Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review:
TL;DR: It is found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care.
Abstract: The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.
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TL;DR: This commentary explores unique aspects of de-implementing inappropriate interventions that differentiate it from implementing evidence-based interventions, including multi-level factors, types of action, strategies for de-IMplementation, outcomes, and unintended negative consequences.
Abstract: De-implementing inappropriate health interventions is essential for minimizing patient harm, maximizing efficient use of resources, and improving population health. Research on de-implementation has expanded in recent years as it cuts across types of interventions, patient populations, health conditions, and delivery settings. This commentary explores unique aspects of de-implementing inappropriate interventions that differentiate it from implementing evidence-based interventions, including multi-level factors, types of action, strategies for de-implementation, outcomes, and unintended negative consequences. We highlight opportunities to continue to advance research on the de-implementation of inappropriate interventions in health care and public health.
152 citations
TL;DR: Thanya Pathirana and colleagues explore strategies to tackle the problem of too much medicine and find ways to reduce the number of prescriptions and improve the quality of treatment.
Abstract: Thanya Pathirana and colleagues explore strategies to tackle the problem of too much medicine
130 citations
02 Oct 2019
TL;DR: This survey study estimates the national frequency and consequences of cascades of care after incidental findings using results from a national survey of US physicians.
Abstract: Importance Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.
93 citations
TL;DR: Care cascades after preoperative EKG for cataract surgery are infrequent but costly, and policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
Abstract: Importance Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care. Objective To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery. Design, Setting, and Participants Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019. Exposures Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG. Main Outcomes and Measures Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade. Results Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade. Conclusions and Relevance Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.
62 citations
TL;DR: Analysis of beneficiaries in the globally-budgeted health system of Alberta, Canada found that low-value care commonly occurred—at a rate of approximately 5% of beneficiaries seeking care, and as high as 30% among those aged >75 years, similar to the USA.
Abstract: Low-value care, or patient care that provides no net benefit in specific clinical scenarios, remains one of the most pressing problems in healthcare across the world—namely because it raises costs, causes iatrogenic patient harm, and often interferes with the delivery of high-value care. Many have argued that above all else the primary cause of low-value care lies in an unchecked fee-for-service payment system, which creates a pervasive culture that rewards providers for delivering more care, not necessarily the right care. Results reported by McAlister et al in this issue of BMJ Quality & Safety seem to up-end this belief.1 In their analysis of 3.4 million beneficiaries in the globally-budgeted health system of Alberta, Canada, they found that low-value care commonly occurred—at a rate of approximately 5% of beneficiaries seeking care, and as high as 30% among those aged >75 years. Notably, these rates are comparable to rates in America’s largely unrestrained fee-for-service system for both commercially insured (~8%) and older Medicare beneficiaries (~25-42%) seeking care, even while McAlister and colleagues used fewer low-value care measures (10) than the latter two American studies (28 and 26 respectively).2 3 Moreover, similar to the USA, the extent of the problem also varied substantially across frequently presumed examples of overuse. For instance, carotid artery imaging in adults without symptoms of cerebrovascular disease occurred in only 0.3% of patients, whereas 55.5% of men 75 years or older without a history of prostate cancer underwent prostate-specific antigen testing.
Although both Canadian and US physicians operate in fee-for-service payment models, Canadian physicians practice within a broader system of strict global budgets for hospitals and regional health authorities.4 Such financial restrictions may reduce the overall volume of certain services: for instance, researchers found higher overall rates of CT utilisation in the USA compared with Canada.5 While global budgets …
58 citations
References
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TL;DR: The approach of GRADE to rating quality of evidence specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies.
5,228 citations
"Interventions Aimed at Reducing Use..." refers background in this paper
...…observational studies (4), downgraded randomized trials, or upgraded observational studies (3), double-downgraded randomized trials, or observational studies (2) and triple-downgraded randomized trials, downgraded observational studies, or case series/case reports (1; Balshem et al., 2011)....
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TL;DR: Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent.
Abstract: In any field, improving performance and accountability depends on having a shared goal that unites the interests and activities of all stakeholders. In health care, however, stakeholders have myriad, often conflicting goals, including access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction. Lack of clarity about goals has led to divergent approaches, gaming of the system, and slow progress in performance improvement. Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent.1 This goal is what matters for patients and unites . . .
3,615 citations
"Interventions Aimed at Reducing Use..." refers background in this paper
...Despite the recent broader acceptance of the term low-value care, a consensus has not been reached on what should be included in the definition (Feeley, Fly, Albright, Walters, & Burke, 2010; Hoverman, 2011; Porter, 2010; Torrance, Thomas, & Sackett, 1972)....
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Posted Content•
TL;DR: This work estimates how cost sharing, the portion of the bill the patient pays, affects the demand for medical services and rejects the hypothesis that less favorable coverage of outpatient services increases total expenditure.
Abstract: We estimate how cost sharing, the portion of the bill the patient pays, affects the demand for medical services. The data come from a randomized experiment. A catastrophic insurance plan reduces expenditures 31 percent relative to zero out-of-pocket price. The price elasticity is approximately -0.2. We reject the hypothesis that less favorable coverage of outpatient services increases total expenditure (for example, by deterring preventive care or inducing hospitalization).
2,063 citations
"Interventions Aimed at Reducing Use..." refers background in this paper
...Cost sharing has also been shown to reduce overall expenditures relative to out-of-pocket price (Manning et al., 1987; Newhouse et al., 1981)....
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TL;DR: Tests for small-study effects should routinely be performed in meta-analysis, particularly for moderate amounts of bias or meta-analyses based on a small number of small studies.
1,821 citations
TL;DR: The need is urgent to bring US health care costs into a sustainable range for both public and private payers and the savings potentially achievable from systematic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage.
Abstract: The need is urgent to bring US health care costs into a sustainable range for both public and private payers. Commonly, programs to contain costs use cuts, such as reductions in payment levels, benefit structures, and eligibility. A less harmful strategy would reduce waste, not value-added care. The opportunity is immense. In just 6 categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—the sum of the lowest available estimates exceeds 20% of total health care expenditures. The actual total may be far greater. The savings potentially achievable from systematic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage. The potential economic dislocations, however, are severe and require mitigation through careful transition strategies.
1,425 citations
"Interventions Aimed at Reducing Use..." refers background in this paper
...Many programs to reduce health care costs use reductions in reimbursement, benefit structures, and eligibility (Berwick & Hackbarth, 2012)....
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