Mathematica, Oakland, California, USA.
Mathematica, Washington, DC, USA.
Health Serv Res. 2022 Dec;57(6):1261-1273. doi: 10.1111/1475-6773.14053. Epub 2022 Sep 6.
To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices.
This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018.
We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level.
DATA COLLECTION/EXTRACTION METHODS: The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites.
Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level.
Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.
使用反映当前治疗实践的低价值服务 (LVS) 衡量标准，研究与更多使用 LVS 相关的受益人群、医生和其就诊场所的特征。
本研究是在一项大型全国性初级保健重新设计计划（综合初级保健加）的背景下进行的，使用了 2018 年的 Medicare 索赔数据。
我们根据现有的 31 项基于索赔的衡量标准，检查了 LVS 的受益人群总计数，这些衡量标准通过排除向 Medicare 受益人群提供的三种服务频率降低的服务，并以最近确定的 LVS 取而代之进行了更新。我们使用分层线性模型，考虑了广泛的受益人群、医生和就诊场所特征，以研究各层次特征对更多使用 LVS 的预测作用。我们还检查了每个层次特征对 LVS 使用的变化的比例。
数据收集/提取方法：该研究包括 5074642 名 Medicare 按服务收费的受益人群，这些受益人群归因于 11009 个初级保健就诊场所的 32406 名初级保健医生。
患有残疾、终末期肾病的患者和处于贫困率较高地区的患者在所有 31 项衡量标准中，每 1000 名受益人群中分别接受 10（标准误差 [SE] = 3.0）、80（SE = 14.0）和 10（SE = 1.0）个 LVS，而没有这些属性的患者则分别接受 10（SE = 3.0）、80（SE = 14.0）和 10（SE = 1.0）个 LVS。医生的综合程度更高，就诊场所的初级保健医生数量增加，每 1000 名受益人群中分别与 40（SE = 20.0）和 20（SE = 6.0）个 LVS 相关。然而，我们检查的解释变量仅占 LVS 使用变化的 11%，大部分变化（87%）归因于受益人群层面无法观察到的差异。
未解释的剩余差异，源自潜在的患者偏好和非初级保健提供者的行为，可能是 LVS 使用的重要决定因素。
