Author Affiliations: Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, New York (Drs Kale and Federman); Division of Outcomes and Effectiveness, Departments of Public Health and Medicine, Weill Cornell Medical College, New York (Dr Bishop); and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, and San Francisco Veterans Affairs Hospital, San Francisco (Dr Keyhani).
The Good Stewardship Working Group presented the top 5 overused clinical activities across 3 primary care specialties (pediatrics, internal medicine, and family medicine), as chosen by physician panel consensus.1 All activities were believed to be common in primary care but of little benefit to patients. We examined the frequency and associated costs of these activities using a national sample of ambulatory care visits.
We performed a cross-sectional analysis using data from the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NAMCS and NHAMCS survey patient visits to physicians in non–federally funded, non–hospital-based offices and non–federally funded hospital outpatient departments, respectively.2
We limited our sample to visits by patients to their primary care physicians. Visits for each “top 5” primary care activity were identified using a combination of the patient-described Reason For Visit (RFV) and the physician's diagnosis as coded by the International Classification of Diseases, Ninth Revision, Clinical Modification (Table). Nonrecommended care ordered during the visit included that defined by the Good Stewardship Working Group (Table), with some exceptions owing to methodological limitations (unable to identify early referral of otitis media with effusion and appropriate use of corticosteroids based on asthma severity). We excluded from the denominator those visits in which the activity could be considered appropriate.
We calculated each activity as the proportion of eligible visits during which the patient received nonrecommended care. We applied the sampling weights and sample design variables to generate national estimates and 95% confidence intervals using Stata statistical software, version 11.0 (StataCorp, College Station, Texas).
We estimated the costs of procedures using the 2011 Medicare physician fee schedule, and in the case of laboratory tests, the 2011 Medicare Clinical Laboratory Fee Schedule3 (eTable). We estimated the costs of drugs using common acquisition costs to consumers from drugstore.com4 or retail pharmacies.5
We found a wide range of frequencies (1.4%-56.0%) of nonrecommended activities in primary care, accounting for an approximate annual cost of $6.76 billion (95% CI, $5.0-$9.1 billion) (Table). The ordering of a complete blood cell count for a general medical examination was the most prevalent activity (56.0%, 95% CI, 40.8%-70.2%) and was associated with a cost of $32.7 million (95% CI, $23.9-$40.8 million).
Several practice activities occurred less commonly, such as ordering of bone density testing in women younger than 65 years (1.4%; 95% CI, 0.9%-2.2%) and Papanicolaou tests for patients younger than 21 years (2.9%; 95% CI, 1.7%-5.0%). We were unable to report the performance of dual-energy x-ray absorptiometry scans in men younger than 70 years and imaging for children with head injuries in ambulatory settings owing to their low frequency (visits <30).
Cost of unnecessary services was a function of both the frequency and the reimbursement rates for each service. The practice activity associated with the highest cost was the prescribing of brand instead of generic statins, resulting in excess expenditures of $5.8 billion per year (95% CI, $4.3-$7.3 billion). Bone density testing in women younger than 65 years was the least prevalent activity but accounted for $527 million (95% CI, $474-$1054 million) in costs.
Our analysis of outpatient visits demonstrates that there is considerable variability in the frequency of inappropriate care and that many of the activities identified in the Good Stewardship “Top 5” lists1 have marginal impact on health care costs. Approximately 86% of the costs associated with the “Top 5” lists were from the use of brand name instead of generic statins. Although generic drug substitutions may appear to be a “low hanging fruit” for drug savings, numerous efforts have already been made by the US states (generic substitution laws), payers (tiered formularies), and health care providers (generic drug detailing) to achieve this goal. In this light, our data suggest that considerably more work is needed to reduce the costs associated with brand name statin use. Our results also demonstrate that highly prevalent activities with small individual costs can result in large overall costs to the health care system and thus warrant further attention.
Our analysis is limited by the available data of the NAMCS/NHAMCS data set and by our ability to accurately estimate visits with inappropriate care. We were conservative in our assessment of inappropriate care and were careful to exclude visits where care could be potentially appropriate, likely lowering our cost estimates.
The recent debate surrounding escalating health care costs and the sustainability of Medicare have focused attention on the delivery of high-quality, efficient care. The discussion certainly needs the participation of physicians who are willing to examine their own practices, such as the Good Stewardship Working Group. However, most primary care activities identified by the working group are not major contributors to health care costs. Expanding the methods of physician consensus to identify “high-value” targets to specialties outside of primary care could bring us closer to achieving the goal of affordable and high-quality health care.
Correspondence: Dr Kale, Division of General Internal Medicine, Mount Sinai School of Medicine, One Gustave Levy Place, PO Box 1087, New York, NY 10029 (firstname.lastname@example.org).
Published Online: October 1, 2011. doi:10.1001/archinternmed.2011.501
Author Contributions:Study concept and design: Kale, Bishop, Federman, and Keyhani. Analysis and interpretation of data: Kale, Bishop, and Keyhani. Drafting of the manuscript: Kale. Critical revision of the manuscript for important intellectual content: Bishop, Federman, and Keyhani. Statistical analysis: Kale. Administrative, technical, and material support: Keyhani. Study supervision: Bishop, Federman, and Keyhani.
Financial Disclosure: None reported.
Funding/Support: This project was not supported by external funds. Dr Kale is a fellow who is supported by a National Research Service Award grant. Dr Keyhani is funded by a Department of Veterans Affairs Health Services Research and Development Service Career Development Award.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Internal Medicine editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 18
Customize your page view by dragging & repositioning the boxes below.
Users' Guides to the Medical Literature
Understanding Class Effects
Users' Guides to the Medical Literature
Solving the Problem: What are Confidence Intervals?
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.