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Study Affirms Link Between Disjointed Care and Unnecessary Medical Procedures

A “look back” study of Medicare fee-for-service claims for more than 1.2 million patients over age 65 has directly affirmed and quantified a long-suspected link between lower rates of coordinated healthcare services and higher rates of unnecessary medical tests and procedures.

In a report on the study published online in JAMA Internal Medicine, Johns Hopkins researchers said they analyzed 5 percent of Medicare claims using a previously validated set of 19 overused procedures and a measure of so-called continuity of care.

For the study, lead author Max Romano, MD, MPH, and his colleagues measured the number of procedures each Medicare patient received that could be classified as potentially overused. The researchers defined overuse as services that may be provided in the absence of a clear medical basis, when the risk of harm exceeds its likely benefit. Examples of commonly overused procedures are antibiotics given for simple respiratory infections. Causes of overuse, according to Romano, include physicians who may not follow clinical guidelines and providers who inadvertently order procedures that a patient has already received.

Their results showed that 14.7 percent of patients were subjected to at least one potentially overused diagnostic, screening, monitoring, or treatment procedure in 2008. Overall, patients who had more continuity in their medical care had a lower chance of having an overused procedure. In particular, higher continuity was significantly associated with lower odds of nine procedures (six out of 13 diagnostic tests and three out of three therapeutic procedures).

Higher continuity was associated with increased overuse for just three procedures: routine monitoring of digoxin, an MRI of the lumbar spine for low back pain prior to conservative therapy, and thorax CT scans with and without contrast.

“Increased continuity was associated with lower rates of overuse, suggesting a potential benefit of high-continuity care,” said Romano, a medical student at the Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health. The strength and direction of the association varied according to the specific procedure.

“Conservative estimates suggest that 30 percent of all healthcare spending nationwide-roughly $600 billion annually-could be eliminated without any decrease in healthcare quality,” said Romano. “This research is important because it suggests that fractured patient care is related to this massive amount of overuse.”

Each year, Romano said, the average Medicare patient racks up 13 medical visits in four different practices, split among an average of two primary-care physicians and five specialists. This lack of continuity has previously been associated with higher costs and lower-quality healthcare, but the links between continuity and specific patterns of procedure overuse had not been examined.

“The scale of overuse is mindboggling,” said Romano. “Unfortunately, patients just don’t know which procedures are necessary and which aren’t. They have to put a lot of trust in the healthcare system and providers. The fragmented healthcare system may make it harder for their providers to make the best decisions.”

Romano cautioned that the current study had limitations because it only examined correlations between continuity and overuse. But Romano hopes that his team’s results will inspire a deeper investigation. “If further research can validate our findings and establish a causal relationship between continuity driving overuse,” Romano said, “then it could really lead to a variety of policy decisions that could change our healthcare system for the better.”

This article was adapted from information provided by Johns Hopkins Medicine.