Frequency of low-value care in Alberta, Canada: a retrospective cohort study

A retrospective cross-sectional study on district-based socioeconomic status and prostate cancer diagnosis

INTRODUCTION

Socioeconomic disparities have been linked to delayed prostate cancer diagnosis and poorer outcomes in various countries. This study aims to evaluate the socioeconomic disparities in prostate cancer diagnostics in Vienna, Austria, by examining initial prostate-specific antigen values and age at diagnosis across different districts and nationalities.

METHODS

This retrospective study included 1356 prostate cancer patients treated at the Medical University of Vienna between 2012 and 2022. Influence of residential districts and nationalities of the patients on the initial prostate-specific antigen (iPSA) value and on the age at diagnosis were analyzed. Patient data, including iPSA values, residential districts, and nationalities, were retrieved from the hospital's internal documentation system. The information on average income of residential districts was obtained from the City of Vienna's municipality data. Nationalities were grouped into EU and non-EU categories. Statistical analyses, including linear regression and t‑tests, were performed to examine the relationship between iPSA values, age at diagnosis, and socioeconomic variables. Linear regression was used to analyze the relationship between district income and both iPSA values and age at diagnosis.

RESULTS

The study found no significant differences in iPSA values and age at diagnosis between patients from higher income and lower income districts. Additionally, there were no significant differences among individual districts or between EU and non-EU nationals.

CONCLUSION

The findings suggest that the Austrian healthcare system provides equitable access to prostate cancer diagnostics across different socioeconomic groups.

Under-reporting of falls in hospitals: a multisite study in South Korea

BACKGROUND

Inpatient falls are adverse events that often result in injury due to complex interactions between the hospital environment and patient risk factors and remain a significant problem in clinical settings.

OBJECTIVES

This study aimed to identify (1) practice variations and key issues ranging from hospital fall management protocols to incident detection, and (2) potential approaches to address these challenges.

DESIGN

Retrospective cohort study.

SETTING

Four general hospitals in South Korea.

METHODS

Qualitative and quantitative data were analysed using the Donabedian quality outcomes model. Data were collected retrospectively during 2015-2023 from four general hospitals on local practice protocols, patient admission and nursing data from electronic records, and incident self-reports. Content analysis of practice protocol and manual chart reviews for hospital falls incidents was conducted at each site. Quantitative analyses of nursing activities and analysis of patient falls prevention interventions were also conducted at each site.

RESULTS

There were variations in fall definitions, risk-assessment tools and inclusion and exclusion criteria among the local fall management protocols. The original and modified versions of the heuristic tools performed poorly to moderately, with areas under the receiver operating characteristic curve of 0.54~0.74 and 0.59~0.80, respectively. Preventive intervention practices varied significantly among the sites, with risk-targeted and tailored interventions delivered to only 1.15%~49.5% of at-risk patients. Fall events were not recorded in self-reporting systems and nursing notes for 29.5%~90.6% and 4.4%~17.1% of patients, respectively.

CONCLUSION

Challenges in fall prevention included weaknesses in the design and implementation of local fall protocols and low-quality incident self-reporting systems. Systematic and sustainable solutions are needed to help reduce hospital fall rates and injuries.

Quantifying Low-Value Care in Germany: An Observational Study Using Statutory Health Insurance Data From 2018 to 2021

OBJECTIVES

Low-value care refers to medical services whose benefits do not outweigh the costs and potential harm. This study estimates the prevalence, distribution, and associated costs of 24 low-value care services within the German public healthcare system.

METHODS

This study was designed as a large-scale retrospective observational study using statutory health insurance data provided by the Techniker Krankenkasse, spanning from 2018 to 2021, covering approximately 11.1 million insured individuals annually. The prevalence of 24 low-value service indicators, which were identified through a systematic review and expert consultations, was calculated. To address uncertainties in distinguishing between appropriate and low-value care, both broad (potential overestimation) and narrow definitions (potential underestimation) were applied to all suitable indicators, providing a range within which the true extent of low-value care is expected to lie.

RESULTS

Between 2019 and 2021, 1.6 million patients were identified as having received at least 1 low-value service using the 24 indicators. Of all 10.6 million delivered services (cases) evaluated, on average per year, 1.1 million cases (broad definition) and 0.43 million cases (narrow definition) were classified as low-value care, corresponding to 10.4% and 4.0%, respectively. The costs incurred by the identified services were approximately euros €15.5 million (broad definition) and €9.9 million (narrow definition) annually.

CONCLUSIONS

Despite the limitations of German statutory health insurance data, considerable low-value care was found within several of the 24 low-value indicators. The findings highlight the necessity for targeted interventions to mitigate low-value care in Germany, guiding healthcare policy and practice to enhance quality and safety effectively.

Cost of Low-Value Imaging Worldwide: A Systematic Review

BACKGROUND AND OBJECTIVE

Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide.

METHODS

This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive.

RESULTS

Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients.

CONCLUSIONS

This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.

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.

Enablers and barriers to a quaternary prevention approach: a qualitative study of field experts

OBJECTIVE

There is a growing concern about the sustainability of healthcare and the impacts of 'overuse' on patients and systems. Quaternary prevention (P4), a concept promoting the protection of patients from medical interventions in which harms outweigh benefits, is well positioned to stimulate reflection and inspire solutions, yet has not been widely adopted. We sought to identify enablers and barriers to a P4 approach, according to field experts and advocates in one health system.

DESIGN

Qualitative methodology, using semistructured interviews and a grounded theory approach facilitated thematic analysis and development of a conceptual model.

SETTING

Virtual interviews, conducted in British Columbia, Canada.

PARTICIPANTS

12 field experts, recruited based on their interest and work related to P4 and related concepts.

RESULTS

Four factors were seen as promoting or hindering P4 efforts depending on context: relationship between patient and clinician, education of clinicians and the public, health system design and influencers. We extracted four broad enablers of P4: evidence-based medicine, personal experiences and questioning attitude, public P4 campaigns and experience in resource-poor contexts. There were six barriers: peer pressure between clinicians, awareness and screening campaigns, cognitive biases, cultural factors, complexity of the problem and industry influence.

CONCLUSIONS

Elicited facilitators and impediments to the application of P4 were similar to those seen in existing literature but framed uniquely; our findings place increased emphasis on the clinician-patient relationship as central to decision-making and position other drivers as influencing this relationship. A transition to a model of care that explicitly integrates conscious protection of patients by reducing overtesting, overdiagnosis and overtreatment will require changes across health systems and society.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Measuring low-value care in hospital discharge records: evidence from China

Background

Plenty of efforts have been made to reduce the use of low-value care (the care that is not expected to provide net benefits for patients) across the world, but measures of low-value care have not been developed in China. This study aims to develop hospital discharge records-based measures of low-value surgical procedures, evaluate their annual use and associated expenditure, and analyze the practice patterns by characterizing its temporal trends and correlations across rates of different low-value procedures within hospitals.

Methods

Informed by evidence-based lists including Choosing Wisely, we developed 11 measures of low-value surgical procedures. We evaluated the count and proportion of low-value episodes, as well as the proportion of expenditure and medical insurance payouts for these episodes, using hospital discharge records in Sichuan Province, China during a period of 2016-2022. We compared the count and expenditure detected by different versions of these measures, which varied in sensitivity and specificity. We characterized the temporal trends in the rate of low-value surgical procedures and estimated the annual percent change using joint-point regression. Additionally, we calculated the Spearman correlation coefficients between the risk-standardized rates of low-value procedures which were estimated by multilevel models adjusting for case mix across hospitals.

Findings

Low-value episodes detected by more specific versions of measures accounted for 3.25% (range, 0.11%-71.66%), and constituted 6.03% (range, 0.32%-84.63%) and 5.90% (range, 0.33%-82.86%) of overall expenditure and medical insurance payouts, respectively. The three figures accounted for 5.90%, 8.41%, and 8.38% in terms of more sensitive versions of measures. Almost half of the low-value procedures (five out of eleven) experienced an increase in rates during the period of 2016-2022, with four of them increasing over 20% per year. There was no significant correlation across risk-standardized rates of different low-value procedures within hospitals (mean r for pairwise, 0.03; CI, -0.02, 0.07).

Interpretation

Despite overall low-value practices detected by the 11 developed measures was modest, certain clinical specialties were plagued by widespread low-value practices which imposed heavy economic burdens for the healthcare system. Given the pervasive and significant upward trends in rates of low-value practices, it has become increasingly urgent to reduce such practices. Interventions in reducing low-value practices in China would be procedure-specific as practice patterns of low-value care varied by procedures and common drivers of low-value practices may not exist.

Funding

The National Science Foundation of China (72074163), Taikang Yicai Public Health and Epidemic Control Fund, Sichuan Science and Technology Program (2022YFS0052 and 2021YFQ0060), and Sichuan University (2018hhf-27 and SKSYL201811).

Low-value preoperative cardiac testing before low-risk surgical procedures: a population-based cohort study

BACKGROUND

Choosing Wisely Canada (CWC) recommends avoiding noninvasive advanced cardiac testing (e.g., exercise stress testing [EST], echocardiography and myocardial perfusion imaging [MPI]) for preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery. In this study, we assessed the temporal trends in testing, overlapping with the introduction of the CWC recommendations in 2014, and patient and provider factors associated with low-value testing.

METHODS

In this population-based retrospective cohort study, we used linked health administrative data in Alberta, Canada, to identify adult patients who underwent elective noncardiac surgery between Apr. 1, 2011, and Mar. 31, 2019, who had preoperative noninvasive advanced cardiac tests (EST, echocardiography or MPI) within 6 months before surgery. We included electrocardiography as an exploratory outcome. We excluded patients at high risk using the Revised Cardiac Risk Index (score ≥ 1 considered to indicate high risk), and modelled patient and temporal factors associated with the number of tests.

RESULTS

We identified 1 045 896 elective noncardiac operations performed in 798 599 patients and 25 599 advanced preoperative cardiac tests; 2.1% of operations were preceded by advanced cardiac testing. The incidence of testing increased over the study period, and, by 2018/19, patients were 1.3 times (95% confidence interval 1.2-1.4) more likely to receive a preoperative advanced test compared to 2011/12. Urban patients were more likely to receive a preoperative advanced cardiac test than their rural counterparts. Electrocardiography was the most common preoperative cardiac test, preceding 182 128 procedures (17.4%).

INTERPRETATION

Preoperative advanced cardiac testing was infrequent in adult Albertans who underwent low-risk elective noncardiac operations. Despite CWC recommendations, the use of some tests appears to be increasing, and there was substantial variation across geographic areas.

Identification of barriers, enablers and interventions to inform deimplementation of low-value care in emergency medicine practice: A protocol for a mixed methods scoping review informed by the Theoretical Domains Framework

INTRODUCTION

Low-value care can lead to patient harm, misdirected clinician time and wastage of finite healthcare resources. Despite worldwide endeavours, deimplementing low-value care has proved challenging. Multifaceted, context and barrier-specific interventions are essential for successful deimplementation. The aim of this literature review is to summarise the evidence about barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice.

METHODS AND ANALYSIS

A mixed methods scoping review using the Arksey and O'Malley framework will be conducted. MEDLINE, CINAHL, EMBASE, EMCare, Scopus and grey literature will be searched from inception. Primary studies will be included. Barriers, enablers and interventions will be mapped to the domains of the Theoretical Domains Framework. Study selection, data collection and quality assessment will be performed by two independent reviewers. NVivo software will be used for qualitative data analysis. Mixed Methods Appraisal Tool will be used for quality assessment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework will be used to present results.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review. This review will generate an evidence summary regarding barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. This review will facilitate discussions about deimplementation with relevant stakeholders including healthcare providers, consumers and managers. These discussions are expected to inform the design and conduct of planned future projects to identify context-specific barriers and enablers then codesign, implement and evaluate barrier-specific interventions.

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.

Identifying drivers of health care value: a scoping review of the literature

BACKGROUND

As health care spending reaches unsustainable levels, improving value has become an increasingly important policy priority. Relatively little research has explored factors driving value. As a first step towards filling this gap, we performed a scoping review of the literature to identify potential drivers of health care value.

METHODS

Searches of PubMed, Embase, Google Scholar, Policy File, and SCOPUS were conducted between February and March 2020. Empirical studies that explored associations between any range of factors and value (loosely defined as quality or outcomes relative to cost) were eligible for inclusion. We created a template in Microsoft Excel for data extraction and evaluated the quality of included articles using the Critical Appraisal Skills Programme (CASP) quality appraisal tool. Data was synthesized using narrative methods.

RESULTS

Twenty-two studies were included in analyses, of which 20 focused on low value service utilization. Independent variables represented a range of system-, hospital-, provider-, and patient-level characteristics. Although results were mixed, several consistent findings emerged. First, insurance incentive structures may affect value. For example, patients in Accountable Care Organizations had reduced rates of low value care utilization compared to patients in traditionally structured insurance plans. Second, higher intensity of care was associated with higher rates of low value care. Third, culture is likely to contribute to value. This was suggested by findings that recent medical school graduation and allopathic training were associated with reduced low value service utilization and that provider organizations had larger effects on value than did individual physicians.

CONCLUSIONS

System, hospital, provider, and community characteristics influence low value care provision. To improve health care value, strategies aiming to reduce utilization of low value services and promote high value care across various levels will be essential.

Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study

BACKGROUND

Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown.

AIM

To assess the prevalence of low-value pharmaceutical care among Dutch GPs.

DESIGN AND SETTING

Retrospective cohort study using data from patient records.

METHOD

The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription.

RESULTS

Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001).

CONCLUSION

The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.

Determinants of the de-implementation of low-value care: a multi-method study

Background

There is an urgent need to understand the determinants (i.e., barriers and facilitators) of de-implementation. The purpose of this study was to develop a comprehensive list of determinants of the de-implementation of low-value care from the published literature and to compare this list to determinants identified by a group of stakeholders with lived experience with de-implementation.

Methods

This was a two-phase multi-method study. First, a systematic review examined published barriers and facilitators to de-implementation. Articles were identified through searches within electronic databases, reference lists and the grey literature. Citations were screened independently and in duplicate and included if they were: 1) written in English; and 2) described a barrier or facilitator to de-implementation of any clinical practice in adults (age ≥ 18 years). ‘Raw text’ determinants cited within included articles were extracted and synthesized into a list of representative determinants using conventional content analysis. Second, semi-structured interviews were conducted with decision-makers (unit managers and medical directors) and healthcare professionals working in adult critical care medicine to explore the overlap between the determinants found in the systematic review to those experienced in critical care medicine. Thematic content analysis was used to identify key themes emerging from the interviews.

Results

In the systematic review, reviewers included 172 articles from 35,368 unique citations. From 437 raw text barriers and 280 raw text facilitators, content analysis produced 29 distinct barriers and 24 distinct facilitators to de-implementation. Distinct barriers commonly cited within raw text included ‘lack of credible evidence to support de-implementation’ (n = 90, 21%), ‘entrenched norms and clinicians’ resistance to change (n = 43, 21%), and ‘patient demands and preferences’ (n = 28, 6%). Distinct facilitators commonly cited within raw text included ‘stakeholder collaboration and communication’ (n = 43, 15%), and ‘availability of credible evidence’ (n = 33, 12%). From stakeholder interviews, 23 of 29 distinct barriers and 20 of 24 distinct facilitators from the systematic review were cited as key themes relevant to de-implementation in critical care.

Conclusions

The availability and quality of evidence that identifies a clinical practice as low-value, as well as healthcare professional willingness to change, and stakeholder collaboration are common and important determinants of de-implementation and may serve as targets for future de-implementation initiatives.

Trial registration

The systematic review was registered in PROSPERO CRD42016050234.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07827-4.

Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication

BACKGROUND

Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise.

METHODS

Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention.

RESULTS

Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse.

CONCLUSION

Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Frequency and estimated costs of ten low-value practices in the Spanish Primary Care: a retrospective study

BACKGROUND

The frequency of low-value practices (LVPs) in the healthcare system is a worldwide challenge. Far less is known about the related extra cost. This study aimed to evaluate the LVPs trend in Spanish primary care (PC), its frequency in both sexes, and estimate its related extra cost.

METHODS

A multicentric, retrospective, and national research project was conducted. Ten LVPs highly frequent and potentially harmful for patients were analyzed. Algorithms were applied to collect the data from 28,872,851 episodes registered into national databases (2015-2017). Cost estimation was made.

RESULTS

LVPs registered a total of 7,160,952 (26.5%) episodes plus a total of 259,326 avoidable PSA screening tests. In adults, a high frequency was found for prescription of 1g paracetamol >3 days, antibiotics for acute bronchitis (unconfirmed comorbidity), and benzodiazepines in patients >65 years with insomnia. Women received more jeopardizing practices (p≤0.001). Pediatrics presented a downward of antibiotic and paracetamol-ibuprofen prescription combination. The estimated extra cost was close to €292 million (2.8% of the total cost in PC).

CONCLUSION

LVPs reduction during the analyzed period was moderate compared to studies following 'Choosing Wisely list' of LVPs and must improve to reduce patient risk and the extra related costs.

Low-value care and excess out-of-pocket expenditure among older adults with incident cancer - A machine learning approach

OBJECTIVE

To evaluate the association of low-value care with excess out-of-pocket expenditure among older adults diagnosed with incident breast, prostate, colorectal cancers, and Non-Hodgkin's Lymphoma.

METHODS

We used a retrospective cohort study design with 12-month baseline and follow-up periods. We identified a cohort of older adults (age ≥ 66 years) diagnosed with breast, prostate, colorectal cancers, or Non-Hodgkin's lymphoma between January 2014 and December 2014. We assessed low-value care and patient out-of-pocket expenditure in the follow-up period. We identified relevant low-value services using ICD9/ICD10 and CPT/HCPCS codes from the linked health claims and patient out-of-pocket expenditure from Medicare claim files and expressed expenditure in 2016 USD.

RESULTS

About 29 % of older adults received at least one low-value care procedure during the follow-up period. Low-value care differed by gender, and rates were higher in women with colorectal cancer (32.7 %) vs. (28.8 %) and NHL (40 %) vs. (39 %) compared to men. Individuals who received one or more low-value care procedures had significantly higher mean out-of-pocket expenditure ($8,726 ± $7,214) vs. ($6,802 ± $6,102). XGBOOST, a machine learning algorithm revealed that low-value care was among the five leading predictors of OOP expenditure.

CONCLUSION

One in four older adults with incident cancer received low-value care in 12-months after a cancer diagnosis. Across all cancer populations, individuals who received low-value care had significantly higher out-of-pocket expenditure. Excess out-of-pocket expenditure was driven by low-value care, fragmentation of care, and an increasing number of pre-existing chronic conditions.

POLICY STATEMENT

This study focuses on health policy issues, specifically value-based care and its findings have important clinical and policy implications for Centers for Medicare and Medicaid Services (CMS) which has issued a roadmap for states to accelerate the adoption of value-based care, with the Department of Health and Human Services (HHS) setting a goal of converting 50 % of traditional Medicare payment systems to alternative payment models tied to value-based care by 2022.

Adherence to Clinical Practice Guideline Recommendations on Low-Value Injury Care: A Multicenter Retrospective Cohort Study

OBJECTIVES

Low-value clinical practices have been identified as one of the most important areas of excess healthcare spending. Nevertheless, there is a knowledge gap on the scale of this problem in injury care. We aimed to identify clinical practice guideline (CPG) recommendations pertaining to low-value injury care, estimate how frequently they are used in practice, and evaluate interhospital variations in their use.

METHODS

We identified low-value clinical practices from internationally recognized CPGs. We conducted a retrospective cohort study using data from a Canadian trauma system (2014-2019) to calculate frequencies and assess interhospital variations.

RESULTS

We identified 29 low-value practices. Fourteen could be measured using trauma registry data. The 3 low-value clinical practices with the highest absolute and relative frequencies were computed tomography (CT) in adults with minor head injury (n = 5591, 24%), cervical spine CT (n = 2742, 31%), and whole-body CT in minor or single-system trauma (n = 530, 32%). We observed high interhospital variation for decompressive craniectomy in diffuse traumatic brain injury. Frequencies and interhospital variations were low for magnetic resonance imaging, intracranial pressure monitoring, inferior vena cava filter use, and surgical management of blunt abdominal injuries.

CONCLUSIONS

We observed evidence of poor adherence to CPG recommendations on low-value CT imaging and high practice variation for decompressive craniectomy. Results suggest that adherence to recommendations for the 10 other low-value practices is high. These data can be used to advance the research agenda on low-value injury care and inform the development of interventions targeting reductions in healthcare overuse in this population.

Uniform criteria for total hip replacement surgery in patients with hip osteoarthritis: a decision tool to guide treatment decisions

Background

Uniform criteria for performing hip replacement surgery in hip osteoarthritis patients are currently lacking. As a result, variation in surgery and inappropriateness of care may occur. The aim of this study was to develop a consensus-based decision tool to support the decision-making process for hip replacement surgery.

Methods

Patients with a diagnosis of unilateral or bilateral osteoarthritis were included. Consensus rounds with orthopedic surgeons were organized to blindly reassess medical files and to decide whether surgery is indicated or not, based on all available pre-treatment information. We compared the outcomes obtained from the blind reassessment by the consensus group with the actual treatment. Furthermore, prediction models were fitted on the reassessment outcome to identify which set of clinical parameters would be most predictive and uniformly shared in the decision to operate.

Two prediction models were fitted, one model without radiologic outcomes and one model where radiologic outcomes were included.

Results

In total, 364 medical files of osteoarthritis patients were included and reassessed in the analyses. Key predictors in the prediction model without radiology were age, flexion, internal rotation and the Hip disability and Osteoarthritis Outcome Score–quality of life. The discriminative power was high (Area Under Receiver Operating Curve (AUC) = 0.86). Key predictors in the prediction model with radiology were age, internal rotation and Kellgren and Lawrence severity score (AUC = 0.94).

Conclusion

The study yielded a decision tool with uniform criteria for hip replacement surgery in osteoarthritis patients. The tool will guide the clinical decision-making process of physicians on whether to perform hip surgery and should be used together with information about patient preferences and social context.

Overuse of diagnostic testing in healthcare: a systematic review

BACKGROUND

Overuse of diagnostic testing substantially contributes to healthcare expenses and potentially exposes patients to unnecessary harm. Our objective was to systematically identify and examine studies that assessed the prevalence of diagnostic testing overuse across healthcare settings to estimate the overall prevalence of low-value diagnostic overtesting.

METHODS

PubMed, Web of Science and Embase were searched from inception until 18 February 2020 to identify articles published in the English language that examined the prevalence of diagnostic testing overuse using database data. Each of the assessments was categorised as using a patient-indication lens, a patient-population lens or a service lens.

RESULTS

118 assessments of diagnostic testing overuse, extracted from 35 studies, were included in this study. Most included assessments used a patient-indication lens (n=67, 57%), followed by the service lens (n=27, 23%) and patient-population lens (n=24, 20%). Prevalence estimates of diagnostic testing overuse ranged from 0.09% to 97.5% (median prevalence of assessments using a patient-indication lens: 11.0%, patient-population lens: 2.0% and service lens: 30.7%). The majority of assessments (n=85) reported overuse of diagnostic testing to be below 25%. Overuse of diagnostic imaging tests was most often assessed (n=96). Among the 33 assessments reporting high levels of overuse (≥25%), preoperative testing (n=7) and imaging for uncomplicated low back pain (n=6) were most frequently examined. For assessments of similar diagnostic tests, major variation in the prevalence of overuse was observed. Differences in the definitions of low-value tests used, their operationalisation and assessment methods likely contributed to this observed variation.

CONCLUSION

Our findings suggest that substantial overuse of diagnostic testing is present with wide variation in overuse. Preoperative testing and imaging for non-specific low back pain are the most frequently identified low-value diagnostic tests. Uniform definitions and assessments are required in order to obtain a more comprehensive understanding of the magnitude of diagnostic testing overuse.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study

BACKGROUND

In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal.

OBJECTIVE

The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease.

METHODS

A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.

RESULTS

Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025.

CONCLUSIONS

The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25619.

External Validation of and Factors Associated with the Overuse Index: a Nationwide Population-Based Study from Taiwan

BACKGROUND

The Overuse Index (OI), previously called the Johns Hopkins Overuse Index, is developed and validated as a composite measure of systematic overuse/low-value care using United States claims data. However, no information is available concerning whether the external validation of the OI is sustained, especially for international application. Moreover, little is known about which supply and demand factors are associated with the OI.

OBJECTIVE

We used nationwide population-based data from Taiwan to externally validate the OI and to examine the association of regional healthcare resources and socioeconomic factors with the OI.

DESIGN AND PARTICIPANTS

We analyzed 1,994,636 beneficiaries randomly selected from all people enrolled in the Taiwan National Health Insurance in 2013.

MAIN MEASURES

The OI was calculated for 2013 to 2015 for each of 50 medical regions. Spearman correlation analysis was applied to examine the association of the OI with total medical costs per capita and mortality rate. Generalized estimating equation linear regression analysis was conducted to examine the association of regional healthcare resources (number of hospital beds per 1000 population, number of physicians per 1000 population, and proportion of primary care physicians [PCPs]) and socioeconomic factors (proportion of low-income people and proportion of population aged 20 and older without a high school diploma) with the OI.

RESULTS

Higher scores of the OI were associated with higher total medical costs per capita (ρ = 0.48, P < 0.001) and not associated with total mortality (ρ = - 0.01, P = 0.882). Higher proportions of PCPs and higher proportions of low-income people were associated with lower scores of the OI (β = - 0.022, P = 0.016 and β = - 0.224, P < 0.001, respectively).

CONCLUSIONS

Our study supported the external validation of the OI by demonstrating a similar association within a universal healthcare system, and it showed the association of a higher proportion of PCPs and a higher proportion of low-income people with less overuse/low-value care.

Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse

Background

Evidence-based campaigns are available to support appropriate diagnostic testing in cardiology, but medico-legal concerns can impede implementation.

Methods

We conducted a retrospective descriptive analysis of medico-legal cases (civil legal, regulatory authority, hospital matters) involving cardiologists in Canada. For eligibility, cases must have closed at the Canadian Medical Protective Association between January 1, 2009 and December 31, 2018. We defined test underuse and overuse using criticisms in the medico-legal record from peer experts, regulatory authorities, or hospitals. We used a contributing factors framework and descriptive statistics for analysis.

Results

From 2009 to 2018, the Canadian Medical Protective Association closed 60,598 cases with 368 (0.6%) involving a cardiologist. Within those cases, there was no criticism of cardiac diagnostic test overuse and 15 cases (4.1%) with criticism of underuse (tests not ordered, not expedited, delayed). In 12 of 15 cases of underuse (80.0%), the patient experienced severe harm or death. Of 8 civil legal cases, 6 were decided in favour of the plaintiff (75.0%) and 2 were dismissed by consent before proceeding to trial (25.0%). Decisions on regulatory authority matters did not favour the cardiologist (7 of 7 cases). In all cases of underuse, there was need for focused testing to investigate new or worsening symptoms. The most common contributing factors included clinical decision-making, situational awareness, and communication with teams and patients.

Conclusions

Medico-legal cases involving cardiologists and the overuse or underuse of cardiac diagnostic tests were extremely rare in Canada, despite the potential for harm. The criticisms of cardiac diagnostic test underuse related to issues with diagnosing symptomatic patients.

Hospital characteristics associated with low-value care in public hospitals in New South Wales, Australia

BACKGROUND

Rates of low-value care vary between hospitals in New South Wales, Australia. Understanding factors associated with this variation will help in understanding the drivers of low-value care and in planning initiatives to reduce low-value care.

METHODS

For eight low-value procedures, we used Poisson regression of the number of low-value episodes at each hospital to assess the association between low-value care and hospital characteristics. We also used hierarchical clustering on the low-value procedures used and their rates at each hospital to try to identify groups of hospitals with higher or lower rates of low-value care across multiple procedures.

RESULTS

Some hospital characteristics, such as hospital peer group and proportion of total episodes that involve the specific procedure, showed associations for some procedures, but none were consistent across all eight procedures. We clustered hospitals into five groups, but low-value care rates did not differ much between these groups.

CONCLUSION

Available hospital variables show little association with rates of low-value care and no patterns across different low-value procedures. We need to investigate factors within hospitals, such as clinician knowledge and beliefs about low-value care.

[Design of a set of indicators for 'Do Not Do' recommendations]

BACKGROUND

There is a growing interest in the optimisation of health care that has fostered and developed initiatives advocating more efficient and safe health care.

OBJECTIVE

To determine indicators set for assessing the 'Do Not Do' Recommendations (DNDR) in a Spanish health area, in order to set interventions in motion for improving the quality of care and the patient safety.

METHOD

The DNDR published by the health care organisation in 2016 were identified, and those that could be analysed were designed and tested using two assessment methods (if possible, directly from the whole data or, if not, by applying the lot quality assurance sampling - LQAS) and 2016 data from a Spanish health area. Both validity and reliability of these indicators were checked.

RESULTS

Of the 271 DNDR identified, 25 (9.3%) were prioritised and their corresponding quality indicator designed. From them, 80% were obtained directly, whereas the rest required LQAS. The interobserver agreement was very high. Efficiency was the quality dimension most frequently involved.

CONCLUSIONS

In order to improve the quality of care in terms of adequacy, safety, and sustainability, to assess the DNDR is possible, compulsory, and urgent. Thus, a set of valid, reliable and useful indicators has been designed. This set is focused on identifying improve opportunities and making it possible to approach them.

Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems

In the past decades, extensive research has been performed on the phenomenon of unwarranted clinical variation in clinical practice. Many studies have been performed on signaling, describing and visualizing clinical variation. We argue that it is time for next steps in practice variation research. In addition to describing and signaling variation patterns, we argue that a better understanding of causes of variation should be gained. Moreover, target points for improving and decreasing clinical variation should be created. Key elements in this new focus should be research on the complex interaction of networks, reflective medicine, patient beliefs and objective criteria for treatment choices. By combining these different concepts, alternative research objectives and new targets for improving and reducing unwarranted variation may be defined. In this perspective, we reflect on these concepts and propose target points for future research.

Assessing volume and variation of low-value care practices in the Netherlands

BACKGROUND

There have been contributions to quantify the volume of low-value care practices in the USA, Canada and Australia but we have no knowledge about the volume in Europe. The purpose of this study was to assess the volume and variation of Dutch low-value care practices.

METHODS

We conducted a cross-sectional study with data of a Dutch healthcare insurance company from general practioners (GP's) and hospitals in the Netherlands from 2016. We used all billing claims made by healthcare providers of 3.5 million Dutch inhabitants. We studied Choosing Wisely recommendations in order to select low-value care practices. We used the percentage low-value care practices per hospital and number of low-value care practices per GP as outcomes.

RESULTS

We assessed the volume of low-back imaging by GPs, screening of patients over 75 years for colorectal cancer and diagnosing varices with Doppler or Plethysmography. We found that 0.4% (range 0-7%) of the eligible patients received low-value screening for colorectal cancer and 8.0% (range 0-88%) of eligible patients received low-value diagnosing of varices. About 52.4% of the GPs ordered X-rays and 11.2% ordered magnetic resonance imagings of the lumbosacral spine. Most healthcare providers did not provide the measured low-value care practices. However, 1 in 12 GPs ordered at least one low-back X-ray a week.

CONCLUSIONS

The three Choosing Wisely recommendations showed a lot of practice variation; many healthcare providers did not order these low-value diagnostic tests; a minor part did order a substantial amount, low-back spine radiology in particular. These healthcare providers should start reducing these activities.

Estimating misclassification error in a binary performance indicator: case study of low value care in Australian hospitals

OBJECTIVE

Indicators based on hospital administrative data have potential for misclassification error, especially if they rely on clinical detail that may not be well recorded in the data. We applied an approach using modified logistic regression models to assess the misclassification (false-positive and false-negative) rates of low-value care indicators.

DESIGN AND SETTING

We applied indicators involving 19 procedures to an extract from the New South Wales Admitted Patient Data Collection (1 January 2012 to 30 June 2015) to label episodes as low value. We fit four models (no misclassification, false-positive only, false-negative only, both false-positive and false-negative) for each indicator to estimate misclassification rates and used the posterior probabilities of the models to assess which model fit best.

RESULTS

False-positive rates were low for most indicators-if the indicator labels care as low value, the care is most likely truly low value according to the relevant recommendation. False-negative rates were much higher but were poorly estimated (wide credible intervals). For most indicators, the models allowing no misclassification or allowing false-negatives but no false-positives had the highest posterior probability. The overall low-value care rate from the indicators was 12%. After adjusting for the estimated misclassification rates from the highest probability models, this increased to 35%.

CONCLUSION

Binary performance indicators have a potential for misclassification error, especially if they depend on clinical information extracted from administrative data. Indicators should be validated by chart review, but this is resource-intensive and costly. The modelling approach presented here can be used as an initial validation step to identify and revise indicators that may have issues before continuing to a full chart review validation.

Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization

INTRODUCTION

Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value.

METHODS

We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices.

RESULTS

BR or DR at admission were recommended in 37% (32-44) and 24% (19-30) of the patients respectively. In 81% (71-87) and 33% (21-45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92-98) had VL and 25% (19-32) UC. VL were not used in 10% (6-12), UC had no indications for insertion in 21% (11-35) and for maintenance in 31% (12-46) patients. Fifty-seven percent (49-64) of the patients were administered VTP and 69% (62-76) were prescribed SUP. Twenty-two percent (15-31) of patients with VTP and 52% (43-60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53-75) with BAF was prescribed in 38% (25-52) of them. An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results.

CONCLUSION

These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.

Systemic overuse of health care in a commercially insured US population, 2010-2015

BACKGROUND

Overuse is a leading contributor to the high cost of health care in the United States. Overuse harms patients and is a definitive waste of resources. The Johns Hopkins Overuse Index (JHOI) is a normalized measure of systemic health care services overuse, generated from claims data, that has been used to describe overuse in Medicare beneficiaries and to understand drivers of overuse. We aimed to adapt the JHOI for application to a commercially insured US population, to examine geographic variation in systemic overuse in this population, and to analyze trends over time to inform whether systemic overuse is an enduring problem.

METHODS

We analyzed commercial insurance claims from 18 to 64 year old beneficiaries. We calculated a semiannual JHOI for each of the 375 Metropolitan Statistical Areas and 47 rural regions of the US. We generated maps to examine geographic variation and then analyzed each region's change in their JHOI quintile from January 2011 to June 2015.

RESULTS

The JHOI varied markedly across the US. Across the country, rural regions tended to have less systemic overuse than their MSA counterparts (p < 0.01). Regional systemic overuse is positively correlated from one time period to the next (p < 0.001). Between 2011 and 2015, 53.7% (N = 226) of regions remained in the same quintile of the JHOI. Eighty of these regions had a persistently high or persistently low JHOI throughout study duration.

CONCLUSIONS

The systemic overuse of health care resources is an enduring, regional problem. Areas identified as having a persistently high rate of systemic overuse merit further investigation to understand drivers and potential points of intervention.

Geographical Variations in Prostate Cancer Outcomes: A Systematic Review of International Evidence

Background: Previous reviews of geographical disparities in the prostate cancer continuum from diagnosis to mortality have identified a consistent pattern of poorer outcomes with increasing residential disadvantage and for rural residents. However, there are no contemporary, systematic reviews summarizing the latest available evidence. Our objective was to systematically review the published international evidence for geographical variations in prostate cancer indicators by residential rurality and disadvantage.

Methods: Systematic searches of peer-reviewed articles in English published from 1/1/1998 to 30/06/2018 using PubMed, EMBASE, CINAHL, and Informit databases. Inclusion criteria were: population was adult prostate cancer patients; outcome measure was PSA testing, prostate cancer incidence, stage at diagnosis, access to and use of services, survival, and prostate cancer mortality with quantitative results by residential rurality and/or disadvantage. Studies were critically appraised using a modified Newcastle-Ottawa Scale.

Results: Overall 169 studies met the inclusion criteria. Around 50% were assessed as high quality and 50% moderate. Men from disadvantaged areas had consistently lower prostate-specific antigen (PSA) testing and prostate cancer incidence, poorer survival, more advanced disease and a trend toward higher mortality. Although less consistent, predominant patterns by rurality were lower PSA testing, prostate cancer incidence and survival, but higher stage disease and mortality among rural men. Both geographical measures were associated with variations in access and use of prostate cancer-related services for low to high risk disease.

Conclusions: This review found substantial evidence that prostate cancer indicators varied by residential location across diverse populations and geographies. While wide variations in study design limited comparisons across studies, our review indicated that internationally, men living in disadvantaged areas, and to a lesser extent more rural areas, face a greater prostate cancer burden. This review highlights the need for a better understanding of the complex social, environmental, and behavioral reasons for these variations, recognizing that, while important, geographical access is not the only issue. Implementing research strategies to help identify these processes and to better understand the central role of disadvantage to variations in health outcome are crucial to inform the development of evidence-based targeted interventions.

Measuring 21 low-value hospital procedures: claims analysis of Australian private health insurance data (2010-2014)

OBJECTIVE

To examine the prevalence, costs and trends (2010-2014) for 21 low-value inpatient procedures in a privately insured Australian patient cohort.

DESIGN

We developed indicators for 21 low-value procedures from evidence-based lists such as Choosing Wisely, and applied them to a claims data set of hospital admissions. We used narrow and broad indicators where multiple low-value procedure definitions exist.

SETTING AND PARTICIPANTS

A cohort of 376 354 patients who claimed for an inpatient service from any of 13 insurance funds in calendar years 2010-2014; approximately 7% of the privately insured Australian population.

MAIN OUTCOME MEASURES

Counts and proportions of low-value procedures in 2014, and relative change between 2010 and 2014. We also report both the Medicare (Australian government) and the private insurance financial contributions to these low-value admissions.

RESULTS

Of the 14 662 patients with admissions for at least 1 of the 21 procedures in 2014, 20.8%-32.0% were low-value using the narrow and broad indicators, respectively. Of the 21 procedures, admissions for knee arthroscopy were highest in both the volume and the proportion that were low-value (1607-2956; 44.4%-81.7%).Seven low-value procedures decreased in use between 2010 and 2014, while admissions for low-value percutaneous coronary interventions and inpatient intravitreal injections increased (51% and 8%, respectively).For this sample, we estimated 2014 Medicare contributions for admissions with low-value procedures to be between $A1.8 and $A2.9 million, and total charges between $A12.4 and $A22.7 million.

CONCLUSIONS

The Australian federal government is currently reviewing low-value healthcare covered by Medicare and private health insurers. Estimates from this study can provide crucial baseline data and inform design and assessment of policy strategies within the Australian private healthcare sector aimed at curtailing the high volume and/or proportions of low-value procedures.

Low-value care in Australian public hospitals: prevalence and trends over time

Objective

To examine 27 low-value procedures, as defined by international recommendations, in New South Wales public hospitals.

Design

Analysis of admitted patient data for financial years 2010–2011 to 2016–2017.

Main outcome measures

Number and proportion of episodes identified as low value by two definitions (narrower and broader), associated costs and bed-days, and variation between hospitals in financial year 2016–2017; trends in numbers of low-value episodes from 2010–2011 to 2016–2017.

Results

For 27 procedures in 2016–2017, we identified 5079 (narrower definition) to 8855 (broader definition) episodes involving low-value care (11.00%–19.18% of all 46 169 episodes involving these services). These episodes were associated with total inpatient costs of $A49.9 million (narrower) to $A99.3 million (broader), which was 7.4% (narrower) to 14.7% (broader) of the total $A674.6 million costs for all episodes involving these procedures in 2016–2017, and involved 14 348 (narrower) to 29 705 (broader) bed-days. Half the procedures accounted for less than 2% of all low-value episodes identified; three of these had no low-value episodes in 2016–2017. The proportion of low-value care varied widely between hospitals. Of the 14 procedures accounting for most low-value care, seven showed decreasing trends from 2010–2011 to 2016–2017, while three (colonoscopy for constipation, endoscopy for dyspepsia, sentinel lymph node biopsy for melanoma in situ) showed increasing trends.

Conclusions

Low-value care in this Australian public hospital setting is not common for most of the measured procedures, but colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopys for melanoma in situ require further investigation and action to reverse increasing trends. The variation between procedures and hospitals may imply different drivers and potential remedies.

Choosing wisely in oncology: necessity and obstacles

In the last decades, the survival of many patients with cancer improved thanks to modern diagnostic methods and progresses in therapy. Still for several tumours, especially when diagnosed at an advanced stage, the benefits of treatment in terms of increased survival or quality of life are at best modest when not marginal, and should be weighed against the potential discomfort caused by medical procedures. As in other specialties, in oncology as well the dialogue between doctor and patient should be encouraged about the potential overuse of diagnostic procedures or treatments. Several oncological societies produced recommendations similar to those proposed by other medical disciplines adhering to the Choosing Wisely (CW) campaign. In this review, we describe what was reported in the medical literature concerning adequacy of screening, diagnostic, treatment and follow-up procedures and the potential impact on them of the CW. We only marginally touch on the more complex topic of treatment appropriateness, for which several evaluation methods have been developed (including the European Society for Medical Oncology-magnitude of clinical benefit scale). Finally, we review the possible obstacles for the development of CW in the oncological setting and focus on the strategies which could allow CW to evolve in the cancer field, so as to enhance the therapeutic relationship between medical professionals and patients and promote more appropriate management.