Current IHPS Work in Healthcare Value and Economics

Rita Redberg, MD, MSc and Sanket Dhruva, MD, MHS, develop strategies to reduce use of low-value care while ensuring patients have access to evidence-based therapies. A large focus is on partnership with payors to ensure that coverage policies for medical device-based procedures are evidence-based. Their New England Journal of Medicine Perspective considers how a Medicare coverage decision deferring to local contractors may increase utilization of a procedure (transvenous pulmonary embolectomy) lacking evidence of benefit, thereby worsening financial threats to the sustainability of Medicare. Additionally, their research study published in JAMA Neurology in November found that spinal cord stimulators were not associated with benefit over conventional medical management in reducing patients’ use of interventions for chronic back pain and extremity pain, but increased costs by $39,000 in the first year of treatment – and had high complication rates requiring revisions or removal. They also conduct patient education research, including a recent study published in JAMA Internal Medicine that showed online health information published by hospitals regarding left atrial appendage occlusion nearly always included the procedure’s benefits while often omitting risks and financial conflicts of interest, underscoring the importance of regulating medical marketing around high-risk treatments.

Catheine Chen, MD  aims to improve our understanding of anesthesia resource utilization during cataract surgery to better allocate anesthesia personnel to those cataract patients who may benefit most from having an anesthesiologist supervising their care intraoperatively In a recent JAMA Internal Medicine article, Chen and colleaguess found that while anesthesia care was used in most cataract surgeries, rates of complications were lower than in other common procedures such as cardiac catheterization or bronchoscopy.  This suggests an opportunity to use anesthesia care more selectively in patients undergoing cataract surgery.  

Justin White, PhD and Dean Schillinger, MD evaluated the impact and cost-effectiveness of a sugar-sweetened beverage (SSB) tax levied in Oakland, California. Several US cities have implemented a sugar-sweetened beverage (SSB) tax aimed at reducing SSB consumption. Yet, there remains relatively little evidence regarding the sustained effects of SSB taxes. Few prior studies of SSB taxes have accounted for the multiple ways consumers might compensate for a tax.

Evidence regarding the cost-effectiveness of SSB taxation in the US has been based on projections of a national tax, rather than empirical estimates from local taxes. White, Schillinger and colleagues applied difference-in-differences and synthetic control approaches comparing changes in SSB purchases before versus after the SSB tax in Oakland with changes in comparator areas.

The excise tax was associated with a 26.8% reduction in SSB purchases in Oakland during the first 30 months after tax implementation, based on the difference-in-differences analysis. The results were similar using a synthetic control approach. They did not find evidence of cross-border shopping or caloric substitution resulting from implementation of the tax. Their findings show that local SSB taxes can both improve dietary intake, result in meaningful improvements in health and generate cost savings. These results provide additional support for a recent recommendation to Congress from a federal diabetes commission to implement a national excise tax on SSBs.

George Sawaya, MD and colleagues have been looking at utilization of cervical cancer screening form women over the age of 65. Their new study published in JAMA Internal Medicine suggests that women over the age of 65 may be undergoing unnecessary cervical cancer screenings and that more public health data is needed on the utilization of cervical cancer screening-associated services among older women. The study looked at Medicare claims data from 1999 to 2019 for fee-for-service care for women over the age of 65.

The analysis showed that in 2019 more than 1.3 million women received cervical cancer screening-associated services, such as a Pap test, colposcopy and other cervical procedures, after age 65. While these services cost more than $83 million, the researchers concluded these services were of “unclear clinical appropriateness.”

According to recommendations and guidelines from the U.S. Preventive Services Task Force, the American Cancer Society and the American College of Obstetrics and Gynecology, women considered to be of average risk can stop undergoing routine cervical cancer screening once they reach the age of 65 and if they have had adequate prior screening. Sawaya and colleagues ay that the high rates of screening among older women is potentially concerning. The study showed that white women were more likely to be screened after age 65 and that Black and Latina women were more likely to undergo a diagnostic colposcopy and subsequent cervical procedures. Overall, the analysis found that the percentage of women over age 65 who received at least one Pap test decreased from 19% (2.9 million women) in1999 to 9% (1.3 million women) in 2019, a reduction of 55%. Rates of colposcopy and cervical procedures decreased 43% and 64%, respectively.