Order History, Machine Ownership Leads to Low-Value Imaging

October 02, 2017 - Providers are more likely to order costly, low-value imaging services if they have a history of ordering the services, a high rate of imaging in another low-value clinical situation, and an ownership stake in the imaging equipment, uncovered a recent JAMA Internal Medicine study.

Healthcare stakeholders are seeking methods for reducing medically unnecessary and low-value resource use. Not only does the wasteful care account for about one-third of all healthcare spending, but low-value services may spur additional unnecessary care downstream, creating patient safety concerns.

Excessive medical testing and treatment result in about 30,000 deaths each year, the National Academy of Medicine reported.

But reducing expensive, low-value resource use may be a challenge for the healthcare industry because the unnecessary care stems from individual provider practice variation.

Using claims data from a large commercial payer from 2010 to 2014, researchers found individual provider behaviors and characteristics influenced the ordering of low-value imaging for low-back pain and headache cases.

The data revealed that the odds that a clinician would order low-value imaging for lower back pain patients were 2.59 times greater if that provider had already ordered low-value back imaging for the previous patient.

The chances were higher for chiropractors and specialists treating patients with low-back pain. The odds of low-value imaging being performed if the prior patient had received imaging was 2.80 times higher for chiropractors and 2.98 times greater for specialists.

On the other hand, primary care providers were less likely to order wasteful low-back imaging services, with the odds of low-value imaging occurring being 2.08 times higher if the provider had just prescribed the service to the previous patient.

Researchers observed a similar trend in headache cases. The median odds that a provider would order low-value headache imaging was 2.49 times higher if the clinician had just prescribed the same service for the prior patient.

The prescription of low-value back imaging was also linked to higher rates of unnecessary or wasteful headache imaging. Clinicians that demonstrated high rates of low-value back imaging were 1.78 times more likely to order low-value headache imaging.

Additionally, the study found that ownership stakes in imaging equipment also prompted providers to engage in low-value resource use.

Provider ownership of imaging equipment significantly increased the odds that all three provider types would order unnecessary or wasteful imaging for noncomplicated acute low-back pain. Primary care providers showed 2.06 increased odds, while chiropractors exhibited 7.76 increased odds and specialist demonstrated 4.96 increased odds.

For low-value headache imaging, provider ownership predicted 1.88 higher odds of the service.

Researchers explained that policymakers have attempted to limit imaging equipment ownership among providers as well as clinician self-referral. However, exceptions to the rules because of patient convenience concerns and changing practice models have made the regulations less effective at controlling ownership stakes among providers.

The study’s findings may have serious financial implications for commercially insured patients, researchers added. With patients increasingly becoming more responsible for healthcare costs under high-deductible plans, low-value imaging may add to patient financial responsibility.

Nearly four in ten adults were enrolled in employer-based high-deductible health plans in 2016. The plans had a minimum of $1,300 in individual deductibles or $2,600 in family coverage deductibles, the National Center for Health Statistics recently reported.

If patients are not able to avoid low-value imaging because of provider orders, the unnecessary or wasteful services create financial toxicity for patients.

However, some stakeholders believe that greater cost sharing may prompt patients to prevent and avoid low-value resource use. Clinicians identified patient demand as the key driver of unnecessary medical care, particularly for imaging, several cited studies reported.

With patients bearing a greater portion of the economic burden, though, patient demand for expensive, low-value services could decrease.

Regardless, researchers recommended that healthcare stakeholders design interventions that target clinicians and their behaviors to successfully reduce low-value resource use.

Implementing EHR changes may be the key to establishing effective clinician-targeted interventions, a recent analysis showed. California-based hospitals that implemented an alert in their physician EHR workflow reduced test ordering.

For example, Cedars-Sinai Medical Center in Los Angeles alerted providers through the EHR when a test or drug order did not align with the Choosing Wisely campaign, an initiative that shares low-value resource use educational tools and best practices with providers.

The EHR alert approach saved the medical center $6 million within the first year of implementation.