Primary Care Practice Location and Ownership and the Provision of Low Value Care in the United States

Abstract

IMPORTANCE

Hospital-employed physicians provide primary care within the hospital or within community office practices. Yet, little is understood regarding the impact of hospital location and ownership on the delivery of low value care.

OBJECTIVE

To assess the impact of hospital location and hospital ownership on the use of low value health services.

DESIGN

We compared low value service use after primary care visits at (1) hospital-based outpatient practices vs. community-based office practices and (2) hospital-owned vs. physician-owned community-based office practices. We used logistic regression models adjusting for patient/provider characteristics and year, and weighted results to reflect population estimates. We also stratified results by symptom acuity and whether the generalist physician (e.g., general internist, family practitioner) was the patient’s primary care provider (PCP).

SETTING

Nationally representative data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey on outpatient visits to generalist physicians from 1997–2013.

PARTICIPANTS

Patients presenting with three common primary care conditions: upper respiratory infections (URIs), back pain, and headache.

MAIN OUTCOMES

Use of antibiotics (for URIs), CT/MRI (for back pain, headache), x-rays (for URIs, back pain), and specialty referrals (for all three conditions).

RESULTS

We identified 31,162 visits (representing ~739 million U.S. visits) during the study period. Compared to visits with community-based physicians, patients in visits to hospital-based physicians were younger (mean age 44.5 vs. 49.1 years, p<.001) and less frequently saw their PCP (52.7% vs. 81.9%, p<.001). Although antibiotic use was similar in both settings, hospital-based visits had more orders of CT/MRI (8.3% vs. 6.3%, p=.012), x-rays (12.8% vs. 9.9%, p<.001), and specialty referrals (19.0 % vs. 7.6%, p<.001) than community-based visits. Multivariable adjustment and symptom-acuity stratification revealed similar findings. Non-PCP visits also were associated with greater provision of low value care, but mainly within hospital-based settings. Visits to hospital-owned community-based practices were associated with more specialty referrals than visits to physician-owned community-based practices.

CONCLUSIONS AND RELEVANCE

Visits to U.S. hospital-based practices are associated with greater use of low value CT/MRI, x-rays, and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. These findings raise concerns about the value of hospital-associated primary care delivery.

Low value care is defined as patient care that provides minimal average benefit in specific clinical scenarios.¹ Despite decades of widely publicized studies and national clinical guidelines, our healthcare system still provides large amounts of low value care, such as advanced diagnostic imaging for low back pain or headache, or antibiotics for upper respiratory infections.^2–5 Evidence also suggests that many of these unnecessary services are increasing over time.^6,7 Eliminating low value care could not only substantially lower healthcare costs, but also reduce preventable patient harm, such as exposure to adverse reactions from unnecessary antibiotics or excessive radiation from diagnostic imaging.^3,6–9

Little is known about the correlates of low value care in the U.S., and such an understanding is essential in determining the most effective interventions to curb the use of such services. Previous work suggests that variation in healthcare delivery is in part influenced by structural factors,¹⁰ such as practice location or practice ownership.^11–13 For example, hospital-based outpatient practices (outpatient practices located on hospital campuses) typically have more readily accessible technologies such as nearby advanced imaging scanners and specialty services when compared with community-based office practices.^14,15 In contrast, community-based office practices that are owned by a hospital may have more salaried physicians with less incentive to overuse health services compared with physician-owned community-based practices, where compensation may be more related to the volume of services provided. Few have evaluated the extent to which practice location and ownership characteristics impact the provision of low value ambulatory care.

In this context, we used nationally representative data on ambulatory visits to generalist (e.g., general internists, family practitioners) providers to determine whether ambulatory practice location and ownership are associated with the provision of low value health services for three common conditions seen in the primary care setting.

METHODS

We used data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) on ambulatory visits to physicians, nurse practitioners, and physician assistants from January 1^st, 1997 to the most recently available data—December 31^st, 2013 for NAMCS and December 31^st, 2011 for NHAMCS. The NAMCS is comprised of probability samples of outpatient visits to nonfederal office-based physician practices, while the NHAMCS consists of data on visits to nonfederal, hospital outpatient departments and emergency departments. Designed in parallel, the NAMCS and NHAMCS share common design, variables, and patient visit weights. They are also both structured to represent ambulatory visits to physicians across the United States.^16,17

Data Collection Procedures

The NAMCS and NHAMCS both use standardized surveys completed soon after the visit. Both contained chief complaint information, symptom duration and context, and 2 other non-primary reasons for the visit. The NAMCS and NHAMCS also both contain up to three ICD-9-CM diagnostic codes and both include patient, provider, payer, and practice setting characteristics, as well as diagnostic tests, treatments, and medications listed during the visit. From 2005–2013, NAMCS and NHAMCS also collected data on 14 common comorbidities (e.g., congestive heart failure, COPD, cancer). Missing data are rare (e.g., answers to the survey question, “Have you or anyone in this practice seen this patient before?” are missing 2.9% of the time), and multiple imputation techniques are used for missing data.¹

Eligible Visits

We selected outpatient visits for common conditions seen in the primary care setting, which we defined as patient visits to an internist, general practitioner, or family practitioner in NAMCS, and patient visits to general medical clinics in NHAMCS.^1,15 Based on prior research, we chose three episodic conditions that are frequently associated with low value care: (1) upper respiratory infections (URIs, such as acute bronchitis and pharyngitis), (2) back pain, and (3) headache, which are commonly treated by generalists or in general medical clinics and based on prior research.^1,6,7

We excluded visits with clinical red flags noted on the presenting complaints or diagnoses addressed at the visit, which would indicate more serious or complex presentations, such as symptoms or diagnoses of cancer for patients presenting with back pain, or symptoms or diagnoses of COPD for patients presenting with URI as described previously.^1,3,6,7,18

Practice Location and Ownership of Community Practices

Hospital-based practices were represented by NHAMCS data whereas community-based practices were derived from NAMCS data. We excluded other settings included in NAMCS, such as health maintenance organizations, federally qualified health centers, mental health centers, non-federal government clinics, family planning clinics, free standing clinic/urgent centers, faculty practice plans, and “other” setting because they fell outside the scope of our primary care focused study and/or had insufficient numbers of visits.

NAMCS also provided information on the owners of the community practice, specifically, whether the practice setting is owned by a physician group or owned by a hospital.^12,19 We defined hospital-owned practices as community-based practices owned by an “academic medical center” or “other hospital”; physician-owned practices were defined as community-based practices owned by a “physician or physician group”.

Primary Outcome Measures

Our primary outcomes were broadly accepted measures of low value care that were also recently endorsed by the Choosing Wisely Campaign for three common conditions: uncomplicated URIs, back pain, and headache.²⁰ We considered low value care as use of antibiotics for patients with URIs, use of computed tomographic scans (CT) or magnetic resonance imaging scans (MRI) for patients with either back pain or headache, and use of plain x-rays for patients with either URIs or back pain. As a secondary outcome, we evaluated referrals to another physician for all three conditions, because these conditions typically should be managed in primary care settings, and specialty referrals could be indicative of further unnecessary downstream utilization (of note, the referral variable was added to the survey instruments starting in 1999).

Potential Confounders

Our analyses adjusted for potential confounders, including age (measured as a continuous variable in years), sex, race/ethnicity (defined as a single, four-level variable including white, black, Hispanic, and other), insurance status, modified Charlson disease count,^1,21 urban vs. rural location, geographic region (one of four quadrants in the U.S.), and calendar year.

We also specifically evaluated whether practice location was confounded by symptom acuity, patient comorbidities, and whether the generalist was the patient’s primary care physician. Importantly, for all chief complaints, the NAMCS and NHAMCS symptom duration/context variable divides into 5 categories: (1) new onset symptoms (<3 months’ duration), (2) acute on chronic flare-up (acute exacerbation of a chronic condition), (3) chronic routine, (4) routine or preventive care, and (5) pre or post-operative visit. We defined acute visits by combining the categories new onset symptoms with acute on chronic flare-up. For additional case mix assessment beyond the Charlson comorbidity count, we also evaluated the 14 comorbidities (e.g., congestive heart failure, COPD, cancer, only available from 2005 on) directly collected by the survey (collected from the problem list or further chart review) from 2005–2011.

Statistical Analysis

Our primary analyses focused on examining two relationships: 1) the association between practice location (hospital-based vs. community-based) and low value service use and 2) the association between hospital-ownership of community-based practices and low value service use. We used the combined data from NAMCS and NHAMCS through 2011 to examine the first relationship and NAMCS data only through 2013 to test the second association.

We pooled all years in each outcome category and used bivariable logistic regression models to compare low value service use between hospital-based practices vs. community-based practices (NHAMCS vs. NAMCS, 1997–2011) and between hospital-owned community-based practices vs. physician-owned community-based practices (NAMCS vs. NAMCS, 1997–2013). In our multivariable adjusted analyses, we adjusted for the previously mentioned demographic, clinical, and provider variables. We also controlled for year.

Because our first study question might be particularly prone to patient selection bias (e.g., patients presenting to hospital-based practices may be more complex than those presenting to community-based practices) we performed four pre-specified sensitivity analyses where we evaluated important potential effect modifiers including (1) stratification of results by whether the patient saw their own primary care provider (PCP) or another generalist, and interacting the PCP variable with the practice location variable, (2) stratification by acute vs. non-acute presentations, (3) comparing the proportion of patients who had any of the 14 comorbidities between hospital-based vs. community-based visits (Supplement) and a sub-analysis of adding patient comorbidity counts to the models from 2005–2011, and (4) evaluating trends in utilization over time among hospital-based practices vs. community-based practices (Supplement).

Importantly, in 2007 the NHAMCS survey changed the question, “are you the patient’s primary care physician/provider?” to “is this clinic the patient’s primary care provider?”, which could affect the PCP vs. non-PCP analysis. We therefore performed an additional sensitivity analysis evaluating this stratification before and after the survey wording change (Supplement, eTables 1–2), which revealed consistent results. Additionally, in order to assess whether the PCP variable also was reflecting continuity of care, we performed a sensitivity analysis of only established clinic patient visits by using a second variable that asked: “Have you or anyone in this practice seen this patient before?” because established patients seeing their PCP would better reflect continuity of care.

We performed all of our analyses using SAS-callable SUDAAN, version 11.0 (RTI International), using SUDAAN subpopulation procedures. These functions use data from the entire NAMCS and NHAMCS sample in order to account for the complex multistage survey design and population weighting in order to produce national estimates.²²

The UCLA Institutional Review Board determined that this study was exempt from review.

RESULTS

We identified 31,162 visits for URIs (n=11,049), back pain (n=14,821), and headache (n=5,695) combined, representing an estimated 739 million U.S. primary care visits from 1997–2013. Patients seen at hospital-based practices generally were younger (mean age 44.5 vs. 49.1 years, p<.001) and the hospital-based providers were less likely to be the patient’s usual PCP (52.7% vs. 81.9%, p<.001) compared with community-based visits (Table 1). Patients seen at hospital-owned and physician-owned community practices were more similar demographically, although physician-owned community-based practices had a greater proportion of non-white patient visits than hospital-owned community-based practices.

Table 1.

Characteristics of All Community-Based Office Practices vs. Hospital-Based Practices and Physician-Owned vs. Hospital-Owned Community Office Practices^a

	All Community Office Practices (n=9,783) (ref)	Hospital-Based Practices (n=16,306)	P- value	Physician-Owned Community Office Practices (n=10,395)	Hospital-Owned Community Office Practices (n=1,038)	P-Value
1997–2011				1997–2013
Mean Age (Years)	49.1	44.5	<.001	49.7	49.6	.88
Female	62.7	65.0	.011	62.5	62.8	.85
Race/Ethnicity			.001			<.001
White	77.8	72.5		76.5	85.4
Black	10.2	15.1		10.7	8.7
Hispanic	7.6	9.2		8.2	3.2
Other	4.4	3.1		4.6	2.7
Mean Charlson Comorbidity Count	0.048	0.043	.39	0.049	0.041	.27
Acute Symptoms	72.2	77.8	.001	71.2	77.1	.015
Insurance			<.001			.68
Private	59.2	45.2		53.2	54.6
Medicare/Medicaid	26.4	33.3		23.9	24.5
Other	14.4	21.6		22.9	20.9
Provider identifies as PCP	81.9	52.7	<.001	82.7	82.1	.79
Urban Location	81.7	74.9	.051	82.4	79.4	.40
Geographic Region			.013			<.001
Northeast	20.3	17.6		21.3	16.5
Midwest	24.1	34.7		21.4	38.0
South	37.6	32.8		38.3	37.3
West	18.1	14.9		19.0	8.2
Complaintsb
URIs	36.0	38.1	.20	35.3	37.8	.31
Back Pain	47.1	45.0	.14	48.4	45.9	.23
Headache	18.2	18.1	..94	17.7	17.2	.79

PCP = primary care provider, URI = upper respiratory infection

^aHospital-based outpatient practice data are only available from 1997–2011.

^bComplaint group proportions may not add to 100% because a small number of patients fit into more than one category.

Practice Location

Antibiotic use was similar in visits to both locations. Visits to hospital-based practices, however, had higher use of CT or MRI (8.3% vs. 6.3%, p=.012), x-rays (12.8% vs. 9.9%, p<.001), and specialty referrals (19.0% vs. 7.6%, p<.001) compared with community-based visits (Table 2). Multivariable adjustment revealed similar findings to the unadjusted results (Table 2).

Table 2.

Unadjusted Utilization Frequencies Presented as Sample Numerator/Sample Denominator^a (%) and Multivariable Adjusted^b Utilization Rates and Adjusted Odds Ratio by Stratified Practice Setting, 1997–2011

	Community-Based Practice (n=9,783) (ref)	Hospital-Based Practices (n=16,306)	P-value	Community- Based Practice (n=9,730) (ref)	Hospital-Based Practices (n=16,306)	aOR
	Unadjusted			Adjusted
Antibiotics (URI)	1,684/3,389 (49.1)	2,898/6,023 (52.1)	.156	49.4	49.2	0.99 [0.82–1.21]
CT/MRI (Back pain/headache)	404/6,443 (6.3)	726/10,346 (8.3)	.012	5.8	8.2	1.44 [1.13–1.85]
X-Ray (Back Pain)	775/8,123 (9.9)	1,689/13,451 (12.8)	<.001	9.5	12.9	1.41 [1.16–1.71]
Specialty Referrals (all 3 conditions)	740/9,783 (7.6)	3,128/16,306 (19.0)	<.001	7.1	17.3	2.74 [2.23–3.36]

Bold values indicate comparisons with p-values less than .05.

URI = upper respiratory infection; aOR = adjusted odds ratio

^aPercentages may not match the value of the numerator divided by the denominator because percentages are population weighted.

^bModels adjusted for age, sex, race/ethnicity, insurance status, symptom acuity, comorbidities, geographic region, urban location, and whether the generalist was the patient’s usual primary care provider.

Practice Location Stratified and Sensitivity Analyses

Regarding our first study question of comparing low value service use at hospital-based vs. community-based practices, we evaluated whether important effect-modifiers could explain differences in practice patterns. Stratification by PCP vs. non-PCP visits revealed that non-PCP visits were associated with higher use of both imaging and specialty referrals, but primarily within hospital-based practices (Table 3). For instance, at hospital-based practice visits with non-PCPs, x-rays were ordered 13.7% of the time vs. 8.5% of the time among community-based non-PCP visits (aOR 1.70 [1.21–2.39], p=.080 for interaction), and referrals were ordered 26.1% of the time vs. 5.5% of the time among community-based non-PCP visits (aOR 6.10 [4.42–8.42], p<.001 for interaction). In contrast, stratification by symptom acuity revealed similar findings in both subgroups (Table 4).

Table 3.

Multivariable Adjusted^a PCP vs. non-PCP Visit Utilization Rates by Practice Location, 1997–2011 (%)

	Community-Based Practice (ref) PCP n=7,913 Non-PCP n=1,870	Hospital-Based Practice PCP n=7,957 Non-PCP n=8,349	aOR
Antibioticsb
PCP	49.0	45.1	0.85 [0.70–1.04]
Non-PCP	50.2	55.3	1.23 [0.92–1.64]
CT/MRIc
PCP	6.2	7.2	1.18 [0.89–1.58]
Non-PCP	4.1	8.8	2.27 [1.49–3.44]
X-Rayd
PCP	9.7	11.4	1.20 [0.98–1.48]
Non-PCP	8.5	13.7	1.70 [1.21–2.39]
Specialty Referralse
PCP	7.4	9.3	1.29 [1.05–1.60]
Non-PCP	5.5	26.1	6.10 [4.42–8.42]

PCP = primary care provider; aOR = adjusted odds ratio

^aModels adjusted for age, sex, race/ethnicity, insurance status, symptom acuity comorbidities, geographic region, and urban location.

^bp=0.058 for interaction between PCP vs. non-PCP and hospital-based practice vs. community-based practice setting.

^cp=0.072 for interaction between PCP vs. non-PCP and hospital-based outpatient practice vs. community office practice setting.

^dp=0.080 for interaction between PCP vs. non-PCP and hospital-based outpatient practice vs. community office practice setting.

^ep<.001 for interaction between PCP vs. non-PCP and hospital-based outpatient practice vs. community office practice setting.

Table 4.

Multivariable Adjusted^* Acute vs. Non-Acute Visit Utilization Rates by Practice Setting, 1997–2011 (%)

	Community-Based Practice (ref) Acute n=7,101 Nonacute n=2,682	Hospital-Based Practice Acute n=12,428 Nonacute n=3,878	aOR
Antibiotics
Acute	51.5	51.2	0.99 [0.82–1.21]
Non-acute	34.2	27.0	0.71 [0.41–1.24]
CT/MRI
Acute	6.9	8.6	1.27 [1.02–1.58]
Non-acute	3.8	7.4	2.03 [1.25–3.31]
X-Ray
Acute	10.5	13.1	1.28 [1.05–1.57]
Non-acute	6.4	12.5	2.09 [1.46–3.00]
Specialty Referrals
Acute	7.1	17.9	2.85 [2.29–3.54]
Non-acute	6.9	13.4	2.10 [1.49–2.96]

aOR = adjusted odds ratio

^*Models adjusted for age, sex, race/ethnicity, insurance status, comorbidities, geographic region, urban location, and whether the generalist was the patient’s usual primary care provider.

In our sensitivity analysis of only established clinic patients, we found similar results to our main findings among non-PCP and PCP visits, supporting the notion that differences in low value care were associated with discontinuity of care within the hospital setting (eTable 3). In our comorbidity sensitivity analysis, which was restricted to 2005 on when these data were available (eTable 4), we found that patients seen at community-based practices had more comorbidities than those seen at hospital-based practices (1.25 vs. 1.09 mean comorbidities per patient respectively, p=.023). When we added comorbidity counts to our adjusted models, results remained unchanged. Finally, utilization trends revealed that hospital-based practices consistently provided more low value CT/MRIs, x-rays, and specialty referrals than community-based practices over time (eTable 5).

Community Practice Ownership

We found no significant differences between visits to hospital-owned community-based practices and physician-owned community-based practices in terms of utilization of antibiotics, CT/MRI, or x-rays. We did find, however, that visits to hospital-owned community-based practices were associated with more specialty referrals than visits to physician-owned community-based practices (Table 5).

Table 5.

Unadjusted Numerator/Denominator and Adjusted^* Visit-Based Utilization Rates in the Community-Based Office Practice Setting by Ownership Arrangement, 1997–2013 (%)

	Physician-owned community-based practice (ref) (n=10,395)	Hospital-owned community-based practice (n=1,038)	P-value	Physician-owned community-based practice (ref) (n=10,395)	Hospital-owned community- based practice (n=1,038)	aOR
	Unadjusted			Adjusted
Antibiotics (URI)	1,704/3,488 (48.3)	194/360 (54.3)	.23	48.3	53.7	1.24 [0.84–1.84]
CT/MRI (Back pain/headache)	340/5,287 (6.4)	26/455 (5.1)	.39	5.8	5.3	0.92 [0.58–1.45]
X-Ray (Back Pain)	801/8,656 (9.6)	97/872 (10.2)	.60	9.2	9.5	1.04 [0.79–1.37]
Specialty Referrals (all 3 conditions)	831/10,395 (7.9)	112/1,038 (9.8)	.071	7.2	9.8	1.40 [1.09–1.82]

URI = upper respiratory infection, aOR = adjusted odds ratio

^*Models adjusted for age, sex, race/ethnicity, insurance status, symptom acuity, comorbidities, geographic region, urban location, and whether the generalist was the patient’s usual primary care

COMMENT

In this large and nationally representative sample of ambulatory care, we find that visits to hospital-based practices are associated with higher use of three forms of low value healthcare services compared to visits to community-based practices—specifically, greater use of low value CT/MRI and x-rays and more low-value referrals to specialists. Moreover, in hospital-based practices, low value care was associated with visits where the provider was not the patient’s PCP. We also found that hospital-owned community-based practices were associated with more low value specialty referrals than physician-owned community-based practices. Overall, these findings raise concerns about the value of hospital-associated primary care delivery.

Few prior studies directly compare the quality and efficiency of care between hospital-based practices and community-based practices. One comprehensive analysis using Medicare data from the 1980s found no meaningful differences in quality and costs of care when comparing the two settings.²³ A different national analysis using NAMCS and NHAMCS data from the 1990s found that clinicians at hospital-based practices used more imaging, minor surgeries, and specialty referrals compared with community-based clinicians—generally consistent with our findings.¹⁵ The data from this latter study are nearly 20 years old, however, and the utilization measures were not calibrated to determine the quality and efficiency of care, as the analysis did not exclude important guideline-based red flags or account for symptom acuity. Moreover, neither of these prior studies specifically compared differences in use of low value care services. Thus our work adds recent data to the literature and specifically highlights the greater use of costly and low value services at hospital-based practices compared with community-based practices.

We found that community-based practices that are owned by hospitals use similar amounts of low value CT/MRI, and x-rays, but made more specialty referrals than physician-owned community-based practices. Although we are unable to determine the cause of this finding with the data at hand, it is possible that hospital ownership of a practice leads to easier access to specialists or a broader network of specialty services than physician ownership. Prior studies have determined that larger, more integrated healthcare providers deliver more costly care without any benefit in quality or efficiency of care, and by some measures even worse quality of care, but at least in part, these findings might be related to higher reimbursement for hospital-owned practices, which we did not assess in this study.^11,24,25 Some commentators have raised concerns that such arrangements could result in both higher prices as well as higher rates of overuse. Our findings add important data to this literature, suggesting that hospital-owned primary care practices provide more potentially unnecessary specialty referrals when compared to physician-owned primary care practices.

Greater use of low value services within hospital-based practices may be related to greater availability of diagnostic imaging and specialty services within hospitals themselves,^14,15 and this notion is supported by the fact that our findings revealed differences primarily with use of CT/MRI, x-rays, and specialty referrals, but not antibiotics, which would not be impacted by hospital location. We also found that in only half of visits in hospital-based practices did the provider identify as the patient’s PCP compared with over 80% of visits to community-based generalists. These non-PCP visits are associated with greater use of low value services, but primarily within hospital-based settings. Such findings suggest that the combination of hospital-based settings and discontinuity of care may be related to greater use of low value health services. Prior studies found that greater continuity of care with a primary care provider is associated with higher value care, in terms of greater use of preventive care, reduced costs, and lower rates of ED visits, hospitalizations, and all-cause mortality.^26–30

Our study has limitations. These measures do not represent all low value care, and we cannot definitively conclude that our outcomes are low value in every instance because we lacked the detailed clinical data required to identify the rare instances when the service might have been of higher value. However, the measures we studied have been widely identified as being low value in the majority of circumstances and we used rigorous methods to exclude cases with any symptoms/diagnoses of clinical red flags, which were created from evidence-based guidelines and prior research.^{1,3,6,7,18,31–34} Moreover, our analysis excluded patients with the most important markers of complexity relevant to our outcomes, such as any diagnosis or symptom of trauma or neurologic deficit among patients with back pain. We also cannot eliminate the possibility of selection bias, as patients presenting to hospital-based practices may be more complex or may have different preferences than patients presenting to community-based practices. However, neither adjustment nor stratification by symptom acuity altered our findings. In addition, our analysis revealed that community-based practice patients were older than hospital-based patients, and our comorbidity sensitivity analysis (using chart-verified comorbidities) found that community-based patients actually had more comorbidities than hospital-based patients. Importantly, because the NAMCS and NHAMCS share common survey design, patient weights, and variables (including clinical diagnoses, imaging studies, specialty referrals, etc.), measurement error would be unlikely to differ by practice setting. Finally, we could not control for physician age and it is possible that younger physicians were in part driving the greater use of low value services within hospital-based practices.^35,36

In this nationally representative sample, we found that hospital-based practices were associated with more low value care compared with community-based practices and that visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. Our results also suggest that low value care may be related to greater discontinuity of care within hospitals. Overall, these findings raise general concerns about the value and efficiency of hospital-associated primary care delivery. As nearly one third of health spending is considered potentially wasteful,² our findings have important implications for policymakers, practice leaders, and clinicians who have an interest in providing the highest quality care at the lowest per-capita cost.

KEY POINTS.

Question

What is the impact of practice location and ownership on the provision of low value care?

Findings

In this nationally representative sample of primary care visits, hospital-based practices used more low value CT/MRI, x-rays, and specialty referrals for common conditions than community-based office practices—particularly during hospital-based visits with someone other than the patient’s primary care provider. Hospital-owned community-based practices made more specialty referrals than physician-owned community-based practices.

Meaning

Hospital-based practices provided more low value care than community-based practices, and hospital-owned community-based practices made more specialty referrals than physician-owned community-based practices. These findings raise concerns about the value of hospital-associated primary care.