Is your practice’s location financially hurting you?

Primary care practices located in community settings do a better job of providing high-value, cost-effective services than primary care practices within hospital settings, according to a recent article in JAMA Internal Medicine. The article’s authors examined the extent to which practices in the two different types of locations used low-value services--unnecessary interventions of questionable worth.

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To cite just one of the three types of low-value care that the researchers studied, hospital-based primary care providers were more likely than their community based counterparts to order MRIs or X-rays for patients with back pain or headaches. These kinds of expensive diagnostic studies are uncalled for, according to current guidelines.

Luci Belnick, MD, independently practices internal medicine in suburban Orlando. However, prior to opening her community-based practice, she practiced for years at a downtown hospital, Orlando Regional Medical Center (ORMC). She described feeing a certain pressure to prescribe imaging studies such as X-rays for back pain while working at ORMC, and ascribed the feeling to the fact that she was practicing in the midst of so many specialists who routinely use the high-tech tools at their disposal.

In their paper, the researchers reported their findings about the use of specific low-value services often associated with three conditions routinely seen by primary care providers: upper respiratory tract infections (RTIs), back pain and headaches. The low-value services that the researchers studied were the use of CT scans or MRIs for back pain or headaches, (as mentioned above), the use of antibiotics or X-rays for upper RTIs and referrals to specialists for all three conditions.

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The study examined the use of these low-value services following 31,162 primary care visits that took place at either hospital-based outpatient practices or community-based practices. All visits occurred between Jan. 1, 1997 and Dec. 31, 2013.

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Less continuity of care within hospitals

Within hospital-based primary care settings, not only were more orders written for low-value imaging tests and referrals to specialists, but patients were also far more likely to be seen by a doctor who was not their usual physician. Thus, the researchers found that community-based primary care practices provided greater continuity of care.

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 In fact, the investigators also found that the clinician seen during a given visit was identified as being the patient’s primary care physician (PCP) in only 50% of the visits that took place in hospital-based offices, compared to more than 80% of the visits in community-based offices. Appointments with non-PCPs are associated with higher usage of low-value services, but mainly in hospital-based offices, the study revealed.

Hospital-based PCPs overuse imaging studies. With regard to the use of antibiotics for RTIs, the study found similar prescribing patterns in both hospital-based and community-based primary care settings. However, patients seen in a hospital-based primary care setting received more orders for CT and MRI imaging and for X-rays, and more referrals to specialists.

Considering patient convenience

Belnick says that transportation issues were likely a contributing factor when it came to the study’s observed differences in orders written for testing. Since hospitals have facilities for CT scans and MRI nearby, primary care providers within such settings can spare their patients expense and trouble by immediately ordering tests that might be needed.

Next: Why low-value care is a growing problem

“Scheduling a test in a week or two will cost the patient more bus fare and childcare, so you tend to try to do more things while they are geographically with you, out of respect for those demands,” she says.

In contrast, she says, a community-based provider like herself would be more likely to think twice about inconveniencing the patient by sending them to keep another appointment at a separate imaging facility.  

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The researchers controlled for potential confounding patient variables including age, sex and race/ethnicity. The study’s authors also compared usage of low-value services between hospital-owned community-based practices versus physician-owned community based practices. Similar practice patterns generally prevailed among hospital-owned versus physician-owned community-based primary care practices, with one exception. Clinicians in hospital-owned practices referred patients to specialists more often than clinicians in physician-owned practices.

Low-value care, a growing problem

The U.S. healthcare system is rife with low-value care. The authors of the study stated that nearly one-third of health spending in the U.S. is considered potentially wasteful. Current research indicates that the use of low-value care is actually increasing, despite the wide availability of clinical guidelines and high-level initiatives meant to limit the use of low-value services.