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Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States.

ABSTRACT: Importance:Hospital-employed physicians provide primary care within the hospital or within community-based office practices. Yet, little is understood regarding the influence of hospital location and ownership on the delivery of low-value care. Objective:To assess the association of hospital location and hospital ownership with the provision of low-value health services. Design, Setting, and Participants:This study compared low-value service use after primary care visits at hospital-based outpatient practices from January 1, 1997, to December 31, 2011, vs community-based office practices and at hospital-owned vs physician-owned community-based office practices from January 1, 1997, to December 31, 2013. Logistic regression models adjusted for patient and health care professional characteristics and year, and weighted results were used to reflect population estimates. Results were also stratified by symptom acuity and whether a generalist physician (eg, general internist or family practitioner) was the patient's primary care provider. This study used nationally representative data from the National Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2013) and the National Hospital Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2011) on outpatient visits to generalist physicians. Participants were patients seen with 3 common primary care conditions, namely, upper respiratory tract infection, back pain, and headache. Main Outcomes and Measures:The use of antibiotics (for upper respiratory tract infection), computed tomography or magnetic resonance imaging (for back pain and headache), radiographs (for upper respiratory tract infection and back pain), and specialty referrals (for all 3 conditions). Results:This study identified 31?162 visits for upper respiratory tract infection, back pain, and headache, representing an estimated 739 million US primary care visits from 1997 to 2013. Compared with visits with community-based physicians, patients in visits to hospital-based physicians were younger (mean age, 44.5 vs 49.1 years; P?

SUBMITTER: Mafi JN

PROVIDER: S-EPMC5540052 | biostudies-literature | 2017 Jun

REPOSITORIES: biostudies-literature

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Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States.

Mafi John N JN Wee Christina C CC Davis Roger B RB Landon Bruce E BE

JAMA internal medicine 20170601 6

<h4>Importance</h4>Hospital-employed physicians provide primary care within the hospital or within community-based office practices. Yet, little is understood regarding the influence of hospital location and ownership on the delivery of low-value care.<h4>Objective</h4>To assess the association of hospital location and hospital ownership with the provision of low-value health services.<h4>Design, setting, and participants</h4>This study compared low-value service use after primary care visits at ...[more]

PMID: 28395013

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Project description:BackgroundSpecialty societies in the United States identified low-value tests and procedures that contribute to waste and poor health care quality via implementation of the American Board of Internal Medicine Foundation's Choosing Wisely initiative.ObjectiveTo develop claims-based algorithms, to use them to estimate the prevalence of select Choosing Wisely services and to examine the demographic, health and health care system correlates of low-value care at a regional level.DesignUsing Medicare data from 2006 to 2011, we created claims-based algorithms to measure the prevalence of 11 Choosing Wisely-identified low-value services and examined geographic variation across hospital referral regions (HRRs). We created a composite low-value care score for each HRR and used linear regression to identify regional characteristics associated with more intense use of low-value services.PatientsFee-for-service Medicare beneficiaries over age 65.Main measuresPrevalence of selected Choosing Wisely low-value services.Key resultsThe national average annual prevalence of the selected Choosing Wisely low-value services ranged from 1.2% (upper urinary tract imaging in men with benign prostatic hyperplasia) to 46.5% (preoperative cardiac testing for low-risk, non-cardiac procedures). Prevalence across HRRs varied significantly. Regional characteristics associated with higher use of low-value services included greater overall per capita spending, a higher specialist to primary care ratio and higher proportion of minority beneficiaries.ConclusionsIdentifying and measuring low-value health services is a prerequisite for improving quality and eliminating waste. Our findings suggest that the delivery of wasteful and potentially harmful services may be a fruitful area for further research and policy intervention for HRRs with higher per-capita spending. These findings should inform action by physicians, health systems, policymakers, payers and consumer educators to improve the value of health care by targeting services and areas with greater use of potentially inappropriate care.

Project description:BackgroundProviding continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent's plan until age 26 yr, was associated with increased labor neuraxial analgesia use.MethodsThis study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 U.S. states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and postintervention periods (January 2009 to August 2010 and September 2010 to December 2013, respectively). The exposure was women's age, categorized as exposed (21 to 25 yr) and unexposed (27 to 31 yr). The outcome was the labor neuraxial analgesia utilization rate.ResultsOf the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 68.9% during the postintervention period (difference, 4.0%; 95% CI, 3.9 to 4.2). For women aged 27 to 31 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 67.7% during the postintervention period (difference, 2.8%; 95% CI, 2.7 to 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI, 0.8 to 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 yr compared with women aged 27 to 31 yr. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women.ConclusionsImplementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size is unlikely of clinical significance.Editor’s perspective

Project description:ImportanceWork environments and practice structural features are associated with both burnout and the ability of practices to enhance quality of care.ObjectiveTo characterize factors associated with primary care practices successfully improving quality scores without increasing clinician and staff burnout.Design, setting, and participantsThis cross-sectional study assessed small- to medium-sized primary care practices that participated in the EvidenceNOW: Advancing Heart Health initiative using surveys that were administered at baseline (September 2015 to April 2017) and after the intervention (January 2017 to October 2018). Data were analyzed from February 2022 to January 2023.Main outcomes and measuresThe primary outcome of being a quality and well-being positive deviant practice was defined as a practice with a stable or improved percentage of clinicians and staff reporting burnout over the study period and with practice-level improvement in all 3 cardiovascular quality measures: aspirin prescribing, blood pressure control, and smoking cessation counseling.ResultsOf 727 practices with complete burnout and aspirin prescribing, blood pressure control, and smoking cessation counseling data, 18.3% (n = 133) met the criteria to be considered quality and well-being positive deviant practices. In analyses adjusted for practice location, accountable care organization and demonstration project participation, and practice specialty composition, clinician-owned practices had greater odds of being a positive deviant practice (odds ratio, 2.02; 95% CI, 1.16-3.54) than practices owned by a hospital or health system.Conclusions and relevanceIn this cross-sectional study, clinician-owned practices were more likely to achieve improvements in cardiovascular quality outcomes without increasing staff member burnout than were practices owned by a hospital or health system. Given increasing health care consolidation, our findings suggest the value of studying cultural features of clinician-owned practices that may be associated with positive quality and experience outcomes.

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Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States.

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Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States.

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