Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
JAMA Health Forum. 2022 Jan 14;3(1):e214543. doi: 10.1001/jamahealthforum.2021.4543. eCollection 2022 Jan.
Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions.
To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery.
In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.
We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites.
Hospitals were linked to health systems using AHRQ's Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0.
There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.
In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.
医疗保健的过度使用是对患者的普遍威胁，需要进行衡量，以便为干预措施的制定提供信息。
测量美国卫生系统中低价值医疗保健的使用情况，并探讨与低价值医疗保健提供相关的卫生系统特征。
设计、设置和参与者：在这项横断面分析中，我们在 3745 家医院和附属门诊点中确定了 17 种低价值服务的发生情况。利用美国医疗保健研究与质量局（AHRQ）的卫生系统综合目录，将医院与美国的 676 个卫生系统联系起来。参与者为 2016 年至 2018 年期间有索赔记录的 100%的医疗保险受益人群。
我们在 3839 家医院和附属门诊点中确定了 17 种低价值服务的发生情况。
利用 AHRQ 的卫生系统综合目录，将医院与卫生系统联系起来。在 2021 年 3 月至 8 月期间，我们使用负二项回归模型对过度使用情况进行建模，该模型包括年季度、程序指标和卫生系统指标。该模型包括了每个指标、医院和季度的医院和受益人的年龄、性别和共病计数的随机效应。与卫生系统术语相关的β系数进行了标准化处理，反映了该系统相对于所有其他系统使用低价值服务的趋势。利用普通最小二乘法回归，我们探讨了与过度使用指数（OI）相关的卫生系统特征，该指数表示为所有卫生系统均值为 0 的标准差。
我们的研究评估了 676 个独特的卫生系统，其中包括 1 至 163 家医院（中位数为 2 家）。合格受益人的平均年龄为 75.5 岁，其中 76%为女性。与最低三分位相比，医疗组数量和床位数量处于上三分位的卫生系统的 OI 分别高出 0.38 个标准差（SD）和 0.44 SD。主要由投资者所有的卫生系统的 OI 比非投资者所有的卫生系统高 0.56 SD。与最低三分位相比，在初级保健医生数量较高、教学强度较高和未补偿护理较多的上三分位卫生系统中，OI 分别低 0.59 SD、0.45 SD 和 0.47 SD。
在这项对美国卫生系统的横断面研究中，卫生系统中过度使用的情况与投资者所有权和初级保健医生人数较少有关。OI 是识别过度使用潜在可改变驱动因素的有用工具，并且可以适应其他调查水平，例如州或地区，这些地区可能受到影响支付或系统整合的地方政策的影响。
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