Low-Value Care at the Actionable Level of Individual Health Systems

Low-value health care, de-implementation, and implications for nursing research: A discussion paper

Globally, the nursing profession constitutes the largest proportion of the health workforce; however, it is challenged by widespread workforce shortages relative to need. Strategies to promote recruitment of the nursing workforce are well-established, with a lesser focus on strategies to alleviate the burden on the existing workforce. This burden may be exacerbated by the impact of low-value health care, characterised as health care that provides little or no benefit for patients, or has the potential to cause harm. Low-value health care is a global problem, a major contributor to the waste of healthcare resources, and a key focus of health system reform. Evidence of variation in low-value health care has been identified across countries and system levels. Research on low-value health care has largely focused on the medical profession, with a paucity of research examining either low-value health care or the de-implementation of low-value health care from a nursing perspective. The objective of this paper is to provide a scholarly discussion of the literature around low-value health care and de-implementation, with the purpose of identifying implications for nursing research. With increasing pressures on the global nursing workforce, research identifying low-value health care and developing approaches to de-implement this care, is crucial.

Use Of High- And Low-Value Health Care Among US Adults, By Income, 2010-19

Health care payment reforms in the US have aimed to encourage the use of high-value care while discouraging the use of low-value care. However, little is known about whether the use of high- and low-value care differs by income level. Using data from the 2010-19 Medical Expenditure Panel Survey, we examined the use of specified types of high- and low-value care by income level. We found that high-income adults were significantly more likely than low-income adults to use nearly all types of high-value care. Findings were consistent across age categories, although differences by income level in the use of high-value care were smaller among the elderly. Our analysis of differences in the use of low-value care had mixed results. Among nonelderly adults, significant differences between those with high and low incomes were found for five of nine low-value services, and among elderly adults, significant differences by income level were found for three of twelve low-value services. Understanding the mechanisms underlying these disparities is crucial to developing effective policies and interventions to ensure equitable access to high-value care and discourage low-value services for all patients, regardless of income.

Cutting back on low-value health care practices supports sustainable kidney care

July 2023 marked the hottest month on record, underscoring the urgent need for action on climate change. The imperative to reduce carbon emissions extends to all sectors, including health care, with it being responsible for 5.5% of global emissions. In decarbonizing health care, although much attention has focused on greening health care infrastructure and procurement, less attention has focused on reducing emissions through demand-side management. An important key element of this is reducing low-value care, given that ≈20% of global health care expenditure is considered low value. "Value" in health care, however, is subjective and dependent on how health outcomes are regarded. This review, therefore, examines the 3 main value perspectives specific to health care. Clinical effectiveness defines low-value care as interventions that offer little to no benefit or have a risk of harm exceeding benefits. Cost-effectiveness compares health outcomes versus costs compared with an alternative treatment. In this case, low-value care is care greater than a societal willingness to pay for an additional unit of health (quality-adjusted life year). Last, community perspectives emphasize the value of shared decision-making and patient-centered care. These values sit within broader societal values of ethics and equity. Any reduction in low-value care should, therefore, also consider patient autonomy, societal value perspectives and opportunity costs, and equity. Deimplementing entrenched low-value care practices without unnecessarily compromising ethics and equity will require tailored strategies, education, and transparency.

Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey

BACKGROUND

Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries.

METHODS

Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results.

RESULTS

Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries.

CONCLUSIONS

More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Healthcare contact days among older adults living with dementia

BACKGROUND

For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population.

METHODS

We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days.

RESULTS

In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days.

CONCLUSIONS

Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.

Development of a disease-based hospital-level diagnostic intensity index

OBJECTIVES

Low-value care is associated with increased healthcare costs and direct harm to patients. We sought to develop and validate a simple diagnostic intensity index (DII) to quantify hospital-level diagnostic intensity, defined by the prevalence of advanced imaging among patients with selected clinical diagnoses that may not require imaging, and to describe hospital characteristics associated with high diagnostic intensity.

METHODS

We utilized State Inpatient Database data for inpatient hospitalizations with one or more pre-defined discharge diagnoses at acute care hospitals. We measured receipt of advanced imaging for an associated diagnosis. Candidate metrics were defined by the proportion of inpatients at a hospital with a given diagnosis who underwent associated imaging. Candidate metrics exhibiting temporal stability and internal consistency were included in the final DII. Hospitals were stratified according to the DII, and the relationship between hospital characteristics and DII score was described. Multilevel regression was used to externally validate the index using pre-specified Medicare county-level cost measures, a Dartmouth Atlas measure, and a previously developed hospital-level utilization index.

RESULTS

This novel DII, comprised of eight metrics, correlated in a dose-dependent fashion with four of these five measures. The strongest relationship was with imaging costs (odds ratio of 3.41 of being in a higher DII tertile when comparing tertiles three and one of imaging costs (95 % CI 2.02-5.75)).

CONCLUSIONS

A small set of medical conditions and related imaging can be used to draw meaningful inferences more broadly on hospital diagnostic intensity. This could be used to better understand hospital characteristics associated with low-value care.

Randomized Experiments to Reduce Overuse of Health Care: A Scoping Review

OBJECTIVE

Health care overuse is pervasive in countries with advanced health care delivery systems. We hypothesize that effective interventions to reduce low-value care that targets patients or clinicians are mediated by psychological and cognitive processes that change behaviors and that interventions targeting these processes are varied. Thus, we performed a scoping review of experimental studies of interventions, including the interventions' objectives and characteristics, to reduce low-value care that targeted psychological and cognitive processes.

METHODS

We systematically searched databases for experimental studies of interventions to change cognitive orientations and affective states in the setting of health care overuse. Outcomes included observed overuse or a stated intention to use services. We used existing frameworks for behavior change and mechanisms of change to categorize the interventions and the mediating processes.

RESULTS

Twenty-seven articles met the inclusion criteria. Sixteen studied the provision of information to patients or clinicians, with most providing cost information. Six studies used educational interventions, including the provision of feedback about individual practice. Studies rarely used counseling, behavioral nudges, persuasion, and rewards. Mechanisms for behavior change included gain in knowledge or confidence and motivation by social norms.

CONCLUSIONS

In this scoping review, we found few experiments testing interventions that directly target the psychological and cognitive processes of patients or clinicians to reduce low-value care. Most studies provided information to patients or clinicians without measuring or considering mediating factors toward behavior change. These findings highlight the need for process-driven experimental designs, including trials of behavioral nudges and persuasive language involving a trusting patient-clinician relationship, to identify effective interventions to reduce low-value care.

Think Twice: De-implementation of Laboratory Testing After Colorectal Surgery

BACKGROUND

Clinically unindicated laboratory testing contributes to low-value care. Most postoperative day 1 laboratory tests after colorectal surgery are normal. However, no published interventions have shown that reducing overall postoperative laboratory testing is safe.

OBJECTIVE

This study aimed to investigate the impact of reducing postoperative laboratory testing after colorectal surgery.

DESIGN

This is a quality improvement study.

SETTINGS

The study was conducted at an academic center with an enhanced recovery after surgery program that included 5 daily laboratory tests until discharge.

PATIENTS

All adults undergoing colorectal or small-bowel surgery formed intervention and nonintervention cohorts based on surgeons who chose to opt into the study. Preimplementation (November 2019-October 2021), there were 545 intervention and 577 nonintervention patients. Postimplementation (November 2021-March 2023), there were 448 intervention and 437 nonintervention patients.

INTERVENTIONS

The intervention included 3 postoperative day 1 laboratory tests and subsequent clinically indicated laboratory tests.

MAIN OUTCOME MEASURES

Outcome measures included laboratory tests and days free of laboratory work.

RESULTS

Postintervention, the intervention group had a 33% reduction in laboratory tests per hospital stay, a 26% reduction in laboratory tests per day, and a 49% increase in laboratory test-free days. There was no difference in length of stay (4 vs 4; p = 0.79) or readmissions (14.9% vs 12.9%; p = 0.39). The nonintervention group had no significant changes in laboratory work or laboratory test-free days, with no differences in length of stay (4 vs 4; p = 0.49) or readmissions (11.1% vs 11.0%; p = 0.96).

LIMITATIONS

Demographics and complication rates were not reported.

CONCLUSIONS

An intervention targeting reflexive laboratory testing after colorectal surgery resulted in safe, significant, sustained reductions in postoperative laboratory work, with substantial cost savings. These findings prompted a change in the laboratory order set to an opt-out system, and laboratory work reduction approaches have been implemented within other surgical divisions. Continuation and spread of these efforts are instrumental for prioritization of high-value surgical care. See Video Abstract .

PINSELO DOS VECES ELIMINACIN DE LAS PRUEBAS DE LABORATORIO DESPUS DE LA CIRUGA COLORRECTAL

ANTECEDENTES:Las pruebas de laboratorio clínicamente no indicadas contribuyen a una atención de bajo valor. La mayoría de los análisis de laboratorio del primer día post operatorios de una cirugía colorrectal son normales. Sin embargo, ninguna intervención publicada ha demostrado que reducir las pruebas de laboratorio post operatorias generales sea seguro.OBJETIVO:El objetivo de este estudio fue investigar el impacto de reducir las pruebas de laboratorio pos toperatorias después de la cirugía colorrectal.DISEÑO:Este es un estudio de mejora de la calidad.AJUSTES:El estudio se llevó a cabo en un centro académico con un programa mejorado de recuperación después de la cirugía que incluye 5 laboratorios diarios hasta el alta.PACIENTES:Todos los adultos sometidos a cirugía colorrectal o de intestino delgado formaron cohortes de intervención y no intervención basadas en los cirujanos que optaron por participar en el estudio. Antes de la implementación (noviembre de 2019 - octubre de 2021) había 545 pacientes con intervención y 577 sin intervención. Después de la implementación (noviembre de 2021 - marzo de 2023) hubo 448 pacientes con intervención y 437 sin intervención.INTERVENCIONES:La intervención incluyó 3 laboratorios post operatorios del primer día y laboratorios posteriores clínicamente indicados.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron pruebas de laboratorio y días sin laboratorio.RESULTADOS:Después de la intervención, el grupo de intervención tuvo una reducción del 33 % en laboratorios por estancia hospitalaria, una reducción del 26 % en laboratorios por día y un aumento del 49 % en los días sin laboratorio. No hubo diferencias en la duración de la estancia hospitalaria (4 frente a 4; p = 0,79) ni en los reingresos (14,9% frente a 12,9%; p = 0,39). El grupo de no intervención no tuvo cambios significativos en el trabajo de laboratorio o en los días sin laboratorio, sin diferencias en la duración de la estadía (4 versus 4; p = 0,49) o reingresos (11,1% versus 11,0%; p = 0,96).LIMITACIONES:No se informaron datos demográficos ni tasa de complicaciones.CONCLUSIONES:Una intervención dirigida a pruebas de laboratorio reflexivas después de la cirugía colorrectal resultó en reducciones seguras, significativas y sostenidas en el trabajo de laboratorio post operatorio, con ahorros sustanciales de costos. Estos hallazgos provocaron un cambio en el orden del laboratorio establecido hacia un sistema de exclusión voluntaria, y se han implementado enfoques de reducción del trabajo de laboratorio en otras divisiones quirúrgicas. La continuación y difusión de estos esfuerzos son fundamentales para priorizar la atención quirúrgica de alto valor. (Traducción-Dr. Mauricio Santamaria ).

Health Care Contact Days Among Older Adults in Traditional Medicare : A Cross-Sectional Study

BACKGROUND

Days spent obtaining health care outside the home can represent not only access to needed care but also substantial time, effort, and cost, especially for older adults and their care partners. Yet, these "health care contact days" have not been characterized.

OBJECTIVE

To assess composition of, variation and patterns in, and factors associated with contact days among older adults.

DESIGN

Cross-sectional study.

SETTING

Nationally representative 2019 Medicare Current Beneficiary Survey data linked to claims.

PARTICIPANTS

Community-dwelling adults aged 65 years and older in traditional Medicare.

MEASUREMENTS

Ambulatory contact days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility); multivariable mixed-effects Poisson regression to identify patient factors associated with contact days.

RESULTS

In weighted results, 6619 older adults (weighted: 29 694 084) had means of 17.3 ambulatory contact days (SD, 22.1) and 20.7 total contact days (SD, 27.5) in the year; 11.1% had 50 or more total contact days. Older adults spent most contact days on ambulatory care, including primary care visits (mean [SD], 3.5 [5.0]), specialty care visits (5.7 [9.6]), tests (5.3 [7.2]), imaging (2.6 [3.9]), procedures (2.5 [6.4]), and treatments (5.7 [13.3]). Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Factors associated with more ambulatory contact days included younger age, female sex, White race, non-Hispanic ethnicity, higher income, higher educational attainment, urban residence, more chronic conditions, and care-seeking behaviors (for example, "go to the doctor…as soon as (I)…feel bad").

LIMITATION

Study population limited to those in traditional Medicare.

CONCLUSION

On average, older adults spent 3 weeks in the year getting care outside the home. These contact days were mostly ambulatory and varied widely not only by number of chronic conditions but also by sociodemographic factors, geography, and care-seeking behaviors. These results show factors beyond clinical need that may drive overuse and underuse of contact days and opportunities to optimize this person-centered measure to reduce patient burdens, for example, via care coordination.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Training the next generation of delivery science researchers: 10-year experience of a post-doctoral research fellowship program within an integrated care system

Introduction

Learning health systems require a workforce of researchers trained in the methods of identifying and overcoming barriers to effective, evidence-based care. Most existing postdoctoral training programs, such as NIH-funded postdoctoral T32 awards, support basic and epidemiological science with very limited focus on rigorous delivery science methods for improving care. In this report, we present the 10-year experience of developing and implementing a Delivery Science postdoctoral fellowship embedded within an integrated health care delivery system.

Methods

In 2012, the Kaiser Permanente Northern California Division of Research designed and implemented a 2-year postdoctoral Delivery Science Fellowship research training program to foster research expertise in identifying and addressing barriers to evidence-based care within health care delivery systems.

Results

Since 2014, 20 fellows have completed the program. Ten fellows had PhD-level scientific training, and 10 fellows had clinical doctorates (eg, MD, RN/PhD, PharmD). Fellowship alumni have graduated to faculty research positions at academic institutions (9), and research or clinical organizations (4). Seven alumni now hold positions in Kaiser Permanente's clinical operations or medical group (7).

Conclusions

This delivery science fellowship program has succeeded in training graduates to address delivery science problems from both research and operational perspectives. In the next 10 years, additional goals of the program will be to expand its reach (eg, by developing joint research training models in collaboration with clinical fellowships) and strengthen mechanisms to support transition from fellowship to the workforce, especially for researchers from underrepresented groups.

Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing

BACKGROUND

Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described.

OBJECTIVE

We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice.

DESIGN

Qualitative study of semi-structured telephone interviews.

PARTICIPANTS

We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate.

APPROACH

Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations.

KEY RESULTS

Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures).

CONCLUSIONS

We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

Patient, provider, and system-level factors associated with preoperative cardiac testing: A systematic review

BACKGROUND

Overuse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system-level factors associated with variation in testing have not been systematically studied.

OBJECTIVE

To conduct a systematic review to better delineate the patient, provider, and system-level factors associated with variation in preoperative cardiac testing.

METHODS

We included studies of an adult US population evaluating a patient, provider, or system-level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle-Ottawa Scale and Evidence Project Risk of Bias tool.

RESULTS

Twenty-eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher-intensity testing. The evidence for provider and system-level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low-value testing can be successful.

CONCLUSIONS

There is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well-defined. Further work should aim to better understand these factors.

Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study

OBJECTIVE

To characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States.

DESIGN

Retrospective cohort study SETTING: 100% Medicare fee-for-service administrative data (2016-18).

PARTICIPANTS

Black and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States.

MAIN OUTCOME MEASURES

Receipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system's population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt.

RESULTS

The cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v 3.2%) and head computed tomography scans for dizziness (3.1% v 1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v 6.5%), prostate specific antigen tests (31.0% v 25.7%), and antibiotics for upper respiratory infections (36.6% v 32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems.

CONCLUSIONS

Black patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.

Differences in use of high- and low-value health care between immigrant and US-born adults

OBJECTIVE

To examine differences in the use of high- and low-value health care between immigrant and US-born adults.

DATA SOURCE

The 2007-2019 Medical Expenditure Panel Survey.

STUDY DESIGN

We split the sample into younger (ages 18-64 years) and older adults (ages 65 years and over). Our outcome measures included the use of high-value care (eight services) and low-value care (seven services). Our key independent variable was immigration status. For each outcome, we ran regressions with and without individual-level characteristics.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Before accounting for individual-level characteristics, the use of high- and low-value care was lower among immigrant adults than US-born adults. After accounting for individual-level characteristics, this difference decreased in both groups of younger and older adults. For high-value care, significant differences were observed in five services and the direction of the differences was mixed. The use of breast cancer screening was lower among immigrant than US-born younger and older adults (-5.7 [95% CI: -7.4 to -3.9] and -2.9 percentage points [95% CI: -5.6 to -0.2]) while the use of colorectal cancer screening was higher among immigrant than US-born younger and older adults (2.6 [95% CI: 0.5 to 4.8] and 3.6 [95% CI: 0.2 to 7.0] percentage points). For low-value care, we did not identify significant differences except for antibiotics for acute upper respiratory infection among younger adults and opioids for back pain among older adults (-3.5 [95% CI: -5.5 to -1.5] and -3.8[95% CI: -7.3 to -0.2] percentage points). Particularly, differences in socioeconomic status, health insurance, and care access between immigrant and US-born adults played a key role in accounting for differences in the use of high- and low-value health care. The use of high-value care among immigrant and US-born adults increased over time, but the use of low-value care did not decrease.

CONCLUSION

Differential use of high- and low-value care between immigrant and US-born adults may be partly attributable to differences in individual-level characteristics, especially socioeconomic status, health insurance, and access to care.

Sources of Low-Value Care Received by Medicare Beneficiaries and Associated Spending Within US Health Systems

This cross-sectional study examines referrals for low-value health care services and associated spending by ordering clinician among Medicare beneficiaries.

Longitudinal Patterns in Testosterone Prescribing After US FDA Safety Communication in 2014

BACKGROUND

The objective of this study was to describe changes in testosterone prescribing following a 2014 US Food and Drug Administration (FDA) safety communication and how changes varied by physician characteristics.

METHODS

Data were extracted from a 20% random sample of Medicare fee-for-service administrative claims data from 2011 through 2019. The sample included 1,544,604 unique male beneficiaries who received evaluation and management (E&M) services from 58,819 unique physicians that prescribed testosterone between 2011 and 2013. Patients were categorized based on presence of coronary artery disease (CAD) and non-age-related hypogonadism. Physician characteristics were identified in the OneKey database and included specialty and affiliations with teaching hospitals, for-profit hospitals, hospitals in integrated delivery networks, and hospitals in the top decile of case mix index. Linear segmented models described how testosterone prescriptions changed following a 2014 FDA safety communication and how changes were associated with physician and organizational characteristics.

RESULTS

Among 65,089,560 physician-patient-quarter-year observations, mean (standard deviation) age ranged from 72.16 (5.84) years for observations without CAD or non-age-related hypogonadism to 75.73 (6.92) years with CAD and without non-age-related hypogonadism. Following the safety communication, immediate changes in off-label testosterone prescription levels fell by 0.22 percentage points (pp) (95% confidence interval [CI] -0.33 to -0.11) for patients with CAD and by -0.16 pp (95% CI -0.19 to -0.16) for patients without CAD. A similar change was noticed in on-label prescribing levels. Off-label testosterone prescription quarterly trend, however, increased for patients with CAD and without CAD; on-label testosterone prescription trends declined for both groups. Declines in off-label prescribing were larger when treated by primary care physicians vs. non-primary care physicians, and physicians affiliated with teaching compared to nonteaching hospitals. Physician and organizational characteristics were not associated with changes in on-label prescribing.

CONCLUSION

On-label and off-label testosterone therapy declined following the FDA safety communication. Certain physician characteristics were associated with changes in off-label, but not on-label, prescribing.

Impact of Active Disinvestment on Decision-Making for Surgery in Patients With Subacromial Pain Syndrome: A Qualitative Semi-structured Interview Study Among Hospital Sales Managers and Orthopedic Surgeons

BACKGROUND

Withdrawal of reimbursement for low-value care through a policy change, ie, active disinvestment, is considered a potentially effective de-implementation strategy. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may be effective is unclear. This study explored how the active disinvestment initiative regarding subacromial decompression (SAD) surgery for subacromial pain syndrome (SAPS) in the Netherlands influenced clinical decision-making around surgery, including the perspectives of orthopedic surgeons and hospital sales managers.

METHODS

We performed 20 semi-structured interviews from November 2020 to October 2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals across the Netherlands as relevant stakeholders in the active disinvestment process. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion.

RESULTS

Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative for SAPS. The first theme was that the active disinvestment represented a "Too small piece of the pie" indicating little financial consequences for the hospital as it was merely used in negotiations with healthcare insurers to reduce costs, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in the overall healthcare insurer agreements. The second theme was "They [healthcare insurer] got it wrong," as the evidence and guidelines had been incorrectly interpreted, the active disinvestment was at odds with clinician experiences and beliefs and was perceived as a reduction in their professional autonomy.

CONCLUSION

The two overarching themes and their underlying factors highlight the complexity for active disinvestment initiatives to be effective. Future de-implementation initiatives including active disinvestment should engage relevant stakeholders at an early stage to incorporate their different perspectives, gain support and increase the probability of success.

Variation in Low-Value Service Use Across Veterans Affairs Facilities

BACKGROUND

It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA).

OBJECTIVE

To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use.

DESIGN

In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics.

PARTICIPANTS

5,242,301 patients across 139 VA facilities.

MAIN MEASURES

Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery.

KEY RESULTS

The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics.

CONCLUSIONS

Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.

Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis

BACKGROUND

Healthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA.

OBJECTIVE

To learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse.

PARTICIPANTS

Leaders at select healthcare systems in the USA.

INTERVENTIONS

None APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework.

KEY RESULTS

We interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse.

CONCLUSIONS

Our qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.

Who's Accountable? Low-Value Care Received By Medicare Beneficiaries Outside Of Their Attributed Health Systems

Policy makers and payers increasingly hold health systems accountable for spending and quality for their attributed beneficiaries. Low-value care-medical services that offer little or no benefit and have the potential for harm in specific clinical scenarios-received outside of these systems could threaten success on both fronts. Using national Medicare data for fee-for-service beneficiaries ages sixty-five and older and attributed to 595 US health systems, we describe where and from whom they received forty low-value services during 2017-18 and identify factors associated with out-of-system receipt. Forty-three percent of low-value services received by attributed beneficiaries originated from out-of-system clinicians: 38 percent from specialists, 4 percent from primary care physicians, and 1 percent from advanced practice clinicians. Recipients of low-value care were more likely to obtain that care out of system if age 75 or older (versus ages 65-74), male (versus female), non-Hispanic White (versus other races or ethnicities), rural dwelling (versus metropolitan dwelling), more medically complex, or experiencing lower continuity of care. However, out-of-system service receipt was not associated with recipients' health systems' accountable care organization status. Health systems might improve quality and reduce spending for their attributed beneficiaries by addressing out-of-system receipt of low-value care-for example, by improving continuity.

Reallocating Cervical Cancer Preventive Service Spending from Low- to High-Value Clinical Scenarios

Timely follow-up care after an abnormal cervical cancer screening test result is critical to the prevention and early diagnosis of cervical cancer. The current inadequate and inequitable delivery of these potentially life-saving services is attributed to several factors, including patient out-of-pocket costs. Waiving of consumer cost-sharing for follow-up testing (e.g., colposcopy and related cervical services) is likely to improve access and uptake, especially among underserved populations. One approach to defray the incremental costs of providing more generous coverage for follow-up testing is reducing expenditures on "low-value" cervical cancer screening services. To explore the potential fiscal implications of a policy that redirects cervical cancer screening resources from potentially low- to high-value clinical scenarios, we analyzed 2019 claims from the Virginia All-Payer Claims Database to quantify (i) total spending on low-value cervical cancer screening and (ii) out-of-pocket costs associated with colposcopy and related cervical services among commercially insured Virginians. In a cohort of 1,806,921 female patients (ages 48.1 ± 24.8 years), 295,193 claims for cervical cancer screening were reported, 100,567 (34.0%) of which were determined to be low-value ($4,394,361 total; $4,172,777 for payers and $221,584 out-of-pocket [$2/patient]). Claims for 52,369 colposcopy and related cervical services were reported ($40,994,016 total; $33,457,518 for payers and $7,536,498 out-of-pocket [$144/patient]). These findings suggest that reallocating savings incurred from unnecessary spending to fund more generous coverage of necessary follow-up care is a feasible approach to enhancing cervical cancer prevention equity and outcomes.

PREVENTION RELEVANCE

Out-of-pocket fees are a barrier to follow-up care after an abnormal cervical cancer screening test. Among commercially insured Virginians, out-of-pocket costs for follow-up services averaged $144/patient; 34% of cervical cancer screenings were classified as low value. Reallocating low-value cervical cancer screening expenditures to enhance coverage for follow-up care can improve screening outcomes. See related Spotlight, p. 363.

A "sludge audit" for health system colorectal cancer screening services

OBJECTIVES

"Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services.

STUDY DESIGN

Mixed methods sludge audit.

METHODS

We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes.

RESULTS

Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients.

CONCLUSIONS

Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

[Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices]

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with "do not do" recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to "do not do" recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients' healthcare, and because most of the citizens' healthcare demands are managed and resolved at the first level of care.

Definition of low-value care in a low-risk preoperative population: A scoping review

RATIONALE

Preoperative care is one of the main areas in which to address low-value care. A detailed definition of what low-value care is in this period of the surgical care journey paves the way for new scientific research, clinical improvements, and reduction of unnecessary costs in this field.

AIMS AND OBJECTIVE

To identify how low-value care in low-risk preoperative population has been defined in the scientific literature and propose a low-value care framework with potential consequences in this setting.

METHODS

Scoping review of theoretical studies and peer-reviewed papers, including reviews, commentaries, or expert opinions, were considered eligible for inclusion. The following databases were consulted: MEDLINE (via PubMed), EMBASE, and SCOPUS (from inception to July 24, 2021), using a structured search with the keywords "low value care", "clinical waste", "preoperative", and "elective procedures." Two independent reviewers performed study selection and data extraction. The definition of low-value care in the preoperative period and their consequences were described after extracting previous low-value care concepts and summarising the contents. Also, a visual framework was built with this information.

RESULTS

From 1519 publications identified in the initial searches, 22 underwent full-text assessment, and 11 conceptual studies were included in the review. A total of four studies (36%) presented a general low-value care definition, and all studies report some situations considered low-value care in the preoperative field of low-risk surgeries. The most common example of preoperative low-value care, listed in nine studies (81%), was having asymptomatic patients undergo screening tests before surgery. The main clinical and nonclinical consequences of low-value care in the preoperative phase included false-positive results from exams as well as psychological distress, increased costs, and delay in surgery.

CONCLUSIONS

Revisiting and integrating previous definitions of low-value care in low-risk surgery into a scoping review is a starting point for de-implementing unnecessary care and promoting improvements in surgical pathways.

Effects of Medicare eligibility and enrollment at age 65 years on the use of high-value and low-value care

OBJECTIVE

To examine the effects of Medicare eligibility and enrollment on the use of high-value and low-value care services.

DATA SOURCES/STUDY SETTING

The 2002-2019 Medical Expenditure Panel Survey.

STUDY DESIGN

We employed a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65. Our primary outcomes included the use of high-value care services (eight services) and low-value care services (seven services). To examine the effects of Medicare eligibility, we conducted a regression discontinuity analysis. To examine the effects of Medicare enrollment, we used the discontinuity in the probability of having Medicare coverage around the age eligibility cutoff and conducted an instrumental variable analysis.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Medicare eligibility and enrollment led to statistically significant increases in the use of only two high-value services: cholesterol measurement [2.1 percentage points (95%: 0.4-3.7) (2.2% relative change) and 2.4 percentage points (95%: 0.4-4.4)] and receipt of the influenza vaccine [3.0 percentage points (95%: 0.3-5.6) (6.0% relative change) and 3.6 percentage points (95%: 0.4-6.8)]. Medicare eligibility and enrollment led to statistically significant increases in the use of two low-value services: antibiotics for acute upper respiratory infections [6.9 percentage points (95% CI: 0.8-13.0) (24.0% relative change) and 8.2 percentage points (95% CI: 0.8-15.5)] and radiographs for back pain [4.6 percentage points (95% CI: 0.1-9.2) (36.8% relative change) and 6.2 percentage points (95% CI: 0.1-12.3)]. However, there was no significant change in the use of other high-value and low-value care services.

CONCLUSION

Medicare eligibility and enrollment at age 65 years led to increases in the use of some high-value and low-value care services, but there were no changes in the use of the majority of other services. Policymakers should consider refining the Medicare program to enhance the value of care delivered.

Assessing patient, physician, and practice characteristics predicting the use of low-value services

OBJECTIVE

To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices.

DATA SOURCES

This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018.

STUDY DESIGN

We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level.

DATA COLLECTION/EXTRACTION METHODS

The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites.

PRINCIPAL FINDINGS

Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level.

CONCLUSIONS

Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.

Development and validation of a new ICD-10-based screening colonoscopy overuse measure in a large integrated healthcare system: a retrospective observational study

BACKGROUND

Low-value use of screening colonoscopy is wasteful and potentially harmful to patients. Decreasing low-value colonoscopy prevents procedural complications, saves patient time and reduces patient discomfort, and can improve access by reducing procedural demand. The objective of this study was to develop and validate an electronic measure of screening colonoscopy overuse using International Classification of Diseases, Tenth Edition codes and then apply this measure to estimate facility-level overuse to target quality improvement initiatives to reduce overuse in a large integrated healthcare system.

METHODS

Retrospective national observational study of US Veterans undergoing screening colonoscopy at 119 Veterans Health Administration (VHA) endoscopy facilities in 2017. A measure of screening colonoscopy overuse was specified by an expert workgroup, and electronic approximation of the measure numerator and denominator was performed ('electronic measure'). The electronic measure was then validated via manual record review (n=511). Reliability statistics (n=100) were calculated along with diagnostic test characteristics of the electronic measure. The measure was then applied to estimate overall rates of overuse and facility-level variation in overuse among all eligible patients.

RESULTS

The electronic measure had high specificity (99%) and moderate sensitivity (46%). Adjusted positive predictive value and negative predictive value were 33% and 95%, respectively. Inter-rater reliability testing revealed near perfect agreement between raters (k=0.81). 269 572 colonoscopies were performed in VHA in 2017 (88 143 classified as screening procedures). Applying the measure to these 88 143 screening colonoscopies, 24.5% were identified as potential overuse. Median facility-level overuse was 22.5%, with substantial variability across facilities (IQR 19.1%-27.0%).

CONCLUSIONS

An International Classification of Diseases, Tenth Edition based electronic measure of screening colonoscopy overuse has high specificity and improved sensitivity compared with a previous International Classification of Diseases, Ninth Edition based measure. Despite increased focus on reducing low-value care and improving access, a quarter of VHA screening colonoscopies in 2017 were identified as potential low-value procedures, with substantial facility-level variability.

Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis

BACKGROUND

Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.

QUESTIONS/PURPOSES

(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?

METHODS

In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.

RESULTS

When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.

CONCLUSION

Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Prevalence and changes of low-value care at acute care hospitals: a multicentre observational study in Japan

OBJECTIVES

We aimed to examine the use and factors associated with the provision of low-value care in Japan.

DESIGN

A multicentre observational study.

SETTING

Routinely collected claims data that include all inpatient and outpatient visits in 242 large acute care hospitals (accounting for approximately 11% of all acute hospitalisations in Japan).

PARTICIPANTS

345 564 patients (median age (IQR): 62 (40-75) years; 182 938 (52.9%) women) seeking care at least once in the hospitals in the fiscal year 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

We identified 33 low-value services, as defined by clinical evidence, and developed two versions of claims-based measures of low-value services with different sensitivity and specificity (broader and narrower definitions). We examined the number of low-value services, the proportion of patients receiving these services and the proportion of total healthcare spending incurred by these services in 2019. We also evaluated the 2015-2019 trends in the number of low-value services.

RESULTS

Services identified by broader low-value care definition occurred in 7.5% of patients and accounted for 0.5% of overall annual healthcare spending. Services identified by narrower low-value care definition occurred in 4.9% of patients and constituted 0.2% of overall annual healthcare spending. Overall, there was no clear trend in the prevalence of low-value services between 2015 and 2019. When focusing on each of the 17 services accounting for more than 99% of all low-value services identified (narrower definition), 6 showed decreasing trends from 2015 to 2019, while 4 showed increasing trends. Hospital size and patients' age, sex and comorbidities were associated with the probability of receiving low-value service.

CONCLUSIONS

A substantial number of patients received low-value care in Japan. Several low-value services with high frequency, especially with increasing trends, require further investigation and policy interventions for better resource allocation.

Patient Symptoms and Stress Testing After Elective Percutaneous Coronary Intervention in the Veterans Affairs Health Care System

IMPORTANCE

Up to 60% of patients in the US receive a stress test within 2 years of percutaneous coronary intervention (PCI), prompting concerns about the possible overuse of stress testing.

OBJECTIVE

To examine the proportion of patients who underwent stress testing within 2 years of elective PCI, proportion of patients who had symptoms that were consistent with coronary artery disease (CAD), timing of stress testing, and site-level variation in stress testing among symptomatic and asymptomatic patients.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used administrative claims data and clinical records from the US Department of Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking program. Patients who underwent stress testing within 2 years of elective PCI for stable CAD between November 1, 2013, and October 31, 2015, at 64 VA facilities were included in the analysis. Patients who received stress testing for staging purposes, cardiac rehabilitation evaluation, or preoperative testing before high-risk surgery were excluded. Data were analyzed from June to December 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was the proportion of patients who underwent stress testing and had symptoms that were consistent with obstructive CAD, using definitions from the 2013 clinical practice guideline (Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease). Secondary outcomes were the timing of stress testing (assessed using a cumulative incidence curve) and site-level variation in stress testing (assessed using multilevel logistic regression models).

RESULTS

A total of 3705 consecutive patients (mean [SD] age 66.3 [7.6] years; 3656 men [98.7%]; 437 Black individuals [11.8%], 3175 White individuals [85.7%], and 93 individuals [2.5%] of other races and ethnicities [Asian, Hispanic or Latinx, or unknown]) had elective PCI. Of these patients, 916 (24.7%) received a stress test within 2 years, among whom 730 (79.7%) had symptoms that were consistent with obstructive CAD at the time of stress testing. Visual inspection of a cumulative incidence curve for stress testing showed no rapid increases in stress testing at 6 months or 1 year after PCI, which might coincide with routine clinical visits. The proportion of symptomatic patients who underwent stress testing at each VA site ranged from 67.7% to 100%, with no significant site-level variation in stress testing.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that most veterans who underwent stress testing within 2 years after elective PCI had symptoms that were consistent with obstructive CAD. Therefore, measuring low-value stress testing using only administrative claims data may overestimate its prevalence, and concerns about overuse of post-PCI stress testing may be overstated.

Racial and ethnic differences in low-value pediatric emergency care

BACKGROUND

Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED).

METHODS

We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital.

RESULTS

We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients.

CONCLUSIONS

NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.

Factors Associated With Overuse of Health Care Within US Health Systems

Question

What features of health care systems in the US are associated with overuse of health care?

Findings

In this cross-sectional study of 676 US health care systems, those that were overusing health care had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned, and were less likely to include a major teaching hospital.

Meaning

In-depth exploration of the drivers of health care overuse is needed at the level of health systems as their incentives may not be aligned with high-value care.

Importance

Overuse of health care is a pervasive threat to patients that requires measurement to inform the development of interventions.

Objective

To measure low-value health care use within health systems in the US and explore features of the health systems associated with low-value care delivery.

Design, Setting, and Participants

In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.

Exposures

We identified occurrences of 17 low-value services in 3839 hospitals and affiliated outpatient sites.

Main Outcomes and Measures

Hospitals were linked to health systems using AHRQ’s Compendium of Health Systems. Between March and August 2021, we modeled overuse occurrences with a negative binomial regression model including the year-quarter, procedure indicator, and a health system indicator. The model included random effects for hospital and beneficiary age, sex, and comorbidity count specific to each indicator, hospital, and quarter. The beta coefficients associated with the health system term, normalized, reflect the tendency of that system to use low-value services relative to all other systems. With ordinary least squares regression, we explored health system characteristics associated with the Overuse Index (OI), expressed as a standard deviation where the mean across all health systems is 0.

Results

There were 676 unique health systems assessed in our study that included from 1 to 163 hospitals (median of 2). The mean age of eligible beneficiaries was 75.5 years and 76% were women. Relative to the lowest tertile, health systems in the upper tertile of medical groups count and bed count had an OI that was higher by 0.38 standard deviations (SD) and 0.44 SD, respectively. Health systems that were primarily investor owned had an OI that was 0.56 SD higher than those that were not investor owned. Relative to the lowest tertile, health systems in the upper tertile of primary care physicians, upper tertile of teaching intensity, and upper quartile of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.

Conclusions and Relevance

In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians. The OI is a valuable tool for identifying potentially modifiable drivers of overuse and is adaptable to other levels of investigation, such as the state or region, which might be affected by local policies affecting payment or system consolidation.