Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims

Abstract

Importance: 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.

Objective: To describe characteristics of hospitals associated with overuse of health care services in the US.

Design, setting, and participants: 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.

Main outcomes and measures: 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.

Results: 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%]).

Conclusions and relevance: 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.

Figure 1.. Overuse Composite Scores by Hospital Characteristic

A, Density plots of the overuse composite score for hospitals with capacity for 7 or more services (cohort A) in safety and non–safety net hospitals, nonprofit and for-profit hospitals, teaching and nonteaching hospitals, number of beds per hospital, rural, suburban, and urban hospitals, and hospitals based on geographic location. B, Density plots of the overuse composite score for hospitals with capacity for 12 services (cohort B) in safety and non–safety net hospitals, nonprofit and for-profit hospitals, teaching and nonteaching hospitals, number of beds per hospital, rural, suburban, and urban hospitals, and hospitals based on geographic location.

Figure 2.. Counts Within Quintiles for 12 Low-Value Services in 4 Identified Hospital Clusters

A, Cluster profiles for hospitals with capacity for 7 or more services (cohort A, N = 2415 hospitals) in reference to the following procedures: knee arthroscopy, vertebroplasty, IVC filter, renal stent, hysterectomy, CEA, coronary stent, and spinal fusion. B, Cluster profiles for hospitals with capacity for 7 or more services in reference to the following diagnostic tests and imaging: electroencephalogram (EEG) (syncope), EEG (headache), carotid artery imaging (syncope), and head imaging (syncope). Bars show the counts of quintiles of the normalized overuse hospital rates for each service across the 4 clusters. CEA indicates carotid endarterectomy; IVC, inferior vena cava.