Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah (K.D., J.V., B.O.).
Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah (J.H., J.A., J.C., B.H., J.L.).
Ann Intern Med. 2024 May;177(5):583-591. doi: 10.7326/M23-1456. Epub 2024 Apr 23.
Using a health systems approach to investigate low-value care (LVC) may provide insights into structural drivers of this pervasive problem.
To evaluate the influence of service area practice patterns on low-value mammography and prostate-specific antigen (PSA) testing.
Retrospective study analyzing LVC rates between 2008 and 2018, leveraging physician relocation in 3-year intervals of matched physician and patient groups.
U.S. Medicare claims data.
8254 physicians and 56 467 patients aged 75 years or older.
LVC rates for physicians staying in their original service area and those relocating to new areas.
Physicians relocating from higher-LVC areas to low-LVC areas were more likely to provide lower rates of LVC. For mammography, physicians staying in high-LVC areas (LVC rate, 10.1% [95% CI, 8.8% to 12.2%]) or medium-LVC areas (LVC rate, 10.3% [CI, 9.0% to 12.4%]) provided LVC at a higher rate than physicians relocating from those areas to low-LVC areas (LVC rates, 6.0% [CI, 4.4% to 7.5%] [difference, -4.1 percentage points {CI, -6.7 to -2.3 percentage points}] and 5.9% [CI, 4.6% to 7.8%] [difference, -4.4 percentage points {CI, -6.7 to -2.4 percentage points}], respectively). For PSA testing, physicians staying in high- or moderate-LVC service areas provided LVC at a rate of 17.5% (CI, 14.9% to 20.7%) or 10.6% (CI, 9.6% to 13.2%), respectively, compared with those relocating from those areas to low-LVC areas (LVC rates, 9.9% [CI, 7.5% to 13.2%] [difference, -7.6 percentage points {CI, -10.9 to -3.8 percentage points}] and 6.2% [CI, 3.5% to 9.8%] [difference, -4.4 percentage points {CI, -7.6 to -2.2 percentage points}], respectively). Physicians relocating from lower- to higher-LVC service areas were not more likely to provide LVC at a higher rate.
Use of retrospective observational data, possible unmeasured confounding, and potential for relocating physicians to practice differently from those who stay.
Physicians relocating to service areas with lower rates of LVC provided less LVC than physicians who stayed in areas with higher rates of LVC. Systemic structures may contribute to LVC. Understanding which factors are contributing may present opportunities for policy and interventions to broadly improve care.
National Cancer Institute of the National Institutes of Health.
采用卫生系统方法研究低价值医疗（LVC），可能有助于深入了解这一普遍问题的结构驱动因素。
评估服务区域实践模式对低价值乳房 X 线摄影术和前列腺特异性抗原（PSA）检测的影响。
回顾性研究，分析了 2008 年至 2018 年的 LVC 率，利用匹配的医生和患者组每 3 年进行一次的医生迁移来利用该数据。
美国医疗保险索赔数据。
8254 名年龄在 75 岁或以上的医生和 56467 名患者。
在留在原始服务区域的医生和迁移到新区域的医生之间的 LVC 率。
从高 LVC 地区迁移到低 LVC 地区的医生更有可能提供较低的 LVC 率。对于乳房 X 线摄影术，留在高 LVC 地区（LVC 率为 10.1%[95%CI，8.8%至 12.2%]）或中 LVC 地区（LVC 率为 10.3%[CI，9.0%至 12.4%]）的医生提供 LVC 的比例高于从这些地区迁移到低 LVC 地区的医生（LVC 率分别为 6.0%[CI，4.4%至 7.5%] [差异，-4.1 个百分点{CI，-6.7 至-2.3 个百分点}和 5.9%[CI，4.6%至 7.8%] [差异，-4.4 个百分点{CI，-6.7 至-2.4 个百分点}）。对于 PSA 检测，留在高或中 LVC 服务区域的医生提供 LVC 的比例分别为 17.5%（CI，14.9%至 20.7%）或 10.6%（CI，9.6%至 13.2%），而从这些地区迁移到低 LVC 地区的医生提供 LVC 的比例分别为 9.9%（CI，7.5%至 13.2%）[差异，-7.6 个百分点{CI，-10.9 至-3.8 个百分点}和 6.2%（CI，3.5%至 9.8%）[差异，-4.4 个百分点{CI，-7.6 至-2.2 个百分点}]。从低 LVC 地区向高 LVC 地区迁移的医生不太可能提供更高的 LVC 率。
使用回顾性观察性数据，可能存在未测量的混杂因素，以及迁居医生的实践方式可能与留守医生不同。
迁往低 LVC 率服务区域的医生提供的低价值医疗服务比例低于留在高 LVC 率服务区域的医生。系统结构可能导致 LVC。了解哪些因素在起作用可能为广泛改善护理提供政策和干预措施的机会。
美国国立卫生研究院国家癌症研究所。
