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

Abstract

IMPORTANCE Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability.OBJECTIVES To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study of health system-attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. MAIN OUTCOMES AND MEASURESUse of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions.RESULTS Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs −0.16 [95% CI, -0.27 to -0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, -0.01 to 0.20] without a teaching hospital vs −0.18 [95% CI, -0.34 to -0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, -0.02 to 0.32] for systems with >20% of non-White beneficiaries vs −0.06 [95% CI, -0.16 to 0.03] for systems with Յ20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with −0.09 [95% CI, -0.26 to 0.08] for the Northeast and −0.44 [95% CI, -0.60 to -0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs −0.24 [95% CI, -0.36 to -0....

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

“…The inconsistent direction of association with hospital size across services suggests the importance of measurement and reporting of specific low-value services at the hospital level 47. The variations in low-value care frequencies across healthcare organisations were similarly reported in previous studies in the USA 8 47 48. Our study extends those findings by suggesting that provider-level drivers influence the overuse of individual low-value care even in the Japanese health insurance system strictly regulated by the government.…”

“…We also found that the probability of receiving low-value care differed depending on hospital characteristics. The inconsistent direction of association with hospital size across services suggests the importance of measurement and reporting of specific low-value services at the hospital level 47. The variations in low-value care frequencies across healthcare organisations were similarly reported in previous studies in the USA 8 47 48.…”

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

“…Applying such a measure at the health system level can be particularly effective, because health systems can leverage efficiencies of scale to apply such metrics across a large number of affiliated clinicians, use such measures to track performance over time, and develop and disseminate new programmes or technologies (including clinical decision support tools, evidence-based guidelines or other tools) to improve system-wide care delivery and change organisational culture to value stewardship of healthcare resources 23. As an electronic measure, the screening colonoscopy overuse measure could be easily integrated into EHR platforms such as Epic or Cerner, and used in clinical decision support (ie, at the time a procedure is ordered) to flag a potential low-value procedure or used for quality monitoring and improvement efforts such as what is being considered in VHA.…”

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

“…9 Other studies similarly used administrative claims data to examine whether there are differences in use of low-value stress testing between health care systems, health care payers, and payment models (fee-for-service vs value-based). 10,11,[14][15][16] In contrast, the present study supplemented administrative claims data with detailed medical record review to understand whether stress testing may have been performed in accordance with the clinical guideline. In this context, the results suggest that without clinical data to ascertain patient symptoms, it is likely that a large proportion of stress tests that were considered to be low value in previous studies may have been clinically indicated; therefore, the true prevalence of low-value stress testing may be lower than previously reported.…”