title: Frequency of and variation in low-value care in primary care: a retrospective cohort study.
abstract: BACKGROUND
  Low-value care, defined as care with a lack of benefit, can lead to higher health care costs, inconvenience to patients and, in some cases, harm to patients. The objectives of this study are to conduct exploratory analyses to understand how frequently selected low-value tests are ordered, to assess the degree of variation in ordering that exists across regions and practices, and to identify services that may warrant further investigation and targeted interventions.
  
  
  METHODS
  We conducted a population-based retrospective cohort study using administrative health care databases from Ontario to identify rates of use of the following low-value services between fiscal years 2008/09 and 2012/13: computed tomography (CT) or magnetic resonance imaging (MRI) after a diagnosis of low back pain, Papanicolaou testing in women less than 21 years of age or older than 69 years of age and repeated dual-energy X-ray absorptiometry (DEXA) scanning within 2 years of an index scan. Regional and practice-level rates were calculated. Bivariate analyses were conducted to explore associations between patient factors and repeat DEXA scans.
  
  
  RESULTS
  Repeated DEXA scans were the most common service (21.0%), whereas cervical cancer screening among women less than 21 years of age or older than 69 years of age (8.0%) and CT or MRI imaging for low back pain (4.5%) were less common. There was substantial variation across practices with rates of repeated DEXA scans, ranging from 4.0% to 54.9%, and cervical cancer screening, ranging from 0.9% to 35.2%. Patients with a high-risk index DEXA were more likely to receive a repeat scan (28.1%) than those with a baseline (8.9%) or low-risk (8.1%) scan.
  
  
  CONCLUSIONS
  There is significant, practice-level variation in the frequency of low-value testing for DEXA scans, back imaging and cervical cancer screening. There is a particular need for interventions that aim to reduce unnecessary DEXA scans.
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Ciara
authors.initials: C
authors.lastname: Pendrith
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Meghan
authors.initials: M
authors.lastname: Bhatia
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Noah M
authors.initials: NM
authors.lastname: Ivers
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Graham
authors.initials: G
authors.lastname: Mecredy
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Karen
authors.initials: K
authors.lastname: Tu
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Gillian A
authors.initials: GA
authors.lastname: Hawker
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Susan B
authors.initials: SB
authors.lastname: Jaglal
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Lynn
authors.initials: L
authors.lastname: Wilson
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Wintemute
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Glazier
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: Wendy
authors.initials: W
authors.lastname: Levinson
authors.affiliation: Institute for Health System Solutions and Virtual Care (Pendrith, S. Bhatia), Women's College Hospital, Toronto, Ont.; Queen's University School of Medicine (M. Bhatia), Kingston, Ont.; Department of Family and Community Medicine (Ivers, Tu, Wilson, Glazier), University of Toronto; Department of Family and Community Medicine (Ivers, Wilson), Women's College Hospital; Institute for Clinical Evaluative Sciences (Mecredy, Tu, Hawker, Jaglal, Glazier); Departments of Medicine (Hawker, Levinson, S. Bhatia) and Physical Therapy (Jaglal), University of Toronto; North York Family Health Team (Wintemute), North York General Hospital, Toronto, Ont.
authors.forename: R Sacha
authors.initials: RS
authors.lastname: Bhatia