‘Low-value’ clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs’ practice

Abstract

Background Non-evidence-based and ‘low value’ clinical care and medical services are ‘questionable’ clinical activities that are more likely to cause harm than good or whose benefit is disproportionately low compared with its cost. This study sought to establish general practitioner (GP), patient, practice, and in-consultation associations of an index of key non-evidence-based or low-value ‘questionable’ clinical practices. Methods The study was nested in the Registrar Clinical Encounters in Training (ReCEnT) study - an ongoing (from 2010) cohort study in which Australian GP registrars (specialist GP trainees) record details of their in-consultation clinical and educational practice 6-monthly. The outcome factor in analyses, performed on ReCEnT data from 2010 to 2020, was score on the Questionable in-Training Clinical Activities Index (QUIT-CAI) which incorporates recommendations of the Australian Choosing Wisely campaign. A cross-sectional analysis used negative binomial regression (with the model including an offset for the number of times the registrar was at risk of performing a questionable activity) to establish associations of QUIT-CAI scores. Results 3,206 individual registrars (response rate 89.9%), recorded 406,812 problems/diagnoses where they were at risk of performing a questionable activity. Of these problems/diagnoses, 15,560 (3.8%) involved questionable activities being performed. In multivariable analyses, higher QUIT-CAI scores (more questionable activities) were significantly associated with earlier registrar training term: incidence rate ratio (IRR) 0.91 (95% CI 0.87, 0.95) and 0.85 (0.80, 0.90) for Term 2 and Term 3, respectively, compared to Term 1. Other significant associations of higher scores included the patient being new to the registrar (IRR 1.27; 95% CI 1.12-1.45), the patient being of non-English speaking background (IRR 1.24 [1.04, 1.47]), the practice being in a higher socioeconomic area decile (IRR 1.01; 1.00-1.02), small practice size (IRR 1.05; [1.00, 1.10]), shorter consultation duration (IRR 0.99 per minute [0.99, 1.00]), and fewer problems addressed in the consultation (IRR 0.84 [0.79-0.89] for each additional problem). Conclusion Senior registrars’ clinical practice entailed less ‘questionable’ clinical actions than junior registrars’ practice. The association of lower QUIT-CAI scores with a measure of greater continuity of care (the patient not being new to the registrar) suggests continuity should be supported and facilitated during GP training (and in established GPs’ practice).

Gender Disparities in Adverse Events Resulting From Low-Value Practices in Family Practice in Spain: A Retrospective Cohort Study

“…In this study, we reach out to test the following hypotheses developed based on the results of previous studies within primary care [ 8 , 20 , 21 ]. H 1 .…”