Rationale for Developing the Initial 20 Measures
The concepts for the measures for the newest MedInsight product, the Health Waste Calculator, were identified from various publications about avoidable healthcare, medical waste, and Choosing Wisely. The team identified an initial list of 134 measures to develop. The prioritization of the initial 20 waste calculator measures, version 1 and 2 (see Appendix I below), was based on the following criteria:
- High prevalence rate or incidence of the wasteful events as reported in different publications
- High cost impact due to the wasteful events
- Representation of different specialties or clinical conditions
- Representation of different types of services – preventive screening tests, diagnostic tests and prescription of drugs
- Representation of relevant measures for different age groups (children, adults, elderly or all population) as well as gender specific measures
The following examples highlight a summary of evidence that supported the prioritization of these measures in version 1.
- Rhinosinusitis related three measures – The prevalence of both acute and chronic rhinosinusitis in a National Health Interview Survey conducted in 2004, found that 14% of people in the US population were diagnosed with sinusitis. Rhinosinusitis accounts for health-care expenditure of more than $3.0 billion per year in the United States. Despite the fact that CT imaging has moderate sensitivity (76%) and specificity (79%) in diagnosing acute bacterial sinusitis, it is still being ordered. In another survey data it was found that 81% of adults presenting with acute sinusitis were prescribed antibiotics. Rhinosinusitis is still the fifth leading indication for practitioners to prescribe antimicrobials despite the fact that 70% of patients improve without antibiotics.
- Imaging for low back pain – Approximately 15 percent of the U.S. population reports having frequent low back pain. Healthcare cost for back pain includes both direct medical expenses and indirect cost of time lost from work, disability payments and diminished productivity. Additionally, medical care for these individuals cost approximately $35 billion dollars, with imaging driving much of the cost. In the calendar year 2000, Medicare made approximately $55 million in combined technical and professional component payments for 1.36 million claims for conventional radiography of the lumbar spine (For CPT code 72100) and $339 million for 592,000 lumbar spine MR imaging claims.
- Pap smear – Pap smear is the most common screening test conducted in women over 21 years of age and in a survey conducted by the National Center for Health Statistics, 93% of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening where 38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Ideally in women with no history of abnormal smears the U.S. Preventive Services Task Force (USPSTF) recommends screening for cervical cancer in women aged 21 to 65 years with cytology (Pap smear) every 3 years.
- Cardiac stress testing – Half of all patients in community practice had 1 or more stress tests within 24 months of coronary revascularization. Of those tested, only 5% required repeat revascularization. From 1993 to 2001, roughly 180,000 cardiac revascularizations, 360,000 catheterizations, and 1 million stress tests and nuclear imaging studies were performed on a 5% national sample of Medicare beneficiaries. As overall rates of stress testing in the US Medicare population doubled from 1993 to 2001, the proportion of tests performed with radionuclide imaging increased from 50% to 80%. The nearly 3-fold absolute rise in US rates of radionuclide imaging suggests that these imaging studies have become the standard of clinical practice without clear evidence to support their routine use in place of exercise tests without radionuclide imaging
Further an analysis was conducted on a set of claims data for a small Midwestern HMO health plan to find the average cost and the number of events that were wasteful out of a total of 10,074 enrollees, about 1% of their total costs were classified as wasteful using the first version of this product. A sample of this claim cost analysis is shown in the table below.