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期刊来源：Ann Intern Med

原文链接：https://doi.org/10.7326/M23-1456

摘要内容如下：

背景

使用卫生系统方法调查低价值护理（LVC）可能有助于深入了解这一普遍问题的结构性驱动因素。

客观

评估服务区域实践模式对低值乳腺摄影和前列腺特异性抗原（PSA）检测的影响。

设计

回顾性研究分析了2008年至2018年间的LVC率，利用匹配的医生和患者群体在3年内的医生搬迁。

设置

美国医疗保险索赔数据。

参与者

8254名医生和56467名75岁以上的患者。

测量

留在原服务区域的医生和搬迁到新区域的医生的LVC费率。

结果

从高LVC区域转移到低LVC区域的医生更有可能提供较低的LVC发生率。对于乳房X光检查，留在高LVC地区（LVC率，10.1%[95%CI，8.8%至12.2%]）或中LVC地区（LVC率，10.3%[CI，9.0%至12.4%]）的医生提供的LVC率高于从这些地区调到低LVC地区的医生（LVC率，6.0%[CI，4.4%至7.5%][差异，-4.1个百分点{CI，-6.7至-2.3个百分点}]和5.9%[CI，4.6%至7.8%][差异，-4.4个百分点{CI，-6.7至-2.4个百分点}]）。对于PSA检测，住在高或中等低容量消费服务区的医生提供的低容量消费率分别为17.5%（置信区间，14.9%至20.7%）或10.6%（置信区间，9.6%至13.2%），而从这些地区搬迁到低容量消费服务区的医生提供的低容量消费率为9.9%[置信区间，7.5%至13.2%][差异，-7.6个百分点{置信区间，-10.9至-3.8个百分点}]和6.2%[CI，3.5%至9.8%][差异，-4.4个百分点{CI，-7.6至-2.2个百分点}]）。从较低的LVC服务区域转移到较高的LVC服务区域的医生不太可能以较高的比率提供LVC。

局限性

回顾性观察数据的使用，可能的未测量的混杂因素，以及重新安置医生的可能性，以不同于那些留下来的医生。

结论

与留在LVC发生率较高地区的医生相比，搬迁到LVC发生率较低的服务地区的医生提供的LVC较少。系统性结构可能有助于LVC。了解哪些因素起作用可能为政策和干预措施提供机会，以广泛改善护理。

主要资金来源

美国国立卫生研究院国家癌症研究所。

英文原文如下：

Abstracts

BACKGROUND  Using a health systems approach to investigate low-value care (LVC) may provide insights into structural drivers of this pervasive problem.

OBJECTIVE  To evaluate the influence of service area practice patterns on low-value mammography and prostate-specific antigen (PSA) testing.

DESIGN  Retrospective study analyzing LVC rates between 2008 and 2018, leveraging physician relocation in 3-year intervals of matched physician and patient groups.

SETTING  U.S. Medicare claims data.

PARTICIPANTS  8254 physicians and 56 467 patients aged 75 years or older.

MEASUREMENTS  LVC rates for physicians staying in their original service area and those relocating to new areas.

RESULTS  Physicians relocating from higher-LVC areas to low-LVC areas were more likely to provide lower rates of LVC. For mammography, physicians staying in high-LVC areas (LVC rate, 10.1% [95% CI, 8.8% to 12.2%]) or medium-LVC areas (LVC rate, 10.3% [CI, 9.0% to 12.4%]) provided LVC at a higher rate than physicians relocating from those areas to low-LVC areas (LVC rates, 6.0% [CI, 4.4% to 7.5%] [difference, -4.1 percentage points {CI, -6.7 to -2.3 percentage points}] and 5.9% [CI, 4.6% to 7.8%] [difference, -4.4 percentage points {CI, -6.7 to -2.4 percentage points}], respectively). For PSA testing, physicians staying in high- or moderate-LVC service areas provided LVC at a rate of 17.5% (CI, 14.9% to 20.7%) or 10.6% (CI, 9.6% to 13.2%), respectively, compared with those relocating from those areas to low-LVC areas (LVC rates, 9.9% [CI, 7.5% to 13.2%] [difference, -7.6 percentage points {CI, -10.9 to -3.8 percentage points}] and 6.2% [CI, 3.5% to 9.8%] [difference, -4.4 percentage points {CI, -7.6 to -2.2 percentage points}], respectively). Physicians relocating from lower- to higher-LVC service areas were not more likely to provide LVC at a higher rate.

LIMITATION  Use of retrospective observational data, possible unmeasured confounding, and potential for relocating physicians to practice differently from those who stay.

CONCLUSION  Physicians relocating to service areas with lower rates of LVC provided less LVC than physicians who stayed in areas with higher rates of LVC. Systemic structures may contribute to LVC. Understanding which factors are contributing may present opportunities for policy and interventions to broadly improve care.

PRIMARY FUNDING SOURCE  National Cancer Institute of the National Institutes of Health.

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