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Original Investigation
Less Is More
September 25, 2017

Clinician-Level Predictors for Ordering Low-Value Imaging

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 2Department of Clinical Science, University of Texas Southwestern Medical Center, Dallas
  • 3Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. Published online September 25, 2017. doi:10.1001/jamainternmed.2017.4888
Key Points

Question  Given that information concerning geographic variation in health care usage and higher overall radiographic imaging among clinicians who own imaging equipment is well described, is there evidence that ownership of imaging equipment, prior ordering history, and ordering behavior in other clinical scenarios are associated with low-value imaging?

Findings  Clinician specialty, imaging for the prior patient, ownership of imaging equipment, and very high rates of low-value imaging for other clinical scenarios are strong predictors of low-value imaging, after adjusting for patient demographics.

Meaning  There are several strong clinician predictors of low-value imaging that can guide intervention targets to improve the value of care for patients.

Abstract

Importance  Clinicians who order unnecessary radiographic imaging may cause financial harm to patients who have increasing levels of cost sharing. Clinician predictors of low-value imaging are largely unknown.

Objective  To characterize clinician predictors of low-value imaging for acute uncomplicated back pain and headache, including clinicians who saw both conditions.

Design, Setting, and Participants  Multivariate logistic regression modeling of imaging rates after acute uncomplicated back pain and headache visits as indicated by January 2010 to December 2014 commercial insurance claims and demographic data from a large US health insurer. Participants included 100 977 clinicians (primary care physicians, specialist physicians, and chiropractors).

Main Outcomes and Measures  Imaging after acute uncomplicated back pain and headache visits was recorded. We identified whether the clinician’s prior patient received imaging, whether the clinician was an owner of imaging equipment, and the varying impact by clinician specialty. We then used high rates of low-value back imaging as a predictor for low-value headache imaging.

Results  Clinicians conducted 1 007 392 visits for 878 720 adults ages 18 to 64 years with acute uncomplicated back pain; 52 876 primary care physicians conducted visits for 492 805 adults ages 18 to 64 years with acute uncomplicated headache; 34 190 primary care clinicians conducted 405 721 visits for 344 991 adults ages 18 to 64 years with headache and had also conducted at least 4 visits from patients with back pain. If a primary care physician’s prior patient received low-value back imaging, the patient had 1.81 higher odds of low-value imaging (95% CI, 1.77-1.85). This practice effect was larger for chiropractors (odds ratio [OR], 2.80; 95% CI, 2.74-2.86) and specialists (OR, 2.98; 95% CI, 2.88-3.07). For headache, a prior low-value head image predicted 2.00 higher odds of a subsequent head imaging order (95% CI, 1.95-2.06). Clinician ownership of imaging equipment was a consistent independent predictor of low-value imaging (OR, 1.65-7.76) across clinician type and imaging scenario. Primary care physicians with the highest rates of low-value back imaging also had 1.53 (95% CI, 1.45-1.61) higher odds of ordering low-value headache imaging.

Conclusions and Relevance  Clinician characteristics such as ordering low-value imaging on a prior patient, high rates of low-value imaging in another clinical scenario, and ownership of imaging equipment are strong predictors of low-value back and headache imaging. Findings should inform policies that target potentially unnecessary and financially burdensome care.

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