• Theresa A Rowe, Tiffany Brown, Ji Young Lee, Jeffrey A Linder, Mark W Friedberg, Jason N Doctor, Daniella Meeker, Jody D Ciolino, and Stephen D Persell.
• Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. theresa.rowe@northwestern.edu.
• J Gen Intern Med. 2020 Jun 1; 35 (6): 179718021797-1802.

ImportanceThe extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood.ObjectiveTo examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults.DesignRetrospective analysis of overall means and clinician-level variation in performance on three new measures.SubjectsAdults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017.MeasuresTwo electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication.ResultsSixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively.ConclusionsWithin the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

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