Importance Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability. Objectives To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. Design, Setting, and Participants This retrospective cohort study of health system-attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. Main Outcomes and Measures Use of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions. Results Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs -0.16 [95% CI, -0.27 to -0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, -0.01 to 0.20] without a teaching hospital vs -0.18 [95% CI, -0.34 to -0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, -0.02 to 0.32] for systems with >20% of non-White beneficiaries vs -0.06 [95% CI, -0.16 to 0.03] for systems with ≤20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with -0.09 [95% CI, -0.26 to 0.08] for the Northeast and -0.44 [95% CI, -0.60 to -0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs -0.24 [95% CI, -0.36 to -0.12] for areas below the median level of spending; P < .001). Conclusions and Relevance The findings of this large cohort study suggest that system-level measurement and reporting of specific low-value services is feasible, enables cross-system comparisons, and reveals a broad range of low-value care use.

中文翻译：

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个人卫生系统可操作级别的低价值护理。

重要性 低价值医疗保健在美国仍然普遍存在，尽管数十年来一直在努力衡量和减少此类医疗保健。努力只取得了一定程度的有效，部分原因是低价值护理的衡量在很大程度上仅限于国家或地区层面，限制了可操作性。目标 测量和报告个体卫生系统内和内部的低价值护理使用情况，并使用医疗保险管理数据识别与更高使用率相关的系统特征。设计、设置和参与者 这项对卫生系统归属的医疗保险受益人的回顾性队列研究在美国卫生系统医疗保健研究和质量纲要机构的 556 个卫生系统中进行，包括年龄超过 65 岁的系统归属受益人，在 2016 年或 2017 年连续参加 Medicare A 部分和 B 部分至少 12 个月，并有资格获得特定的低价值服务。统计分析于 2021 年 1 月 26 日至 7 月 15 日进行。主要结果和措施 使用 41 项单独的低价值服务和系统归因受益人中 28 项最常见服务的综合测量，标准化为与平均值的距离。措施基于 Milliman MedInsight 健康废物计算器和公布的基于索赔的定义。结果 在为 11 637 763 名受益人提供服务的 556 个卫生系统中，41 项低价值服务中每一项的平均 (SD) 使用范围为合格受益人的 0% (0.01%) 至 28% (4%)。最常见的低价值服务是术前实验室检测（平均 [SD] 率，28% [4%] 符合条件的受益人），70 岁以上男性的前列腺特异性抗原检测（平均 [SD] 率，27% [8%]）和痴呆患者使用抗精神病药物（平均 [SD] 率，24% [8%]）。在多变量分析中，与低价值护理使用率较高相关的卫生系统特征是初级保健医生的比例较小（调整后的综合评分，0.15 [95% CI，0.04-0.26]，对于初级保健比例低于中位数的系统）医生与 -0.16 [95% CI, -0.27 至 -0.05] 对于那些超过初级保健医生百分比中位数的人；P < .001)，没有主要教学医院（调整后的复合材料，0.10 [95% CI, -0.01到 0.20] 没有教学医院与 -0.18 [95% CI, -0.34 到 -0.02] 有教学医院；P = .01)，非白人患者的比例更大（调整后的复合材料，0.15 [95% CI，- 0.02 到 0。32] 对于非白人受益人 >20% 的系统，而对于非白人受益人 ≤20% 的系统，则为 -0.06 [95% CI，-0.16 至 0.03]；P = .04)，总部位于南部或西部（调整后的综合，南部为 0.28 [95% CI, 0.14-0.43]，西部为 0.22 [95% CI, 0.02-0.42]，相比之下，-0.09 [95%东北部的 CI，-0.26 到 0.08]，中西部的 CI，-0.44 [95% CI，-0.60 到 -0.28]；P < .001)，以及服务于医疗保健支出较多的地区（调整后的综合，0.23 [95% CI, 0.11-0.35] 高于中位支出水平的地区，而低于中位支出水平的地区为 -0.24 [95% CI, -0.36 至 -0.12]；P < .001)。结论和相关性 这项大型队列研究的结果表明，特定低价值服务的系统级测量和报告是可行的，可以进行跨系统比较，