Background: For many common conditions, expert guidelines such as Choosing Wisely recommend against ordering specific low-value tests, yet overuse of these tests remains widespread, and unnecessary care may account for up to a third of all medical expenditures. Studies have demonstrated that there is considerable geographic variation in health care usage and higher overall imaging among clinicians who own imaging equipment. No prior study has assessed whether prior ordering patterns of low-value care predict future ordering patterns or whether providers who order low-value imaging in one clinical scenario are more likely to do so in another scenario.
Study design: Retrospective analysis of insurance claims data.
Setting: Medical claims data from a large U.S. commercial health insurer, inclusive of 29 million commercially insured members across all 50 states from January 2010 to December 2014.
Synopsis: Using the claims database, researchers created three unique study samples to examine clinician predictors of low-value imaging. The study involved outpatient visits by patients aged 18-64 years without red-flag symptoms. The first included 1,007,392 visits across 878,720 patients with acute, uncomplicated low-back pain. Physicians who ordered imaging for the prior patient with back pain were 1.8 times more likely to do so again. Similarly, in 492,804 visits by 417,010 patients with headache, clinicians who ordered imaging on the prior patient demonstrated a twofold higher odds of imaging. Physicians who practiced low-value ordering for one condition were 1.8 times more likely to do so for the other. Across all studies, imaging ownership was an independent predictor (odds ratio, 1.8).
As this study analyzed only claims data, some patients may have warranted imaging based on red-flag symptoms that were not documented. Hospitalists designing initiatives to reduce low-value testing should consider targeting specific providers with a history of low-value test use.
Bottom line: Among commercially insured patients, a clinician’s prior imaging pattern and ownership of imaging equipment were strong independent predictors of low-value back pain and headache imaging.
Citation: Hong AS et al. Clinician-level predictors for ordering low-value imaging. JAMA Intern Med. 2017 Nov 1;177(11):1577-85.
Dr. Amber Inofuentes
Dr. Inofuentes is assistant professor of medicine, division of hospital medicine, University of Virginia.