Hospital-based primary care clinics more likely to order unnecessary tests and services

Primary care clinics at hospitals provide low-value care services to patients more often than community-based primary care clinics, according to a new study.

Researchers at the David Geffen School of Medicine at UCLA and Harvard Medical School say hospital-based clinics tend to refer too many patients to specialists and order too many CT scans, MRIs and X-rays. The findings, study authors said in an announcement, raised concerns about the value of care delivered in hospital-based primary care settings.

But the problem isn’t because the clinic is owned by a hospital or a physician. The disparity, researchers said, appears to be due to the location of the clinic.

Physicians who work in hospitals may be more likely to refer patients for those types of follow-up because they’re more immediately accessible and convenient, according to lead author John Mafi, M.D., an assistant professor of medicine at the Geffen School of Medicine and a primary care physician at Ronald Reagan UCLA Medical Center.

The research team compared records of 31,000 appointments over a 17-year period from The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases on outpatient visits to generalist physicians. They focused on patients who sought care for three common primary care conditions: Upper respiratory tract infection, back pain and headaches.

The study, published Monday in JAMA Internal Medicine, found both hospital-based and community-based clinics prescribed antibiotics at roughly the same rate. But patients who visited the hospital clinics were referred for MRIs and CT scans more often (8%) than those who went to community clinics (6%). They were also referred more often for X-rays (13% versus 9%) and far more often for an evaluation by a specialist (19% versus approximately 8%).

The patients most likely to receive unnecessary tests and services were those visiting hospital-based primary care clinics and seeing someone other than their usual physician. The study authors said this indicates that patients are more likely to be over-tested or over-treated when they bounce from physician to physician.

“Not seeing your regular primary care physician—what we call discontinuity of care—might be a weak spot where low-value care can creep in,” Bruce Landon, the study’s senior author, a Harvard Medical School professor of healthcare policy and of medicine who practices general internal medicine at the Beth Israel Deaconess Medical Center, said in the announcement. “The more we know about what situations are most likely to lead to patients receiving low-value care, the more we can do to prevent it.”

Insights from the study could help hospital-based clinics develop strategies to limit unnecessary referrals and tests. The first step: Hospital-based practices must be aware of their tendency to overuse certain tests and services of questionable therapeutic value for patients with uncomplicated conditions. “That knowledge can help both frontline clinicians and hospital leadership find ways to eliminate, or at least reduce, such unnecessary services,” Landon said.