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 health care services and higher rates of unnecessary medical tests and procedures.

In a report on the study published online May 18 in JAMA Internal Medicine, a trio of Johns Hopkins researchers say they analyzed 5 percent of Medicare claims using a previously validated set of 19 over-used procedures and a measure of so-called continuity of care.

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," says lead author Max Romano, M.D., M.P.H, a medical student at the Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health, "suggesting a potential benefit of high-continuity care," although the strength and direction of the association varied according to the specific procedure.

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

Each year, Romano says, 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 health care, but the links between continuity and specific patterns of procedure overuse had not been examined.

For the study, Romano 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.

"Our patients receive too much care that doesn't improve their health, and there is often a lack of continuity in the care they receive," says senior author Craig Evan Pollack, M.D., M.H.S., an associate professor of medicine at the Johns Hopkins University School of Medicine. "This work finds that poor continuity is linked with overuse of medical care."

"The scale of overuse is mindboggling," says 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 health care system and providers. The fragmented health care system may make it harder for their providers to make the best decisions."

Romano cautioned that the current study had limitations. For example, 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 says, "then it could really lead to a variety of policy decisions that could change our health care system for the better."