Abstract:
Importance:Facing new financial incentives to reduce unnecessary spending, health care organizations may attempt to reduce wasteful care by influencing physician practices or selecting more cost-effective physicians. However, physicians' role in determining the use of low-value services has not been well described. Objectives:To quantify variation in provision of low-value health care services among primary care physicians and to estimate the proportion of variation attributable to physician characteristics that may be used to predict performance. Design, Setting, and Participants:This retrospective analysis included national Medicare fee-for-service claims of 3 159 834 beneficiaries served by 41 773 generalist physicians from January 1, 2008, through December 31, 2013 (data were analyzed in 2016 through 2018). Multilevel modeling was used to estimate the extent of variation in service use across physicians within their region and provider organization, adjusted for patient clinical and sociodemographic characteristics and sampling variation. The proportion of variation attributable to physician characteristics that may be used to predict performance (age, sex, academic degree, professorship, publication record, trial investigation, grant receipt, pharmaceutical or device manufacturer payment, and panel size) was estimated via additional regression analysis. Main Outcomes and Measures:Annual count per beneficiary of 17 primary care-associated services that provide minimal clinical benefit. Results:Among the 3 159 834 beneficiaries (58.3% women; mean [SD] age, 73.2 [11.0] years) served by 41 773 physicians (74.9% men; mean [SD] age, 48.0 [10.1] years), the mean annual rate of low-value services was 33.1 services per 100 beneficiaries. Considerable variation across physicians within the same region was found (SD, 8.8 [95% CI, 8.7-8.9]; 90th:10th percentile ratio, 2.03 [95% CI, 2.01-2.06]) and across physicians within the same organization (SD, 6.1 [95% CI, 6.0-6.2]; 90th:10th percentile ratio, 1.61 [95% CI, 1.60-1.63]). The corresponding rates at the 10th percentile of physicians within region and within organization respectively were 21.8 and 25.3 services per 100 beneficiaries. Observable physician characteristics accounted for only 4.4% of physician variation within region and 1.4% of physician variation within organization. Conclusions and Relevance:Physician practices may substantially contribute to low-value service use, which is prevalent even among the least wasteful physicians. Because little variation is predicted by measured physician characteristics, direct measures of low-value care provision may aid organizational efforts to encourage high-value practices.
journal_name
JAMA Intern Medjournal_title
JAMA internal medicineauthors
Schwartz AL,Jena AB,Zaslavsky AM,McWilliams JMdoi
10.1001/jamainternmed.2018.5086subject
Has Abstractpub_date
2019-01-01 00:00:00pages
16-25issue
1eissn
2168-6106issn
2168-6114pii
2717501journal_volume
179pub_type
杂志文章abstract:Importance:Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed. Objective:To develop a reproducible index of nursing home crowding and dete...
journal_title:JAMA internal medicine
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doi:10.1001/jamainternmed.2020.6466
更新日期:2021-02-01 00:00:00
abstract:IMPORTANCE:There is wide variation in the management of thyroid nodules identified on ultrasound imaging. OBJECTIVE:To quantify the risk of thyroid cancer associated with thyroid nodules based on ultrasound imaging characteristics. METHODS:Retrospective case-control study of patients who underwent thyroid ultrasound ...
journal_title:JAMA internal medicine
pub_type: 杂志文章
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更新日期:2013-10-28 00:00:00
abstract:Importance:Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication. Objective:To evaluate the efficacy of a patient-specific preconversation communication-priming intervent...
journal_title:JAMA internal medicine
pub_type: 杂志文章,多中心研究,随机对照试验
doi:10.1001/jamainternmed.2018.2317
更新日期:2018-07-01 00:00:00
abstract:IMPORTANCE:Adherence to long-term therapies in chronic disease is poor. Traditional interventions to improve adherence are complex and not widely effective. Mobile telephone text messaging may be a scalable means to support medication adherence. OBJECTIVES:To conduct a meta-analysis of randomized clinical trials to as...
journal_title:JAMA internal medicine
pub_type: 杂志文章,meta分析,评审
doi:10.1001/jamainternmed.2015.7667
更新日期:2016-03-01 00:00:00
abstract:Importance:Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care. Objective:To describe cascades (tests, treatments, visits, hosp...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2019.1739
更新日期:2019-06-03 00:00:00
abstract:Importance:Medicare adopted transitional care management (TCM) payment codes in 2013 to encourage clinicians to furnish TCM services after beneficiaries were discharged to the community from medical facilities. To bill for the 30-day service, a care team member must communicate with the beneficiary or the caregiver wit...
journal_title:JAMA internal medicine
pub_type: 社论
doi:10.1001/jamainternmed.2018.2572
更新日期:2018-09-01 00:00:00
abstract:IMPORTANCE:Policies and practices that promote advance care planning and advance directive completion implicitly assume that patients' choices for end-of-life (EOL) care are stable over time, even with changes in health status. OBJECTIVE:To systematically evaluate the evidence on the stability of EOL preferences over ...
journal_title:JAMA internal medicine
pub_type: 杂志文章,评审
doi:10.1001/jamainternmed.2014.1183
更新日期:2014-07-01 00:00:00
abstract:IMPORTANCE:Chronic obstructive pulmonary disease (COPD) is a common and deadly disease. Long-acting inhaled β-agonists and anticholinergics, first-line medications for COPD, have been associated with increased risk of cardiovascular outcomes. When choosing between the medications, patients and physicians would benefit ...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2013.1016
更新日期:2013-07-08 00:00:00
abstract:IMPORTANCE:Healthcare overuse, the delivery of low-value services, is increasingly recognized as a critical problem. However, little is known about the comparative effectiveness of alternate formats for presenting benefits and harms information to patients as a strategy to reduce overuse. OBJECTIVE:To examine the effe...
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pub_type: 杂志文章,随机对照试验
doi:10.1001/jamainternmed.2015.7339
更新日期:2016-01-01 00:00:00
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journal_title:JAMA internal medicine
pub_type: 杂志文章,多中心研究
doi:10.1001/jamainternmed.2013.1026
更新日期:2013-07-08 00:00:00
abstract:Importance:Diabetic retinopathy (DR) is the leading cause of blindness in adults of working age in the United States. In the Los Angeles County safety net, a nonvertically integrated system serving underinsured and uninsured patients, the prevalence of DR is approximately 50%, and owing to limited specialty care resour...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2017.0204
更新日期:2017-05-01 00:00:00
abstract:Importance:The electronic cigarette (EC) has become popular among smokers who wish to reduce their tobacco use levels or quit smoking, but its effectiveness as a cessation aid is uncertain. Objective:To examine the association of regular EC use with the number of cigarettes smoked per day, smoking cessation among curr...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2019.1483
更新日期:2019-07-15 00:00:00
abstract:Importance:After a drug receives regulatory approval, researchers often pursue small, underpowered trials, called exploratory trials, aimed at testing additional indications. If favorable early findings from exploratory trials are not promptly followed by confirmatory trials, then physicians, patients, and payers can b...
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pub_type: 杂志文章
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更新日期:2019-01-01 00:00:00
abstract:IMPORTANCE:In individuals with human immunodeficiency virus 1 (HIV-1) infection who are receiving antiretroviral therapy (ART), factors that promote full immune recovery are not well characterized. OBJECTIVE:To investigate the influence of the timing of ART relative to HIV-1 infection on normalization of CD4+ T-cell c...
journal_title:JAMA internal medicine
pub_type: 杂志文章,多中心研究
doi:10.1001/jamainternmed.2014.4010
更新日期:2015-01-01 00:00:00
abstract:IMPORTANCE:Older patients with diabetes mellitus receiving medical treatment whose blood pressure (BP) or blood glucose level are potentially dangerously low are rarely deintensified. Given the established risks of low blood pressure and blood glucose, this is a major opportunity to decrease medication harm. OBJECTIVE...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2015.5110
更新日期:2015-12-01 00:00:00
abstract:IMPORTANCE:Studies have shown that bisphosphonates may have antitumor and antimetastatic properties. Recently, observational studies have suggested a possible protective effect of bisphosphonates on breast cancer, but the effect of bisphosphonate use on risk of breast cancer has not been tested in randomized trials. O...
journal_title:JAMA internal medicine
pub_type: 杂志文章,多中心研究,随机对照试验
doi:10.1001/jamainternmed.2014.3634
更新日期:2014-10-01 00:00:00
abstract:IMPORTANCE:The 2008 Physical Activity Guidelines for Americans recommended a minimum of 75 vigorous-intensity or 150 moderate-intensity minutes per week (7.5 metabolic-equivalent hours per week) of aerobic activity for substantial health benefit and suggested additional benefits by doing more than double this amount. H...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2015.0533
更新日期:2015-06-01 00:00:00
abstract:Importance:Approximately 1 million patients in the United States with type 2 diabetes mellitus and mild-to-moderate kidney disease do not receive guideline-directed therapy with metformin. This may reflect uncertainty regarding the risk of acidosis in patients with chronic kidney disease. Objective:To quantify the ass...
journal_title:JAMA internal medicine
pub_type: 杂志文章,多中心研究
doi:10.1001/jamainternmed.2018.0292
更新日期:2018-07-01 00:00:00
abstract:IMPORTANCE:For antidepressants, the translation of evidence of comparative effectiveness into practice is suboptimal. This deficit directly affects outcomes and quality of care for patients with depression. To overcome this problem, we developed the Depression Medication Choice (DMC) encounter decision aid, designed to...
journal_title:JAMA internal medicine
pub_type: 杂志文章,随机对照试验
doi:10.1001/jamainternmed.2015.5214
更新日期:2015-11-01 00:00:00
abstract:IMPORTANCE:Transthoracic echocardiography (TTE) accounts for almost half of all cardiac imaging services and is a widely available and versatile tool. Appropriate use criteria (AUC) for echocardiography were developed to improve patient care and health outcomes. Prior studies have shown that most TTEs are appropriate b...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2013.8972
更新日期:2013-09-23 00:00:00
abstract:IMPORTANCE:Cardiac biomarker testing is not routinely indicated in the emergency department (ED) because of low utility and potential downstream harms from false-positive results. However, current rates of testing are unknown. OBJECTIVE:To determine the use of cardiac biomarker testing overall, as well as stratified b...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2014.5830
更新日期:2015-01-01 00:00:00
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journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2019.4434
更新日期:2019-10-28 00:00:00
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journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2015.1853
更新日期:2015-07-01 00:00:00
abstract:BACKGROUND:A challenge in intensive obesity treatment is making care scalable. Little is known about whether the outcome of physician-directed weight loss treatment can be improved by adding mobile technology. METHODS:We conducted a 2-arm, 12-month study (October 1, 2007, through September 31, 2010). Seventy adults (b...
journal_title:JAMA internal medicine
pub_type: 杂志文章,随机对照试验
doi:10.1001/jamainternmed.2013.1221
更新日期:2013-01-28 00:00:00
abstract:Importance:Lung cancer has become a leading cause of death among people living with human immunodeficiency virus (HIV) (PLWH). Over 40% of PLWH in the United States smoke cigarettes; HIV independently increases the risk of lung cancer. Objective:To project cumulative lung cancer mortality by smoking exposure among PLW...
journal_title:JAMA internal medicine
pub_type: 杂志文章
doi:10.1001/jamainternmed.2017.4349
更新日期:2017-11-01 00:00:00
abstract:IMPORTANCE:Experts debate optimal 25-hydroxyvitamin D (25[OH]D) levels for musculoskeletal health. OBJECTIVE:To compare the effects of placebo, low-dose cholecalciferol, and high-dose cholecalciferol on 1-year changes in total fractional calcium absorption, bone mineral density, Timed Up and Go and five sit-to-stand t...
journal_title:JAMA internal medicine
pub_type: 杂志文章,随机对照试验
doi:10.1001/jamainternmed.2015.3874
更新日期:2015-10-01 00:00:00
abstract:IMPORTANCE:Biofeedback with device-guided lowering of breathing frequency could be an alternate nonpharmacologic treatment option for hypertension. Evidence from trials with high methodologic quality is lacking. OBJECTIVE:To evaluate the effects of device-guided lowering of breathing frequency on blood pressure in pat...
journal_title:JAMA internal medicine
pub_type: 杂志文章,随机对照试验
doi:10.1001/jamainternmed.2013.6883
更新日期:2013-07-22 00:00:00
abstract:Importance:Among patients who had acute kidney injury (AKI) during hospitalization, there is a need to improve risk prediction such that those at highest risk for subsequent loss of kidney function are identified for appropriate follow-up. Objective:To evaluate the association of post-AKI proteinuria with increased ri...
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pub_type: 杂志文章
doi:10.1001/jamainternmed.2019.6390
更新日期:2020-03-01 00:00:00
abstract:IMPORTANCE:The Institute of Medicine recently called for systematic improvements in clinician-led conversations about goals, values, and care preferences for patients with serious and life-threatening illnesses. Studies suggest that these conversations are associated with improved outcomes for patients and their famili...
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pub_type: 杂志文章,评审
doi:10.1001/jamainternmed.2016.3212
更新日期:2016-09-01 00:00:00
abstract:Importance:Chlorthalidone is currently recommended as the preferred thiazide diuretic to treat hypertension, but no trials have directly compared risks and benefits. Objective:To compare the effectiveness and safety of chlorthalidone and hydrochlorothiazide as first-line therapies for hypertension in real-world practi...
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pub_type: 杂志文章,多中心研究
doi:10.1001/jamainternmed.2019.7454
更新日期:2020-04-01 00:00:00