Patients at hospital-based primary clinics are more likely to get unnecessary tests and services

Findings of UCLA–Harvard Medical School study suggest practices could reduce use of unneeded referrals

People with back pain, headaches and upper respiratory infections are more likely to receive tests and services of little diagnostic or therapeutic value — so-called low-value care — when they visit primary care clinics at hospitals rather than at community-based primary care clinics.

A national study led by researchers at the David Geffen School of Medicine at UCLA and Harvard Medical School found that the key factor driving the disparity appears to be the location of the clinic, rather than whether the clinic is owned by a hospital or a physician. In fact, aside from referring patients to specialists slightly more often, hospital-owned community clinics delivered care otherwise similar to physician-owned community clinics.

The research, published April 10 in JAMA Internal Medicine, found that providers at hospital-based clinics tend to refer too many patients to specialists, and order too many CT scans, MRIs and X-rays. The findings raise concerns about the value of care delivered in hospital-based primary care settings.

The paper suggests that 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 Dr. John Mafi, the study’s lead author, an assistant professor of medicine at the Geffen School of Medicine and a primary care physician at Ronald Reagan UCLA Medical Center.

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

The subject is a serious concern because research has shown that up to one-third of medical care may be wasteful or unnecessary, which can be expensive for patients and drive up overall health care costs. Insights from the study could help hospital-based clinics develop strategies to limit unnecessary referrals and tests.

“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,” said Bruce Landon, the study’s senior author, a Harvard Medical School professor of health care policy and of medicine who practices general internal medicine at the Beth Israel Deaconess Medical Center. “That knowledge can help both frontline clinicians and hospital leadership find ways to eliminate, or at least reduce, such unnecessary services.”

The team compared records of 31,000 appointments over a 17-year period from two national databases, analyzing instances during which patients sought treatment for upper respiratory infections, back pain and headaches. To better identify people for whom the services were likely of low value, the researchers excluded those with more complex symptoms that suggested more serious disorders, and they accounted for people with different underlying disorders and chronic conditions.

Hospital-based and community-based clinics prescribed antibiotics at roughly the same rate. But people who visited hospital clinics were referred for MRIs and CT scans more often (8 percent) than those who went to community clinics (6 percent). They also were referred more often for X-rays (13 percent versus 9 percent) and far more often for an evaluation by a specialist (19 percent versus approximately 8 percent).

The people who were most likely to receive unnecessary tests and services were those visiting hospital-based primary care clinics and seeing someone other than their usual physician. That indicates that patients may be more likely to be over-tested or over-treated when they bounce from physician to physician.

“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.”

The study’s co-authors are Christina Wee and Roger Davis, both of Harvard and Beth Israel Deaconess Medical Center. The research was supported by the National Institutes of Health (Midcareer Mentorship Award K24DK087932 and Harvard Catalyst National Institutes of Health Award UL1 TR001102). 

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