Overuse in US Medicare during the COVID-19 pandemic: 2020 versus 2019

  1. Kelsey Chalmers
  2. Shannon Brownlee
  3. Valérie Gopinath
  4. Vikas Saini

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Abstract

The COVID-19 pandemic and March 2020 shutdown in the US reduced the volume of healthcare services, but the impact on overuse has not been investigated.

Objective

To examine the change in overuse rates and volumes through 2020.

Design

A retrospective cohort study using Medicare fee-for-service claims.

Setting

Outpatient and inpatient claims.

Participants

Patients who met the criteria for one of 10 overuse measures with a claim between January 1 2019 to December 31 2020.

Measurements

Overuse volumes were reported as patients with claims meeting overuse metric criteria per 100,000 Medicare beneficiaries. Overuse rates were measured by the same overuse cohort per 100 patients meeting the denominator criteria of the metric. Rates in 2020 were compared to the same date period in 2019 using incidence rate ratios (IRRs) estimated from Poisson regressions.

Results

In 2019, 302,379 patients had an overuse claim (14.72% of 2,053,792 patients in the cohort) versus 234,481 (13.79% of 1,699,807) in 2020. The overall cohort included 2,112,904 (61.0%) women and a mean (SD) age of 76.5 (8.1) years. There was a 52.3% decrease in overall cohort volume during the COVID-19 shutdown; 2,341,017 patients in 2020 versus 4,912,453 in 2019. There was a 72.57% decrease in patients with an overuse procedure between April 2019 (N = 11,794) and 2020 (N = 3,220) (IRR 0.27 (95% CI 0.25 to 0.3; p <0.001)), including spinal fusion/laminectomy, carotid endarterectomy, knee arthroscopy, hysterectomy and vertebroplasty.

Limitations

This study uses claim-based measures of overuse and is limited to the first ten months of the COVID-19 pandemic.

Conclusions

The shutdown period during March through May in 2020 had a drastic impact on both the overuse volume and rates for these 10 overuse metrics.

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  1. Version published to 10.1101/2022.05.25.22275006v2 on medRxiv
  2. ScreenIT

    SciScore for 10.1101/2022.05.25.22275006: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: The WCG Institutional Review Board approved this study.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical analysis was performed using SAS Enterprise Guide version 7.15 and visualizations in R statistical software version 4.0.5 (R Project for Statistical Computing).
    R Project for Statistical
    suggested: (R Project for Statistical Computing, RRID:SCR_001905)

    Results from OddPub: Thank you for sharing your code and data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: These overuse measures are indicators of low-value care, and are limited by the diagnostic information available in claims data. We used measures from the Lown Institute overuse metric that had a specific denominator cohort.7 We did not include the two measures from this metric that have a denominator of all patients at the hospital over the selected time period (inferior vena caval filters and renal stenting). We adjusted for and investigated state-level beneficiary counts and COVID-19 incidence rates. A more granular approach could have used counts at the hospital referral region or county level and explored within and across region differences. COVID-19 incidence at more local regional levels may be more predictive of overuse or patient volumes than at the state level. This could be future research built from this current study, which presents a more high-level overview of specific denominator and numerator overuse measure rates throughout 2020. This study only investigated the impact on services through 2020. By the end of 2020, the US was entering another COVID-19 surge that lasted most of the winter. Later in 2021, the COVID-19 Omicron variant wave caused another surge in cases and hospitalizations. The changes to denominator and overuse rates of these measures may be different during each pandemic stage. Conclusions: For most investigated overuse measures, we observed the largest decrease in overuse rates during the COVID-19 shutdown period. These were lar...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  3. Version published to 10.1101/2022.05.25.22275006v1 on medRxiv