused Procedures Sources

Potentially Overused Procedure References

Stress echocardiography for detection of CAD/risk assessment in symptomatic or ischemic equivalent acute chest pain *

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Hendel RC, Patel MR, Peterson ED, WolkMJ, Allen JM; American College of Cardiology Foundation; American Society of Echocardiography; American College of Emergency Physicians; American Heart Association; American Society of Nuclear Cardiology; Society for Cardiovascular Angiography and Interventions; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. J Am Coll Cardiol. 2008 Mar 18;51(11):1127-47.PubMed PMID: 18342240.

Stress echocardiography for risk assessment within months of an ACS and prior to initiation of cardiac rehabilitation*

Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O'Gara P, Rubin GD; American College of Cardiology Foundation Appropriate Use Criteria Task Force; Society of Cardiovascular Computed Tomography; American College of Radiology; American Heart Association; American Society of Echocardiography; American Society of Nuclear Cardiology; North American Society for Cardiovascular Imaging; Society for Cardiovascular Angiography and Interventions; Society for Cardiovascular Magnetic Resonance, Kramer CM, Berman D, Brown A, Chaudhry FA, Cury RC, Desai MY, Einstein AJ, Gomes AS, Harrington R, Hoffmann U, Khare R, Lesser J, McGann C, Rosenberg A, Schwartz R, Shelton M, Smetana GW, Smith SC Jr. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010 Nov 23;56(22):1864-94. PubMed PMID: 21087721.

Stress echocardiography for risk assessment after revascularization and prior to initiation of cardiac rehabilitation*

Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA; American College of Cardiology Foundation Appropriate Use Criteria Task Force; American Society of Nuclear Cardiology; American College of Radiology; American Heart Association; American Society of Echocardiography; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; Society of Nuclear Medicine. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of

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Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009 Jun 9;119(22):e561-87. Epub 2009 May 18. PubMed PMID:19451357

Cardiac Radionuclide Imaging for risk assessment within months of an ACS and prior to initiation of cardiac rehabilitation *

Mansour IN, Lang RM, Furlong KT, Ryan A, Ward RP. Evaluation of the application of the ACCF/ASE appropriateness criteria for transesophageal echocardiography in an academic medical center. J Am Soc Echocardiogr. 2009 May;22(5):517-22. Epub 2009 Apr 2. PubMed PMID: 19345062. TTE/TEE Appropriateness Criteria Writing Group, Douglas PS, Khandheria B, Stainback RF, Weissman NJ; TTE/TEE Appropriateness Criteria Technical Panel, Brindis RG, Patel MR, Alpert JS, Fitzgerald D, Heidenreich P, Martin ET, Messer JV, Miller AB, Picard MH, Raggi P, Reed KD, Rumsfeld JS, Steimle AE, Tonkovic R, Vijayaraghavan K, Yeon SB; ACCF Appropriateness Criteria Working Group, Hendel RC, Peterson E, Wolk MJ, Allen JM; American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group; American Society of Echocardiography; American College of Emergency Physicians; American Society of Nuclear Cardiology; Society for Cardiovascular Angiography and Interventions; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance. Endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. J Am Soc Echocardiogr. 2007 Jul;20(7):787-805.

Cardiac Radionuclide Imaging for risk assessment after revascularization and prior to initiation of cardiac rehabilitation *

Mansour IN, Lang RM, Furlong KT, Ryan A, Ward RP. Evaluation of the application of the ACCF/ASE appropriateness criteria for transesophageal echocardiography in an academic medical center. J Am Soc Echocardiogr. 2009 May;22(5):517-22. Epub 2009 Apr 2. PubMed PMID: 19345062. TTE/TEE Appropriateness Criteria Writing Group, Douglas PS, Khandheria B, Stainback RF, Weissman NJ; TTE/TEE Appropriateness Criteria Technical Panel, Brindis RG, Patel MR, Alpert JS, Fitzgerald D, Heidenreich P, Martin ET, Messer JV, Miller AB, Picard MH, Raggi P, Reed KD, Rumsfeld JS, Steimle AE, Tonkovic R, Vijayaraghavan K, Yeon SB; ACCF Appropriateness Criteria Working Group, Hendel RC, Peterson E, Wolk MJ, Allen JM; American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group; American Society of Echocardiography; American College of Emergency Physicians; American Society of Nuclear Cardiology; Society for Cardiovascular Angiography and Interventions; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions

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Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance. Endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. J Am Soc Echocardiogr. 2007 Jul;20(7):787-805.

Laminectomy or spinal fusion National Quality Measures Clearinghouse http://www.guideline.gov/content.aspx?id=15368

Hysterectomy for benign disease National Quality Measures Clearinghouse http://www.guideline.gov/content.aspx?id=15367

Broad spectrum allergy testing in patients with a diagnosis of sinusitis *

Blue Cross Blue Shield of Massachusetts. The Alternative Quality Contract. March 2009 http://www.bluecrossma.com/visitor/about-us/affordability-quality/aqc.html

Fiberoptic laryngoscopy for sinusitis diagnosis*


Nasal endoscopy for sinusitis diagnosis*


Cervical cancer screening in older women (over 65 years)

National Priorities Partnership. National priority: Overuse. https://www.qualityforum.org/Measures_List.aspx

Prostate cancer screening in men over 75 years

National Priorities Partnership. National priority: Overuse. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, Leblond R, Moyer D, Wiese JG, Weinberger S. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012 Jan 17;156(2):147-149.

More than one emergency department visit in last 30 days of life


Knee MRI prior to knee athroplasty Gordon AC, et al "Over-utilization of MRI in the osteoarthritis patient" AAOS meeting 2008; P145

Routine monitoring of digoxin in patients with congestive heart failure

NHS "Do not do" List http://www.nice.org.uk/usingguidance/donotdorecommendations/detail.jsp?action=details&dndid=648

EEG monitoring in individuals presenting with syncope*

NHS "Do not do" List http://www.nice.org.uk/usingguidance/donotdorecommendations/detail.jsp

http://www.guideline.gov/content.aspx?id=15368�

http://www.guideline.gov/content.aspx?id=15367�

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?action=details&dndid=761

MRI in individuals with lung cancer except those with superior sulcus tumors

NHS "Do not do" List http://www.nice.org.uk/usingguidance/donotdorecommendations/detail.jsp?action=details&dndid=954 http://www.nice.org.uk/usingguidance/donotdorecommendations/detail.jsp?action=details&dndid=797

Hyperbaric oxygen for individuals with foot ulcers*


Serological tests for helicobacter pylori


Appropriate Head CT Imaging in Adults with Mild Traumatic Brain Injury*

Identification of Potential 2013 e-Quality Measures. NQF. http://www.qualityforum.org/MeasureDetails.aspx?actid=0&SubmissionId=61

MRI in individuals with Ductal Carcinoma in Situ


PET, CT, and radionuclide bone scan in individuals with prostate CA at low risk for metastasis

Five Things Physicians and Patients Should Question from the American Society of Clinical Oncology http://choosingwisely.org/?page_id=13

Traction for low back pain* Institute of Medicine (IOM). Knowing what works in health care: A roadmap for the nation. Institute of Medicine (IOM). Washington, DC: The National Academies Press. 2008

Screening for colorectal cancer in adults older than age 85 years

Screening for Colorectal Cancer, Topic Page. March 2009. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm

Routine screening for abdominal aortic aneurysm in women

Screening for Abdominal Aortic Aneurysm, Topic Page. February 2005. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsaneu.htm

Screening for asymptomatic carotid artery stenosis in the general adult population

Screening for Carotid Artery Stenosis, Topic Page. December 2007. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsacas.htm

Preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology*

Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, Leblond R, Moyer D, Wiese JG, Weinberger S. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012 Jan 17;156(2):147-149.

In asymptomatic women with previously treated breast cancer, performing follow-up tumor marker studies

Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, Leblond R, Moyer D, Wiese JG, Weinberger S. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012 Jan 17;156(2):147-149.

Diagnostic tests, such as immunoglobulin G testing or an indiscriminate battery of immunoglobulin E tests, in the evaluation of allergy*

Five Things Physicians and Patients Should Question from the American Academy of Allergy, Asthma & Immunology http://choosingwisely.org/?page_id=13

Sinus CT or indiscriminately prescribe antibiotics for

Five Things Physicians and Patients Should Question from the American Academy of Allergy, Asthma & Immunology;

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uncomplicated acute rhinosinusitis*

http://choosingwisely.org/?page_id=13

Routine cancer screening for dialysis patients with limited life expectancies without signs or symptom*

Five Things Physicians and Patients Should Question from the American Society of Nephrology; http://choosingwisely.org/?page_id=13

MRI Lumbar Spine for Low Back Pain*

Quality net Imaging Efficiency Measures http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228695266120

Thorax CT Use of Contrast Material*


Abdomen CT use of contrast material*


Simultaneous Use of Brain Computed Tomography and Sinus Computed Tomography*

Imaging measures by CMS and Lewin Group - Measure 3 http://www.imagingmeasures.com/measureThree.htm

*count is per 1000 eligible episodes rather than per 1000 beneficiaries, ACS=acute coronary syndrome CAD=coronary artery disease, CT=computed tomography, EEG=electroencephalography, MRI=magnetic resonance imaging, PET=positron emission tomography,

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Appendix II. Utilization Indicators

Utilization Indicators References

Percutaneous transluminal coronary angioplasty (area rate)


Coronary artery bypass graft (area rate)


Knee arthoplasty National Priorities Partnership. National priority: Overuse. https://www.qualityforum.org/Measures_List.aspx

Hip arthoplasty National Priorities Partnership. National priority: Overuse. https://www.qualityforum.org/Measures_List.aspx

identifying systematic overuse in the medicare fee for service population

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