Hospital-Linked Practices Use More Low-Value Care

Marcia Frellick

April 11, 2017

Hospital-based primary care practices in the United States use more low-value care and specialty referrals than physician-owned community-based practices, researchers have found.

John N. Mafi, MD, MPH, from the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at University of California, Los Angeles, and colleagues also found an association between low-value care and visits in which the clinician was not the patient's usual primary care provider. That association was mostly found within hospital-based practices.

"These findings suggest that practice location has a larger role than ownership or incentive factors in low-value care delivery and that the association of these structural attributes also appears to be related to visits to physicians who are not the patient's [primary care provider]," the authors write. They published their findings online April 10 in JAMA Internal Medicine.

The researchers looked at 31,162 visits for upper respiratory tract infection (such as acute bronchitis and pharyngitis), back pain, and headache, representing an estimated 739 million primary care visits from 1997 to 2013. In a small portion of visits, more than one condition was treated.

Hospital-based visits included more imaging than did community-based visits (8.3% vs 6.3% [P = .01] for computed tomography and magnetic resonance imaging, and 12.8% vs 9.9% [P < .001] for radiographs). They also included more than twice the rate of specialty referrals as community-based visits (19.0% vs 7.6%; P < .001).

Antibiotic use was similar in both venues. The outcomes were similar after adjusting for potential confounders such as age, sex, race/ethnicity, comorbidities, insurance status, geographic location, urban vs rural status, and symptom severity.

Researchers used data from the National Ambulatory Medical Care Survey (1997 - 2013) and the National Hospital Ambulatory Medical Care Survey (1997 - 2011) to identify outpatient visits.

Patients who visited hospital-based practices tended to be younger than those who visited community-based practices (average age, 44.5 vs 49.1 years), and they saw their primary care provider less frequently (52.7% vs 81.9%).

Easier access to imaging and specialty services within hospitals may contribute to greater use of low-value services within hospital-based practices, the authors acknowledge.

They point out that other studies have shown higher costs, but no higher care quality or efficiency, with more integrated care.

"This notion is supported by the fact that our results revealed differences primarily with the use of [computed tomography and magnetic resonance imaging], radiographs, and specialty referrals but not antibiotics, which would not be influenced by hospital location," they write.

The authors conclude that identifying where low-value care is coming from is important amid reports that a third of health spending is potentially wasteful.

"[O]ur findings have important implications for policymakers, health care practice leaders, and clinicians, who have an interest in providing the highest-quality care at the lowest per capita cost," they write.

The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online April 10, 2017. Abstract

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