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    1 Comment for this article
    Improving value in health care
    Frederick Rivara, MD, MPH | University of Washington
    All of our medical centers and health care systems are working on improving value based care in order to survive. This study points out a way to identify physicians who may need the most help in changing their practices to reduce low-value tests.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    Health Policy
    October 12, 2018

    Physician Characteristics Associated With Ordering 4 Low-Value Screening Tests in Primary Care

    Author Affiliations
    • 1Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
    • 2currently a student at Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
    • 3Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
    • 4Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    • 5Center for Clinical Management, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
    • 6Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    • 7Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    • 8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
    • 9Division of General Internal Medicine and Geriatrics, Sinai Health System and Health Network, Toronto, Ontario, Canada
    • 10Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
    • 11Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
    • 12Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
    JAMA Netw Open. 2018;1(6):e183506. doi:10.1001/jamanetworkopen.2018.3506
    Key Points español 中文 (chinese)

    Question  Do physicians who order a high frequency of 1 low-value screening test also order a high frequency of other low-value screening tests?

    Findings  In this cohort study of 2394 primary care physicians, 18.4% of the physicians were in the top ordering quintile of at least 2 of 4 low-value screening tests. These physicians ordered 39.2% of all low-value screening tests.

    Meaning  The study findings suggest that efforts to reduce low-value care should consider strategies that focus on physicians who order a high frequency of low-value care.


    Importance  Efforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently.

    Objectives  To measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care.

    Design, Setting, and Participants  A retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests—repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)—among low-risk outpatients rostered to a common cohort of primary care physicians.

    Exposures  Physician sex, years since medical school graduation, and primary care model.

    Main Outcomes and Measures  This study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician’s propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2).

    Results  The final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users.

    Conclusions and Relevance  This study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.