Medical specialists order low value, unnecessary imaging at higher rates than their peers

Medical specialists appear to order low-value, unnecessary imaging at rates higher than their peers, according to a research letter recently published in JAMA Network Open [1].

For instance, such specialists ordered or referred patients for nearly 80% of unneeded imaging related to eye disease, compared to 20% for primary care physicians and 0.2% among advanced-practice clinicians. Specialists also ordered emergency department head CTs for dizziness (76%), computed tomography for sudden hearing loss (73%) and MRI for rheumatoid arthritis (63%) at much higher rates than other providers.

The findings are derived from an analysis of 2016 to 2018 fee-for-service Medicare data recorded across 595 U.S. health systems. Emma D. Chant, PhD, and co-authors focused on unnecessary healthcare services, as defined by the Choosing Wisely campaign, including 12 imaging exams.

“In this national analysis, specialists accounted for a higher share of spending relative to volume across 40 low-value services, building on evidence that specialists have greater aggregate low-value spending to suggest they may both offer higher-cost services (e.g., procedures) and use higher cost options within given low-value service definitions,” Chant, with Brigham and Women’s Hospital in Boston, and colleagues wrote Sept. 20. “To encourage employed and affiliated clinicians to reduce these services, health systems could use evidence-based interventions including clinical decision support (e.g., point-of-care alerts) and clinician feedback (e.g., peer comparisons),” the authors added later.

For the analysis, researchers calculated the volume of services received by “system-attributed beneficiaries” between 2017-2018. The authors also deduced whether each low-value service was ordered or referred for by in-system clinicians, including the individual’s attributed primary care physician, other PCPs, advanced-practice clinicians and specialists. Chant et al. calculated overall Medicare spending using a narrower, more conservative approach (counting only payments associated with a claim line identified as low value), along with a broader equation (which included the entire payment, if a component claim line was identified as low value).

The study included 10.9 million beneficiaries at an average age of nearly 75, who received 8.4 million low-value services. Of those, 4.9 million (or 59%) were delivered in-system. Among the in-system services, 2.2 million (or 45%) originated from attributed primary care physicians, 14% from other PCPs, 4% from advanced-practice clinicians, and 37% from specialists.

Total in-system spending on low-value care was about $347.3 million using the narrower approach and almost $1.1 billion using the broader calculation. Of the narrow spending total, 29% originated from attributed PCPs, 12% from other primary care docs, 2% from APCs, and 57% from specialists. Some of the biggest-ticket low-value imaging services (using the narrow approach) related to eye disease ($39.7 million), the carotid artery ($13.5 million), uncomplicated headaches ($5 million), short-interval repeat DEXA scans ($3 million), and ED-based CT for dizziness ($2.4 million).

“Direct spending on low-value services likely accounts for a small share of total Medicare spending, yet cascading costs and other harms compound,” the authors noted. “Understanding the scope and sources of within-system low-value care among attributed patients can inform targeted approaches to reduce such care, which may contribute materially to health systems’ success while improving patient outcomes.”

Read much more in JAMA at the link below.