Value-based Care
Cohort study: Higher Telehealth Use Linked to Lower Rates of Select Low-Value Services in Medicare
3 Jan, 2025 | 09:30h | UTCBackground: Telehealth has rapidly expanded in recent years, potentially transforming how primary care is delivered. However, questions remain regarding its impact on low-value services—tests or procedures that confer minimal benefit and might be wasteful. Previous research raised concerns that virtual encounters could either reduce or increase unnecessary care, but rigorous data on this matter have been limited.
Objective: To assess whether a primary care practice’s adoption of telehealth is associated with changes in the rate of eight established low-value services, comprising office-based procedures, laboratory tests, imaging studies, and mixed-modality interventions.
Methods: This retrospective cohort study used Medicare fee-for-service claims from 2019 through 2022 for 577,928 beneficiaries attributed to 2,552 primary care practices in Michigan. Practices were grouped into low, medium, or high tertiles of telehealth volume in 2022. A difference-in-differences approach was performed, comparing annualized low-value service rate changes between the prepandemic (2019) and postpandemic (2022) periods.
Results: Overall, high-telehealth practices demonstrated reduced rates of certain office-based low-value services, specifically cervical cancer screening (−2.9 services per 1000 beneficiaries, 95% CI −5.3 to −0.4) among older women. Additionally, high-telehealth practices showed lower rates of select low-value thyroid tests (−40 per 1000 beneficiaries, 95% CI −70 to −9). For five other measures—including imaging for low back pain, imaging for uncomplicated headache, and PSA tests in older men—no significant association was observed between greater telehealth use and low-value service rates. Notably, telehealth volume increased markedly from 2019 to 2022, while in-person visits generally decreased.
Conclusions: These findings suggest that widespread telehealth adoption in Michigan primary care was not associated with elevated low-value service use. In fact, certain office-based low-value tests appeared to decline, possibly owing to fewer face-to-face opportunities to perform unnecessary interventions. Nonetheless, caution is warranted in generalizing these findings, as telehealth’s effects may vary across different clinical contexts.
Implications for Practice: Health care systems should consider structured telehealth protocols that encourage judicious testing and minimize overuse. While telehealth can broaden access, clinicians must remain vigilant to avoid missing necessary care. Clear guidelines, effective triage, and patient education might help balance convenience with quality.
Study Strengths and Limitations: Strengths include a large Medicare population and established low-value service metrics, enhancing the study’s validity. Limitations include a single-state focus (Michigan) and reliance on claims data without detailed clinical information, restricting the scope of outcomes assessed.
Future Research: Further investigation is needed to verify whether these trends extend to other states, different insurance models, and additional low-value services (including medications). Evaluations of telehealth’s role in both low-value and high-value care could offer deeper insights into its broader effects on cost and quality.
Reference: Liu T, Zhu Z, Thompson MP, et al. Primary Care Practice Telehealth Use and Low-Value Care Services. JAMA Network Open. 2024;7(11):e2445436. DOI: http://doi.org/10.1001/jamanetworkopen.2024.45436
Cohort Study: Higher Telehealth Intensity May Reduce Certain Office-Based Low-Value Services in Medicare Primary Care
2 Jan, 2025 | 08:00h | UTCBackground: The rapid expansion of telehealth has raised concerns about its potential to foster wasteful services, especially in primary care. While telehealth can eliminate certain in-person interventions, it might also increase unnecessary laboratory or imaging requests, given the more limited physical exam. Evaluating how telehealth intensity affects the provision of low-value care is crucial for guiding future policy and clinical practice.
Objective: To determine whether higher telehealth utilization at the practice level is associated with changes in the rates of common low-value services among Medicare fee-for-service beneficiaries in Michigan.
Methods: Using Medicare claims data from January 1, 2019, to December 31, 2022, this retrospective cohort employed a difference-in-differences design. A total of 577,928 beneficiaries attributed to 2,552 primary care practices were included. Practices were stratified into low, medium, or high telehealth tertiles based on the volume of virtual visits per 1,000 beneficiaries in 2022. Eight low-value services relevant to primary care were grouped into four main categories: office-based (e.g., cervical cancer screening in women older than 65), laboratory-based, imaging-based, and mixed-modality services.
Results: Among the 577,928 beneficiaries (332,100 women; mean age, 76 years), practices with high telehealth utilization had a greater reduction in office-based cervical cancer screening (−2.9 [95% CI, −5.3 to −0.4] services per 1,000 beneficiaries) and low-value thyroid testing (−40 [95% CI, −70 to −9] tests per 1,000 beneficiaries), compared with low-utilization practices. No significant association emerged for other laboratory- or imaging-based low-value services, including PSA testing for men over 75 or imaging for uncomplicated low back pain. These findings suggest that while telehealth can lower certain office-based low-value services, it does not appear to substantially increase other types of wasteful care.
Conclusions: High telehealth intensity was linked to reductions in specific low-value procedures delivered in-office, without raising the overall rates of other potentially unnecessary interventions. These data may alleviate some policy concerns that telehealth drives excessive or wasteful care due to its convenience. Instead, substituting certain in-person visits with virtual encounters might curtail opportunities for procedures with minimal clinical benefit.
Implications for Practice: For clinicians and policymakers, these results underscore the possibility that carefully implemented telehealth may reduce some low-value services. Nonetheless, sustained monitoring is needed to confirm whether telehealth encourages or discourages appropriate clinical decision-making across a broader range of interventions.
Study Strengths and Limitations: Strengths include a sizable cohort, a pre- versus post-pandemic time frame, and comprehensive analysis of multiple low-value outcomes. Limitations involve the exclusive focus on beneficiaries in Michigan, the inability to capture prescription-related low-value practices (e.g., antibiotic overuse), and the reliance on claims-based measures, which lack clinical details.
Future Research: Subsequent studies should expand to different geographic areas, assess additional low-value endpoints such as overtreatment with medications, and explore whether demographic or socioeconomic factors modify telehealth’s impact on care quality.
Reference: Liu T, Zhu Z, Thompson MP, et al. Primary Care Practice Telehealth Use and Low-Value Care Services. JAMA Netw Open. 2024;7(11):e2445436. DOI: http://doi.org/10.1001/jamanetworkopen.2024.45436
ACP cost-effectiveness analysis: Newer antidiabetic medications in type 2 diabetes – Ann Intern Med
3 May, 2024 | 13:57h | UTCThis systematic review evaluates the cost-effectiveness of newer antidiabetic medications for type 2 diabetes from U.S. clinical and economic perspectives. Analyzing non-industry funded cost-effectiveness analyses (CEAs) using GRADE and Drummond criteria, the study identifies varying cost per quality-adjusted life-year (QALY) values for medications such as GLP1a and SGLT2i. It concludes that while GLP1a and SGLT2i offer low value as primary therapies due to high costs, they may present intermediate value as adjunct treatments to metformin. The study highlights the methodological variability in CEAs and the influence of drug cost and effectiveness assumptions on outcomes. The results suggest cautious interpretation in clinical decision-making due to varied evidence quality and cost-effectiveness profiles among the reviewed medications.
Reference (link to free full-text):
Meta-Analysis: Effectiveness of therapist-guided remote vs. in-person cognitive behavioral therapy
20 Mar, 2024 | 19:32h | UTCStudy Design and Population: This systematic review and meta-analysis investigated the efficacy of therapist-guided remote cognitive behavioral therapy (CBT) compared to traditional in-person CBT. The authors conducted a comprehensive search across several databases, including MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials, up to July 4, 2023. A total of 54 randomized controlled trials (RCTs) were included, encompassing 5463 adult patients presenting with various clinical conditions. The study meticulously assessed the risk of bias and extracted data using a standardized approach, and outcomes were analyzed using a random-effects model.
Main Findings: The primary analysis focused on patient-important outcomes, comparing the effectiveness of remote and in-person CBT across diverse conditions such as anxiety and related disorders, depressive symptoms, insomnia, chronic pain or fatigue syndromes, body image or eating disorders, tinnitus, alcohol use disorder, and mood and anxiety disorders. The meta-analysis, based on moderate-certainty evidence, found little to no difference in effectiveness between remote and in-person CBT (standardized mean difference [SMD] −0.02, 95% confidence interval −0.12 to 0.07), suggesting that both delivery methods are comparably effective across a range of disorders.
Implications for Practice: The findings indicate that therapist-guided remote CBT is nearly as effective as in-person CBT for treating a variety of mental health and somatic disorders. This supports the potential for remote CBT to significantly increase access to evidence-based care, especially in settings where in-person therapy is not feasible or is limited by geographic, economic, or social barriers. Future research should explore optimizing remote CBT delivery methods to further enhance accessibility and efficacy.
Reference: Zandieh, S. et al (2024). Therapist-guided remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized controlled trials. CMAJ, 196(10), E327-E340. [Link]
Study | The high financial and human cost of quality metric reporting in hospitals
11 Aug, 2023 | 15:36h | UTCThe Volume and Cost of Quality Metric Reporting – JAMA (link to abstract – $ for full-text)
Author Interview: The Costs of Quality Reporting – JAMA
Commentaries:
The Cost of “Quality” – Emergency Medicine Literature of Note
How John Hopkins spent $5m and 108,478 hours on quality reporting in one year – HealthLeaders
The cost of quality metric reporting – Becker’s Hospital Review
Study | Uncovering the potential overuse of laboratory tests by combining cost, abnormal result proportion, and physician variation
11 Aug, 2023 | 15:34h | UTC
Perspective | An AI-enhanced electronic health record could boost primary care productivity
9 Aug, 2023 | 15:36h | UTCAn AI-Enhanced Electronic Health Record Could Boost Primary Care Productivity – JAMA (free for a limited period)
What are effective strategies to reduce low-value care? An analysis of 121 randomized deimplementation studies
17 Jul, 2023 | 13:55h | UTC
AHA Policy Statement | Value-based payment for clinicians treating cardiovascular disease
13 Jul, 2023 | 13:13h | UTCNews Release: Policy guidance offers strategies to shift to value-based health care and payment – American Heart Association
Commentary: AHA Reviews Value-Based Payment Systems and Proposes Next Steps – TCTMD
Cohort Study | Increased revision rates seen in shoulder replacement surgeries by surgeons with less than 10 procedures annually
27 Jun, 2023 | 13:48h | UTCSummary: This prospective cohort study investigated the correlation between surgeon volume and patient outcomes after elective shoulder replacement surgeries. Utilizing data from 39,281 procedures performed by 638 surgeons in UK public and private hospitals between 2012-20, the study focuses on adults aged 18 years or older.
The results indicate a significant connection between a surgeon’s mean annual volume and risk of adverse patient outcomes. Surgeons performing fewer than 10.4 procedures per year demonstrated a significantly increased risk of revision surgery, with the hazard ratio being almost twice as high as that of the lowest risk surgeons. Higher mean annual surgical volume correlated with lower risks of reoperations, fewer serious adverse events, and shorter hospital stays.
These findings suggest the need for strategic resource planning in surgical services, with considerations given to surgeon’s annual procedure volume to improve patient outcomes after shoulder replacement surgery. It should be noted that the study was limited in scope to surgeries performed within the NHS and private hospitals in England. Furthermore, potential confounding factors like patients’ social circumstances, carer availability, or body mass index were not considered.
Editorial: Surgeon volume and patient outcomes in shoulder replacement surgery – The BMJ
News Release: Patients do better when surgeon averages 10 + annual shoulder ops – BMJ Newsroom
M-A | Biosimilar and reference biologics in rheumatoid arthritis show equivalent results
15 Jun, 2023 | 14:47h | UTCCommentary: Adalimumab, Etanercept, Infliximab Biosimilars Show Clinically Equivalence to Biologics in RA – HCP Live
Saving time and money in biomedical publishing: the case for free-format submissions with minimal requirements
13 Jun, 2023 | 14:08h | UTCCommentary: Revealed: the millions of dollars in time wasted making papers fit journal guidelines – Nature
RCT | Immediate vs. delayed sequential bilateral cataract surgery: non-inferior in safety, higher cost-effectiveness
6 Jun, 2023 | 14:41h | UTCSafety, effectiveness, and cost-effectiveness of immediate versus delayed sequential bilateral cataract surgery in the Netherlands (BICAT-NL study): a multicentre, non-inferiority, randomised controlled trial – The Lancet (link to abstract – $ for full-text)
News Release: Cataract surgery: two-sided treatment better than one-by-one approach – Maastricht University
Quality-improvement intervention | Impact of stopping preoperative screening for asymptomatic bacteriuria
2 Jun, 2023 | 12:29h | UTCCommentary: Hospital intervention reduces unnecessary screening, antibiotics for bacteriuria – CIDRAP
SR | Unclear evidence on the efficacy of case management in integrated care for frail elderly
31 May, 2023 | 13:50h | UTCSummary: Case management programmes for older people living with frailty in the community – Cochrane Library
The future of cancer care at home: findings from an American Cancer Society summit
31 May, 2023 | 13:48h | UTC
RCT | Morning discharge prioritization fails to shorten hospital stay or expedite orders
9 May, 2023 | 14:58h | UTCCommentary: “Discharge Before Noon”: Time to Jump Off the Bandwagon? – Physician’s First Watch
Position Statement | Telehealth policy, practice, and education
4 May, 2023 | 14:01h | UTC
Top POEMs (Patient-Oriented Evidence that Matters) of 2022 for choosing wisely in practice
27 Mar, 2023 | 13:30h | UTCSummary: Top POEMs of 2022 for choosing wisely in practice are based on Canadian Medical Association member ratings. These recommendations promote evidence-based and cost-effective clinical practices while reducing unnecessary treatments and diagnostic procedures.
Key recommendations from the article:
- Hypnotic agents are effective for insomnia but have adverse effects; avoid benzodiazepines as the first choice for older adults.
- For type 2 diabetes in older adults, avoid medications causing hypoglycemia to achieve A1c <7.5%; moderate control is better.
- Postoperative opioids provide no better pain relief than nonopioids; avoid prolonged use beyond the immediate postoperative period.
- Arthroscopic debridement is not recommended as the primary treatment for knee osteoarthritis.
- Proton pump inhibitor (PPI) use is associated with an increased risk of gastric cancer, although the association is observational and does not imply causation. Use the lowest dose and duration possible.
- For children with community-acquired pneumonia, low-dose amoxicillin for 3 days is noninferior to high-dose for 7 days.
- White blood cells in urine do not equate to bacterial cells; avoid urine dip tests or cultures unless urinary tract symptoms are present.
- Avoid measuring vitamin D in low-risk adults as a routine test.
- Antidepressants should not be routinely used as first-line treatment for mild or subsyndromal depressive symptoms in adults.
- ACG guideline for GERD management: try discontinuing PPIs after an 8-week trial in patients with classic GERD symptoms & no alarming symptoms.
- British Society of Gastroenterology guidelines for IBS management: colonoscopy only for alarming signs or microscopic colitis risk.
- USPSTF advises against ASA initiation for primary prevention of cardiovascular disease in adults >60.
Top POEMs of 2022 for choosing wisely in practice – Canadian Family Physician
See complete lists of low-value practices: Choosing Wisely U.S. / Choosing Wisely UK / Choosing Wisely Australia AND Choosing Wisely Canada
SR | Interventions to reduce repetitive ordering of low-value inpatient laboratory tests
27 Mar, 2023 | 13:22h | UTC
Study reveals overuse of surveillance colonoscopy in older adults with limited life expectancy
23 Mar, 2023 | 13:11h | UTCSummary: This study investigated the association between estimated life expectancy, surveillance colonoscopy findings, and follow-up recommendations among older adults. The study utilized data from the New Hampshire Colonoscopy Registry and included adults over 65 who underwent colonoscopy for surveillance after prior polyps.
Life expectancy was estimated using a validated prediction model and categorized into three groups: less than 5 years, 5 to less than 10 years, and 10 or more years.
Out of the 9,831 adults included in the study, 8% had advanced polyps or CRC. Among the 5,281 patients with available recommendations, 86.9% were advised to return for a future colonoscopy. Surprisingly, 58.1% of older adults with less than 5 years of life expectancy were also recommended to return for future surveillance colonoscopy.
The study concluded that many older adults with limited life expectancy are still recommended for future surveillance colonoscopy. This data could help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.
Article: Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults – JAMA Internal Medicine (link to abstract – $ for full-text)
JAMA Patient Page: What Should I Know About Stopping Routine Cancer Screening?
Commentary on Twitter
Findings suggest that recommending against future surveillance colonoscopy in older adults with low-risk colonoscopy findings and/or limited life expectancy should be considered more frequently than is currently practiced. https://t.co/7jKpYyuZON
— JAMA Internal Medicine (@JAMAInternalMed) March 13, 2023
Analysis | Networks of care to strengthen primary healthcare in resource constrained settings
21 Mar, 2023 | 13:08h | UTCNetworks of care to strengthen primary healthcare in resource constrained settings – The BMJ
M-A | Low-intensity follow-up after cancer surgery does not reduce patient satisfaction or well-being
16 Mar, 2023 | 13:10h | UTCOncological surgery follow-up and quality of life: meta-analysis – British Journal of Surgery
An overview of systematic reviews and meta-analyses on the effect of medication interventions targeting polypharmacy for frail older adults
3 Mar, 2023 | 14:07h | UTCSummary: This overview of published systematic reviews examined the effectiveness of medication reviews on managing polypharmacy in frail older adults. The overview identified 10 systematic reviews, which included 154 studies. Medication reviews were the most common intervention, and the evidence suggests that they help reduce inappropriate medication use in frail older adults, but their impact on frailty scores and hospital admission is unclear. Pharmacist-led medication interventions were the most common, reducing inappropriate prescriptions in various settings. Tools, such as clinical decision-making computer support tools, were also found to be effective. The evidence quality ranged from moderate to critically low, highlighting the need for further research to establish if interventions directed at polypharmacy could have an impact on frailty syndromes.
Related:
RCT | A deprescribing intervention reduced medication burden among older adults in post-acute care
Deprescribing proton pump inhibitors – Australian Journal of General Practice
Antihypertensive Deprescribing in Older Adults: a Practical Guide – Current Hypertension Reports
Deprescribing in Palliative Cancer Care – Life
Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review – Kidney360
Polypharmacy Management in Older Patients – Mayo Clinic Proceedings
Eliminating Medication Overload: A National Action Plan – Lown Institute
Common ED Medication Errors: Polypharmacy – emDocs
Current and future perspectives on the management of polypharmacy – BMC Family Practice
Polypharmacy—an Upward Trend with Unpredictable Effects – Deutsches Ärzteblatt international
Clinical Consequences of Polypharmacy in Elderly – Expert Opinion on Drug Safety
Choosing Wisely in Cardiology | New ACC list of five things physicians and patients should question
28 Feb, 2023 | 14:03h | UTCSummary: The American College of Cardiology (ACC) has released a list of “Five Things Physicians and Patients Should Question” in cardiology as part of the Choosing Wisely campaign, which encourages conversations between clinicians and patients about potentially unnecessary tests, treatments, and procedures. The list includes recommendations to:
- Avoid the routine use of invasive hemodynamic monitoring with pulmonary artery catheters in patients with uncomplicated acute decompensated heart failure.
- Avoid performing atrial fibrillation ablation for the sole purpose of discontinuing chronic anticoagulation.
- Avoid routine imaging stress tests or coronary CT angiography for the workup of palpitations or presyncope.
- Avoid obtaining a coronary artery calcium score in patients with known clinical atherosclerotic cardiovascular disease.
- Avoid obtaining routine serial echocardiograms for chronic heart failure if there has been no change in signs, symptoms, or management.
The recommendations are based on published national guidelines and aim to broadly represent the field of cardiology.
Commentary: ACC Releases New List of Choosing Wisely Recommendations – American College of Cardiology
See complete lists of low-value practices: Choosing Wisely U.S. / Choosing Wisely UK / Choosing Wisely Australia AND Choosing Wisely Canada