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Table. Prevalence of Good Stewardship Working Group “Top 5” Activities in US Ambulatory Care, 2009
Table. Prevalence of Good Stewardship Working Group “Top 5” Activities in US Ambulatory Care, 2009
1.
The Good Stewardship Working Group.  The “top 5” lists in primary care: meeting the responsibility of professionalism.  Arch Intern Med. 2011;171(15):1385-139021606090PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  NAMCS scope and design. http://www.cdc.gov/nchs/ahcd/ahcd_scope.htm#namcs_scope. Accessed July 29, 2011
3.
Centers for Medicare and Medicaid Services.  CMS files for download for Medicare. http://www.cms.gov/ClinicalLabFeeSched/02_clinlab.asp#TopOfPage. Accessed on July 27, 2011
4.
Choudhry NK, Avorn J, Antman EM, Schneeweiss S, Shrank WH. Should patients receive secondary prevention medications for free after a myocardial infarction? an economic analysis.  Health Aff (Millwood). 2007;26(1):186-19417211028PubMedGoogle ScholarCrossref
5.
Lazar LD, Pletcher MJ, Coxson PG, Bibbins-Domingo K, Goldman L. Cost-effectiveness of statin therapy for primary prevention in a low-cost statin era.  Circulation. 2011;124(2):146-15321709063PubMedGoogle ScholarCrossref
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    1 Comment for this article
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    Criteria for bone density testing in younger women
    Allan R. Glass, MD | N/A
    The authors' criteria for determining appropriateness of care in performing bone density screening in women under age 65 (fracture history, steroid exposure, vitamin D deficiency, anorexia, tobacco) seem to be much more restrictive than those currently recommended by the latest USPTF guidelines (http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm). According to the USPTF guidelines, bone density testing for a woman under age 65 is appropriate if she has a risk for future fracture (using the WHO FRAX algorithm) greater than that of a 65-year-old woman without risk factors (i.e., 9.3% risk for fracture over 10 years). This USPTF criterion would certainly include others besides those listed in the article's Table. The new USPTF guidelines were issued only recently - March 2011 - so the article's authors cannot be faulted for using what material was available to them at the time that their article was prepared. Nevertheless, using the current guidelines, wasteful spending on inappropriate bone density testing is likely to be considerably lower than is suggested by the article.

    Conflict of Interest: None declared
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    Nov 14, 2011

    “Top 5” Lists Top $5 Billion

    Author Affiliations

    Author Affiliations: Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, New York (Drs Kale and Federman); Division of Outcomes and Effectiveness, Departments of Public Health and Medicine, Weill Cornell Medical College, New York (Dr Bishop); and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, and San Francisco Veterans Affairs Hospital, San Francisco (Dr Keyhani).

    Arch Intern Med. 2011;171(20):1858-1859. doi:10.1001/archinternmed.2011.501

    The Good Stewardship Working Group presented the top 5 overused clinical activities across 3 primary care specialties (pediatrics, internal medicine, and family medicine), as chosen by physician panel consensus.1 All activities were believed to be common in primary care but of little benefit to patients. We examined the frequency and associated costs of these activities using a national sample of ambulatory care visits.

    Methods

    We performed a cross-sectional analysis using data from the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NAMCS and NHAMCS survey patient visits to physicians in non–federally funded, non–hospital-based offices and non–federally funded hospital outpatient departments, respectively.2

    We limited our sample to visits by patients to their primary care physicians. Visits for each “top 5” primary care activity were identified using a combination of the patient-described Reason For Visit (RFV) and the physician's diagnosis as coded by the International Classification of Diseases, Ninth Revision, Clinical Modification (Table). Nonrecommended care ordered during the visit included that defined by the Good Stewardship Working Group (Table), with some exceptions owing to methodological limitations (unable to identify early referral of otitis media with effusion and appropriate use of corticosteroids based on asthma severity). We excluded from the denominator those visits in which the activity could be considered appropriate.

    We calculated each activity as the proportion of eligible visits during which the patient received nonrecommended care. We applied the sampling weights and sample design variables to generate national estimates and 95% confidence intervals using Stata statistical software, version 11.0 (StataCorp, College Station, Texas).

    We estimated the costs of procedures using the 2011 Medicare physician fee schedule, and in the case of laboratory tests, the 2011 Medicare Clinical Laboratory Fee Schedule3 (eTable). We estimated the costs of drugs using common acquisition costs to consumers from drugstore.com4 or retail pharmacies.5

    Results

    We found a wide range of frequencies (1.4%-56.0%) of nonrecommended activities in primary care, accounting for an approximate annual cost of $6.76 billion (95% CI, $5.0-$9.1 billion) (Table). The ordering of a complete blood cell count for a general medical examination was the most prevalent activity (56.0%, 95% CI, 40.8%-70.2%) and was associated with a cost of $32.7 million (95% CI, $23.9-$40.8 million).

    Several practice activities occurred less commonly, such as ordering of bone density testing in women younger than 65 years (1.4%; 95% CI, 0.9%-2.2%) and Papanicolaou tests for patients younger than 21 years (2.9%; 95% CI, 1.7%-5.0%). We were unable to report the performance of dual-energy x-ray absorptiometry scans in men younger than 70 years and imaging for children with head injuries in ambulatory settings owing to their low frequency (visits <30).

    Cost of unnecessary services was a function of both the frequency and the reimbursement rates for each service. The practice activity associated with the highest cost was the prescribing of brand instead of generic statins, resulting in excess expenditures of $5.8 billion per year (95% CI, $4.3-$7.3 billion). Bone density testing in women younger than 65 years was the least prevalent activity but accounted for $527 million (95% CI, $474-$1054 million) in costs.

    Comment

    Our analysis of outpatient visits demonstrates that there is considerable variability in the frequency of inappropriate care and that many of the activities identified in the Good Stewardship “Top 5” lists1 have marginal impact on health care costs. Approximately 86% of the costs associated with the “Top 5” lists were from the use of brand name instead of generic statins. Although generic drug substitutions may appear to be a “low hanging fruit” for drug savings, numerous efforts have already been made by the US states (generic substitution laws), payers (tiered formularies), and health care providers (generic drug detailing) to achieve this goal. In this light, our data suggest that considerably more work is needed to reduce the costs associated with brand name statin use. Our results also demonstrate that highly prevalent activities with small individual costs can result in large overall costs to the health care system and thus warrant further attention.

    Our analysis is limited by the available data of the NAMCS/NHAMCS data set and by our ability to accurately estimate visits with inappropriate care. We were conservative in our assessment of inappropriate care and were careful to exclude visits where care could be potentially appropriate, likely lowering our cost estimates.

    The recent debate surrounding escalating health care costs and the sustainability of Medicare have focused attention on the delivery of high-quality, efficient care. The discussion certainly needs the participation of physicians who are willing to examine their own practices, such as the Good Stewardship Working Group. However, most primary care activities identified by the working group are not major contributors to health care costs. Expanding the methods of physician consensus to identify “high-value” targets to specialties outside of primary care could bring us closer to achieving the goal of affordable and high-quality health care.

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    Article Information

    Correspondence: Dr Kale, Division of General Internal Medicine, Mount Sinai School of Medicine, One Gustave Levy Place, PO Box 1087, New York, NY 10029 (minal.kale@mountsinai.org).

    Published Online: October 1, 2011. doi:10.1001/archinternmed.2011.501

    Author Contributions:Study concept and design: Kale, Bishop, Federman, and Keyhani. Analysis and interpretation of data: Kale, Bishop, and Keyhani. Drafting of the manuscript: Kale. Critical revision of the manuscript for important intellectual content: Bishop, Federman, and Keyhani. Statistical analysis: Kale. Administrative, technical, and material support: Keyhani. Study supervision: Bishop, Federman, and Keyhani.

    Financial Disclosure: None reported.

    Funding/Support: This project was not supported by external funds. Dr Kale is a fellow who is supported by a National Research Service Award grant. Dr Keyhani is funded by a Department of Veterans Affairs Health Services Research and Development Service Career Development Award.

    References
    1.
    The Good Stewardship Working Group.  The “top 5” lists in primary care: meeting the responsibility of professionalism.  Arch Intern Med. 2011;171(15):1385-139021606090PubMedGoogle ScholarCrossref
    2.
    Centers for Disease Control and Prevention.  NAMCS scope and design. http://www.cdc.gov/nchs/ahcd/ahcd_scope.htm#namcs_scope. Accessed July 29, 2011
    3.
    Centers for Medicare and Medicaid Services.  CMS files for download for Medicare. http://www.cms.gov/ClinicalLabFeeSched/02_clinlab.asp#TopOfPage. Accessed on July 27, 2011
    4.
    Choudhry NK, Avorn J, Antman EM, Schneeweiss S, Shrank WH. Should patients receive secondary prevention medications for free after a myocardial infarction? an economic analysis.  Health Aff (Millwood). 2007;26(1):186-19417211028PubMedGoogle ScholarCrossref
    5.
    Lazar LD, Pletcher MJ, Coxson PG, Bibbins-Domingo K, Goldman L. Cost-effectiveness of statin therapy for primary prevention in a low-cost statin era.  Circulation. 2011;124(2):146-15321709063PubMedGoogle ScholarCrossref
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