OBJECTIVES: Low-value esophagogastroduodenoscopies (EGDs) for uncomplicated gastro-oesophageal reflux disease (GERD) can harm patients and raise patient and payer costs. We developed an electronic health record (EHR) eMeasure to detect low-value EGDs. DESIGN: Retrospective cohort of 518 adult patients diagnosed with GERD who underwent initial EGD between 1 January 2019 and 31 December 2019. SETTING: Outpatient primary care and gastroenterology clinics at a large, urban, academic health centre. PARTICIPANTS: Adult primary care patients at the University of California Los Angeles who underwent initial EGD for GERD in 2019. MAIN OUTCOME MEASURES: EGD appropriateness criteria were based on the American College of Gastroenterology 2012 guidelines. An initial EGD was considered low-value if it lacked a documented guideline-based indication, including alarm symptoms (eg, iron-deficiency anaemia); failure of an 8-week proton pump inhibitor trial or elevated Barretts oesophagus risk. We performed manual chart review on a random sample of 204 patients as a gold standard of the eMeasures validity. We estimated EGD costs using Medicare physician and facility fee rates. RESULTS: Among 518 initial EGDs performed (mean age 53 years; 54% female), the eMeasure identified 81 (16%) as low-value. The eMeasures sensitivity was 42% (95% CI 22 to 61) and specificity was 93% (95% CI 89 to 96). Stratifying across clinics, 62 (74.6%) low-value EGDs originated from 2 (12.5%) out of 16 clinics. Total cost for 81 low-value EGDs was approximately US$75 573, including US$14 985 in patients out-of-pocket costs. CONCLUSIONS: We developed a highly specific eMeasure that showed that low-value EGDs occurred frequently in our healthcare system and were concentrated in a minority of clinics. These results can inform future QI efforts at our institution, such as best practice alerts for the ordering physician. Moreover, this open-source eMeasure has a much broader potential impact, as it can be integrated into any EHR and improve medical decision-making at the point of care.

Although pandemic-era telemedicine flexibilities may have preserved access to care, concerns remain that telemedicine may have been inequitably distributed among older adults, especially those with mild cognitive impairment or dementia (MCID). As telemedicine flexibilities are set to fully expire on December 31, 2024, we aimed to examine pandemic-era and future-intended telemedicine use among older Americans to help inform post-pandemic telemedicine policy design. We hypothesized that telemedicine would be disproportionately underutilized among older adults with MCID or with racial and ethnic minority status. We used nationally representative survey data from the Health and Retirement Study and analyzed pandemic-era and future-intended telemedicine use among 10 075 Medicare beneficiaries aged >50 years during 2020-2022 by cognition across beneficiaries-level characteristics such as age, gender, insurance status, education, and multimorbidity. Results were adjusted by survey weights and nonresponse rates for national representativeness. Contrary to our hypothesis, compared with White Medicare beneficiaries, Hispanic and Black beneficiaries with normal cognition reported 44% and 57% greater pandemic-era and future-intended telemedicine use, respectively, while Black beneficiaries with MCID reported 57% greater pandemic-era telemedicine use. Our findings suggest that pandemic-era telemedicine utilization was especially common among racial and ethnic minority groups and those with MCID.