The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.

This survey study estimates the national frequency and consequences of cascades of care after incidental findings using results from a national survey of US physicians.

IMPORTANCE Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.OBJECTIVE To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between

Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.

Objective: To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes. Data Sources: Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data. Study Design: Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse. Data Collection/Extraction Methods: 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions). Principal Findings: Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level healthrelated outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts:

Together with physician specialty societies, the Choosing Wisely® campaign has codified recommendations of which health care services' use should be questioned and discussed with patients. The ABIM Foundation administered surveys in 2014 and 2017 to examine physicians' attitudes toward and awareness of the use of low-value care. The surveys included questions on the factors driving that use, physicians' comfort in having conversations with patients about that use, and physicians' exposure to the Choosing Wisely campaign. Despite continued publicity and physician outreach efforts, there were no significant changes between 2014 and 2017 in awareness of the campaign among physicians (awareness increased from 21 percent to 25 percent) or physician-reported difficulty in talking to patients about avoiding a low-value service (42 percent reported that such conversations had gotten harder in 2014, and 46 percent did so in 2017). Barriers to the adoption of recommendations included malpractice concerns, patient demand and satisfaction, and physicians' desire for more information to reduce uncertainty. Multifaceted interventions that reinforce guidelines through personalized education, follow-up, and feedback, as well as aligned financial incentives, should be pursued to reduce the use of low-value services.

Key Points Question What are the prevalence of low-value testing during Medicare annual wellness visits and of cascades of medical services and new diagnoses that might follow? Findings In this cohort study of 75 275 fee-for-service Medicare beneficiaries aged 66 and older who received an annual wellness visit, 19% of beneficiaries received at least 1 routine electrocardiogram, urinalysis, or thyrotropin test during their visit, more often those who were younger and lived in urban, high-income areas. An estimated 6 cascade-attributable events per 100 electrocardiogram recipients and 5 events per 100 urinalysis recipients occurred in the subsequent 90 days. Meaning In this study, a minority of healthy Medicare beneficiaries received routine tests during their annual wellness visits, and low-value electrocardiograms and urinalyses were associated with cascades of care.

This cross-sectional study uses data from the US National Survey of Accountable Care Organizations to assess the association between accountable care organization–reported care management and coordination activities and outcomes in older adults with complex needs.