A US study conducted by researchers at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA) and Harvard Medical School found that doctors based at hospital primary clinics tend to order unnecessary tests or referrals more than doctors in community practices.

“Physicians working in hospitals may be more likely to refer patients for those types of follow-up because they’re more immediately accessible and convenient,” said the study's lead author Dr. John Mafi, an assistant professor at UCLA's David Geffen School of Medicine.

Higher tendency of low-value care

The study - conducted from 1997 to 2013 - compared data gathered from more than 31,000 patient visits for treatment of headaches, back pain and upper respiratory tract infection.

Based on the findings from the 17-year period, patients who visited hospital-based primary clinics rather than community-based clinics were more likely to be referred for MRI or CT scans and X-rays even though the rate of antibiotic prescription was similar in both settings.

Mafi says, “Doctors on hospital campuses often have ready access to specialised equipment like MRI scanners, and so are more likely to use it — even though several studies have suggested it is unnecessary in most cases of lower back pain.”

In addition, patients who bounce from physician to physician - for example, by visiting hospital-based primary clinics and then seeing someone other than their usual physician - were more likely to be over-tested or over-treated. Doctors who did not have a continuous relationship with their patients were also more likely to offer low-value care, or tests that have little diagnostic or therapeutic value for the patient.

“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,” said Bruce Landon, the study’s senior author and a Harvard professor of healthcare policy and medicine.

Recognising the factors to prevent negative effects

Landon states that 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”.

“That knowledge can help both frontline clinicians and hospital leadership find ways to eliminate, or at least reduce, such unnecessary services,” he adds.

“We need to know where the really problematic places within our healthcare system in terms of delivering low-value care [are]. We need the diagnosis in order to know what to do,” says John Romley, associate professor at USC's Price School of Public Policy. He adds that the study is important to pinpoint the factors that are driving up the cost of healthcare in the US.

According to the lead author of the study, “an estimated one-third of healthcare spending in the United States stems from services that provide low-value care.”

Mafi says that patients also play a role in reducing unnecessary testing by having thorough discussions with their doctor about the tests. “Reducing the use of such services can not only help curb healthcare costs — and redirect such resources in more meaningful ways — but it can also protect patients from the potentially harmful effects associated with them.” MIMS

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