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Hospital-based primary care settings more likely to provide unnecessary services

Patients with common conditions such as upper respiratory tract infections, back pain and headaches are more likely to receive unnecessary tests and services when seeking care at hospital-based primary practices as opposed to community-based practices, according to research published in JAMA Internal Medicine.

“Low-value care is defined as patient care that provides minimal average benefit in specific clinical scenarios,” 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 wrote. “Despite decades of widely publicized studies and national clinical guidelines, our health care system still provides large amounts of low-value care ... Evidence also suggests that many of these unnecessary services are increasing over time. Eliminating low-value care could not only substantially lower health care costs but also reduce preventable patient harm.”

Mafi and colleagues investigated the effect of hospital location and ownership on the delivery of low-value care. They used nationally representative data on outpatient visits to generalist physicians from the National Hospital Ambulatory Medical Care Survey from Jan. 1, 1997, to Dec. 31, 2011, and the National Ambulatory Medical Care Survey from Jan. 1, 1997, to Dec. 31, 2013. The researchers compared low-value service use after primary care visits at hospital-based outpatient practices vs. community-based office practices, as well as at hospital-owned vs. physician-owned community-based office practices.

They identified 31,162 primary care visits for upper respiratory infection, back pain and headache. Low-value care was considered to be the use of antibiotics for patients with upper respiratory tract infections, the use of CT or MRI for patients with back pain or headache, and the use of radiographs for patients with upper respiratory tract infections or back pain, as well as specialty referrals for all three conditions.

CT and MRI (8.3% vs. 6.3%, P = .01), radiographs (12.8% vs. 9.9%, P < .001) and specialty referrals (19% vs. 7.6%, P < .001) were used more frequently in hospital-based visits than community-based visits, while both settings had similar rates of antibiotic use. Comparable results were seen after multivariable adjustment and symptom acuity stratification. Delivery of low-value care was greater in visits with a generalist other than the patient’s PCP; however, this association was observed mainly within hospital-based settings. Hospital-owned and physician-owned community-based practices had similar practice patterns, except for specialty referrals, which were more common in hospital-owned community-based practices.

This disparity in low-value service use seems to be driven by clinic location rather than clinic ownership, the researchers noted.

“Hospital-based practices need to be aware of their tendency to overuse certain tests and services of questionable therapeutic value for patients with uncomplicated conditions,” Bruce Landon, MD, MBA, MSc, coauthor of the study from the department of health care policy at Harvard Medical School, said in a press release. “That knowledge can help both frontline clinicians and hospital leaderships find ways to eliminate or at least reduce such unnecessary services.”

Overuse of tests and services may be a result of more immediate access to specialists and the proximity and convenience of imaging services in hospitals, according to the researchers.

“An estimated 10% to 30% of health care spending in the United States stems from services that provide low-value care,” Mafi said in the release. “Reducing the use of such services can not only help curb health care costs — and redirect such resources in more meaningful way — but also protect patients from the potentially harmful effects associated with such services.”

These findings suggest that discontinuity of care leads to a higher risk of being overtested or overtreated, according to the researchers.

“Not seeing your regular primary care physician — what we call discontinuity of care — might be a weak spot where low value care can creep in,” Landon said. “The more we know about what situations are most likely to lead to patients’ receiving low-value care, the more we can do to prevent it.” – by Alaina Tedesco

Disclosure: The researchers report funding from NIH.