Abstract
Overuse of health care services exposes patients to unnecessary risk of harm and costs. Distinguishing patterns of overuse among hospitals requires hospital-level measures across multiple services. To describe characteristics of hospitals associated with overuse of health care services in the US. This retrospective cross-sectional analysis used Medicare fee-for-service claims data for beneficiaries older than 65 years from January 1, 2015, to December 31, 2017, with a lookback of 1 year. Inpatient and outpatient services were included, and services offered at specialty and federal hospitals were excluded. Patients were from hospitals with the capacity (based on a claims filter developed for this study) to perform at least 7 of 12 investigated services. Statistical analyses were performed from July 1, 2020, to December 20, 2020. Outcomes of interest were a composite overuse score ranging from 0 (no overuse of services) to 1 (relatively high overuse of services) and characteristics of hospitals clustered by overuse rates. Twelve published low-value service algorithms were applied to the data to find overuse rates for each hospital, normalized and aggregated to a composite score and then compared across 6 hospital characteristics using multivariable regression. A k-means cluster analysis was used on normalized overuse rates to identify hospital clusters. The primary analysis was performed on 2415 cohort A hospitals (ie, hospitals with capacity for 7 or more services), which included 1 263 592 patients (mean [SD] age, 72.4 [14] years; 678 549 women [53.7%]; 101 017 191 White patients [80.5%]). Head imaging for syncope was the highest-volume low-value service (377 745 patients [29.9%]), followed by coronary artery stenting for stable coronary disease (199 579 [15.8%]). The mean (SD) composite overuse score was 0.40 (0.10) points. Southern hospitals had a higher mean score than midwestern (difference in means: 0.06 [95% CI, 0.05-0.07] points; P < .001), northeast (0.08 [95% CI, 0.06-0.09] points; P < .001), and western hospitals (0.08 [95% CI, 0.07-0.10] points; P < .001). Nonprofit hospitals had a lower adjusted mean score than for-profit hospitals (-0.03 [95% CI, -0.04 to -0.02] points; P < .001). Major teaching hospitals had significantly lower adjusted mean overuse scores vs minor teaching hospitals (difference in means, -0.07 [95% CI, -0.08 to -0.06] points; P < .001) and nonteaching hospitals (-0.10 [95% CI, -0.12 to -0.09] points; P < .001). Of the 4 clusters identified, 1 was characterized by its low counts of overuse in all services except for spinal fusion; the majority of major teaching hospitals were in this cluster (164 of 223 major teaching hospitals [73.5%]). This cross-sectional study used a novel measurement of hospital-associated overuse; results showed that the highest scores in this Medicare population were associated with nonteaching and for-profit hospitals, particularly in the South.
Highlights
Overuse is defined as the delivery of tests and procedures that provide little or no clinical benefit, are unlikely to have an impact on clinician decisions, increase health care spending without improving health outcomes, or risk patient harm in excess of potential benefits.[1]
Key Points Question What hospital characteristics are associated with overuse of health care services in the US? Findings In this cross-sectional study of 1 325 256 services performed at 3351 hospitals, we found that hospitals in the South, for-profit hospitals, and nonteaching hospitals were associated with the highest rates of overuse
Studies at the level of physicians, organizations, and hospital referral regions have measured overuse patterns in claims data, including Medicare, Medicaid, and commercially insured populations.[5,6,7,8,9,10]. These results show considerable variation across physician organizations, including within hospital referral regions and across physicians within the same organization, the included physician demographic characteristics did not explain a substantial amount of such variation.[10]
Summary
Overuse is defined as the delivery of tests and procedures that provide little or no clinical benefit, are unlikely to have an impact on clinician decisions, increase health care spending without improving health outcomes, or risk patient harm in excess of potential benefits.[1]. Hospital-level interventions to reduce overuse exist,[11] but to measure and compare their success, a hospital-level measure is required. This study offers such a measure, based on the overuse rates of 12 low-value services, and compares rates across hospital regions, ownership type, safety net status, and teaching status. We use cluster analysis to investigate patterns of overuse and whether these patterns are associated with particular hospital characteristics
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