PROJECT SUMMARY/ABSTRACT The provision of low-value medical services contributes to high healthcare costs in the US. Studies showing regional variation in the intensity of healthcare provision within the US that are not explained by differences in medical complexity and not associated with differences in outcomes demonstrate that low-value healthcare is not homogenously distributed throughout the country. However, variation in healthcare intensity at the hospital level has not been well-studied. Well-calibrated and validated hospital-level measures of diagnostic intensity are lacking. Effective methods to identify outlier hospitals with respect to diagnostic intensity will allow a better understanding of the drivers of low-value care and diagnostic overuse. Additionally, this will allow for better characterization of the relationship between diagnostic intensity and quality of care, specifically missed diagnoses. It will also allow identification of hospitals with lower levels of diagnostic testing and yet low rates of missed diagnoses so their care processes can be studied and replicated. The candidate is a hospitalist physician and junior investigator at Johns Hopkins University. He has recently published a manuscript describing the development of a hospital-level diagnostic intensity index which utilizes non-specific diagnosis codes paired with specific diagnostic tests as a proxy for diagnostic yield. He has assembled a mentoring/advising team with expertise in evaluating the strength of evidence, measuring low- value care, and identifying diagnostic errors. The candidate’s long-term goal is to become an independent investigator with expertise in understanding the drivers of low-value health, the relationship between diagnostic intensity and quality, and ultimately developing interventions to help low-performing hospital systems minimize overuse without compromising quality. This work will characterize hospital-level diagnostic intensity such that outlier hospitals can be identified and the relationship between diagnostic intensity and missed diagnoses at the hospital level can be elucidated. The project includes three aims: 1) Perform a systematic review of the literature characterizing hospital-level diagnostic intensity, 2) Apply the hospital-level diagnostic intensity index to Medicare claims data and develop and test an augmented diagnostic intensity index, 3) Utilize this index to characterize the relationship between diagnostic intensity and missed diagnoses. Aims 2 and 3 will use Medicare 100% limited dataset claims. In addition to executing these aims, the candidate will take courses, learn from directed readings by his mentors and advisor, attend seminars and national conferences, and meet with his mentoring team regularly. He will learn the skills necessary to conduct systematic reviews, gain expertise in analyzing large claims datasets, and develop a better understanding of how to measure quality. This mentored research and career development will help him achieve his goal of becoming an independent investigator.

Project Narrative: Overuse of diagnostic testing in hospitalized adults is an important contributor to unsustainably high healthcare costs and also has harmful effects on individual patients. Methods to identify hospitals with high levels of diagnostic intensity, potentially associated with diagnostic overuse, are lacking. I propose to (1) perform a systematic review of published studies evaluating hospital-level diagnostic overuse, (2) use a hospital-level diagnostic intensity index, with hospital claims data from the Medicare program, to identify hospitals with high levels of diagnostic intensity, and (3) evaluate the relationship between diagnostic intensity and quality of care, specifically missed diagnoses.