An Evidence Review of Low-Value Care Recommendations: Inconsistency and Lack of Economic Evidence Considered

Can we nudge to reduce the perioperative low value care? Decision making factors influencing safe practice implementation

PURPOSE OF THE REVIEW

Highlight sources of low-value care (LVC) during the perioperative period help understanding the decision making behind its persistence, the barriers for change, and the potential implementation strategies to reduce it.

RECENT FINDINGS

The behavioural economics science spread of use through aligned strategies or nudge units offer an opportunity to improve success in the LVC reduction.

SUMMARY

LVC, such as unneeded surgeries, or preanaesthesia tests for low-risk surgeries in low-risk patients, is a relevant source of waste and preventable harm, most especially in the perioperative period. Despite the international focus on it, initial efforts to reduce it in the last decade have not clearly shown a sustainable improvement. Understanding the shared decision-making process and the barriers to be expected when tackling LVC is the first step to build the change. Applying a structured strategy based on the behavioural science principles may be the path to increasing high value care in an effective an efficient way. It is time to foster nudge units at different healthcare system levels.

Managing Resource Utilization Cost of Laboratory Tests for Patients on Chemotherapy in Johns Hopkins Aramco Healthcare

Introduction

Laboratory testing is a fundamental diagnostic and prognostic tool to ensure the quality of healthcare, treatment, and responses. This study aimed to evaluate the cost of laboratory tests performed for patients undergoing chemotherapy treatment in the oncology treatment center at Johns Hopkins Aramco Healthcare in Saudi Arabia. Additionally, we aimed to reduce the cost of unnecessary laboratory tests in a 1-year period.

Methods

This was a quality improvement study with a quasi-experimental design using DMAIC methodology. The intervention strategy involved educating staff about adhering to the British Columbia Cancer Agency (BCCA) guidelines when ordering laboratory tests for chemotherapy patients, then integrating those guidelines into the electronic health record system. Data were collected for 200 randomly selected cases with 10 different chemotherapy protocols before and after the intervention. A paired t test was used to analyze differences in mean cost for all laboratory tests and unnecessary testing before and after the intervention.

Results

A significant cost reduction was achieved for unnecessary laboratory tests (77%, p < 0.01) when following the BCCA guidelines. In addition, the mean cost of all laboratory tests (including necessary and unnecessary) was significantly reduced by 45.5% (p = 0.023).

Conclusion

Lean thinking in clinical practice, realized by integrating a standardized laboratory test guided by BCCA guidelines into the electronic health record, significantly reduced financial costs within 1 year, thereby enhancing efficient resource utilization in the organization. This quality improvement project may serve to increase awareness of further efforts to improve resource utilization for other oncology treatment protocols.

Impact of PSA testing on secondary care costs in England and Wales: estimates from the Cluster randomised triAl of PSA testing for Prostate cancer (CAP)

BACKGROUND

Screening men for prostate cancer using prostate-specific antigen (PSA) testing remains controversial. We aimed to estimate the likely budgetary impact on secondary care in England and Wales to inform screening decision makers.

METHODS

The Cluster randomised triAl of PSA testing for Prostate cancer study (CAP) compared a single invitation to men aged 50-69 for a PSA test with usual care (no screening). Routinely collected hospital care data were obtained for all men in CAP, and NHS reference costs were mapped to each event via Healthcare Resource Group (HRG) codes. Secondary-care costs per man per year were calculated, and cost differences (and population-level estimates) between arms were derived annually for the first five years following randomisation.

RESULTS

In the first year post-randomisation, secondary-care costs averaged across all men (irrespective of a prostate cancer diagnosis) in the intervention arm (n = 189279) were £44.80 (95% confidence interval: £18.30-£71.30) higher than for men in the control arm (n = 219357). Extrapolated to a population level, the introduction of a single PSA screening invitation could lead to additional secondary care costs of £314 million.

CONCLUSIONS

Introducing a single PSA screening test for men aged 50-69 across England and Wales could lead to very high initial secondary-care costs.

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.

Low-Value Prostate-Specific Antigen Test for Prostate Cancer Screening and Subsequent Health Care Utilization and Spending

IMPORTANCE

Delivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios.

OBJECTIVE

To evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021.

EXPOSURES

At least 1 claim for low-value PSA tests for prostate cancer screening during the observation period.

MAIN OUTCOMES AND MEASURES

Utilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting.

RESULTS

Of 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.

State-Level Variation In Low-Value Care For Commercially Insured And Medicare Advantage Populations

Low-value care is a major source of health care inefficiency in the US. Our analysis of 2009-19 administrative claims data from OptumLabs Data Warehouse found that low-value care and associated spending remain prevalent among commercially insured and Medicare Advantage enrollees. The aggregated prevalence of twenty-three low-value services was 1,920 per 100,000 eligible enrollees, which amounted to $3.7 billion in wasteful expenditures during the study period. State-level variation in spending was greater than variation in utilization, and much of the variation in spending was driven by differences in average procedure prices. If the average price for twenty-three low-value services among the top ten states in spending were set to the national average, their spending would decrease by 19.8 percent (from $735,000 to $590,000 per 100,000 eligible enrollees). State-level actions to improve the routine measurement and reporting of low-value care could identify sources of variation and help design state-specific policies that lead to better patient-centered outcomes, enhanced equity, and more efficient spending.

Effect of the 2012 US Preventive Services Task Force Recommendations on Prostate-Specific Antigen Screening in a Medicare Advantage Population

BACKGROUND

In 2012, the US Preventive Service Task Force revised its recommendations for prostate-specific antigen (PSA) screening from "insufficient evidence" to "do not recommend" for men aged 70-74 while maintaining "do not recommend" for men aged 75+.

METHODS

Using the difference-in-difference approach, we evaluated whether the rate of change in the use of low-value PSA screening differed between the control group (men aged 75+, N=7,856,204 person-years) and the intervention group (men aged 70-74, N=5,329,192 person-years) enrolling in the Medicare Advantage plan without a history of prostate cancer within the OptumLabs Data Warehouse claims data (2009-2019). A generalized estimating equation logistic model was specified with independent variables: an intervention group indicator, a pre- and post-period (after 2012 Q2) indicator, index time, and interaction terms. We assumed a 12-month dissemination period.

RESULTS

Before the revised recommendation in 2012, the trends did not significantly differ between the 2 age groups with the odds of receiving PSA screening decreasing by 1.2% (95% confidence interval [1.0, 1.4%]) per quarter. However, the odds of receiving PSA screening increased by 3.0% [2.8, 3.2%] per quarter across both groups since the revision. There was no significant additional change in the trend for those aged 70-74 (0.1% [-0.2, 0.5%]).

CONCLUSIONS

Although the 2012 US Preventive Service Task Force's recommendations were expected to only change behaviors among men aged 70-74, our analysis found that men aged 70-74 and aged 75+ exhibited similar trends from 2009 to 2019, including the increased use of low-value PSA screening since 2016. Multifaceted efforts to discourage low-value PSA screening would be important for a sustained impact.

Associations Between Low-Value Medication in Dementia and Healthcare Costs

BACKGROUND

Low-value medications (Lvm) provide little or no benefit to patients, may be harmful, and waste healthcare resources and costs. Although evidence from the literature indicates that Lvm is highly prevalent in dementia, evidence about the financial consequences of Lvm in dementia is limited. This study analyzed the association between receiving Lvm and healthcare costs from a public payers' perspective.

METHODS

This analysis is based on data of 516 community-dwelling people living with dementia (PwD). Fourteen Lvm were extracted from dementia-specific guidelines, the German equivalent of the Choosing Wisely campaign, and the PRISCUS list. Healthcare utilization was retrospectively assessed via face-to-face interviews with caregivers and monetarized by standardized unit costs. Associations between Lvm and healthcare costs were analyzed using multiple linear regression models.

RESULTS

Every third patient (n = 159, 31%) received Lvm. Low-value antiphlogistics, analgesics, anti-dementia drugs, sedatives and hypnotics, and antidepressants alone accounted for 77% of prescribed Lvm. PwD who received Lvm were significantly less cognitively impaired than those not receiving Lvm. Receiving Lvm was associated with higher medical care costs (b = 2959 €; 95% CI 1136-4783; p = 0.001), particularly due to higher hospitalization (b = 1911 €; 95% CI 376-3443; p = 0.015) and medication costs (b = 905 €; 95% CI 454-1357; p < 0.001).

CONCLUSION

Lvm were prevalent, more likely occurring in the early stages of dementia, and cause financial harm for payers due to higher direct medical care costs. Further research is required to derive measures to prevent cost-driving Lvm in primary care, that is, implementing deprescribing interventions and moving health expenditures towards higher value resource use.

Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely Interventions across Canadian hospitals

BACKGROUND

Choosing Wisely (CW) is an international movement comprised of campaigns in more than 20 countries to reduce low-value care (LVC). De-implementation, the reduction or removal of a healthcare practice that offers little to no benefit or causes harm, is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations.

METHODS

Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis.

FINDINGS

Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not 'patient facing'; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, providing insight into the complexities and nuances of harm, resources and prevalence. Harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions.

CONCLUSIONS

This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

Do Centers for Medicare and Medicaid Services Quality Measures Reflect Cost-Effectiveness Evidence?

OBJECTIVES

Despite its importance of quality measures used by the Centers for Medicare and Medicaid Services, the underlying cost-effectiveness evidence has not been examined. This study aimed to analyze cost-effectiveness evidence associated with the Centers for Medicare and Medicaid Services quality measures.

METHODS

After classifying 23 quality measures with the Donabedian's structure-process-outcome quality of care model, we identified cost-effectiveness analyses (CEAs) relevant to these measures from the Tufts Medical Center CEA Registry based on the PICOTS (population, intervention, comparator, outcome, time horizon, and setting) framework. We then summarized available incremental cost-effectiveness ratios (ICERs) to determine the cost-effectiveness of the quality measures.

RESULTS

The 23 quality measures were categorized into 14 process, 7 outcome, and 2 structure measures. Cost-effectiveness evidence was only available for 8 of 14 process measures. Two measures (Tobacco Screening and Hemoglobin bA1c Control) were cost-saving and quality-adjusted life-years (QALYs) improving, and 5 (Depression Screening, Influenza Immunization, Colon Cancer Screening, Breast Cancer Screening, and Statin Therapy) were highly cost-effective (median ICER ≤ $50 000/QALY). The remaining measure (Fall Screening) had a median ICER of $120 000/QALY. No CEAs were available for 15 measures: 10 defined by subjective patient ratings and 5 employed outcome measures without specifying an intervention or process.

CONCLUSIONS

When relevant CEAs were available, cost-effectiveness evidence was consistent with quality measures (measures were cost-effective). Nevertheless, most quality measures were based on subjective ratings or outcome measures, posing a challenge in identifying supporting economic evidence. Refining and aligning quality measures with cost-effectiveness evidence can help further improve healthcare efficiency by demonstrating that they are good indicators of both quality and cost-effectiveness of care.

Prevalence of Low-Value Care and Its Associations with Patient-Centered Outcomes in Dementia

Background:

Low-value care (LvC) is defined as care unlikely to provide a benefit to the patient regarding the patient’s preferences, potential harms, costs, or available alternatives. Avoiding LvC and promoting recommended evidence-based treatments, referred to as high-value care (HvC), could improve patient-reported outcomes for people living with dementia (PwD).

Objective:

This study aims to determine the prevalence of LvC and HvC in dementia and the associations of LvC and HvC with patients’ quality of life and hospitalization.

Methods:

The analysis was based on data of the DelpHi trial and included 516 PwD. Dementia-specific guidelines, the “Choosing Wisely” campaign and the PRISCUS list were used to indicate LvC and HvC treatments, resulting in 347 LvC and HvC related recommendations. Of these, 77 recommendations (51 for LvC, 26 for HvC) were measured within the DelpHi-trial and finally used for this analysis. The association of LvC and HvC treatments with PwD health-related quality of life (HRQoL) and hospitalization was assessed using multiple regression models.

Results:

LvC was highly prevalent in PwD (31%). PwD receiving LvC had a significantly lower quality of life (b = –0.07; 95% CI –0.14 – –0.01) and were significantly more likely to be hospitalized (OR = 2.06; 95% CI 1.26–3.39). Different HvC treatments were associated with both positive and negative changes in HRQoL.

Conclusion:

LvC could cause adverse outcomes and should be identified as early as possible and tried to be replaced. Future research should examine innovative models of care or treatment pathways supporting the identification and replacement of LvC in dementia.