Avoiding Low-Value Care

Fewer procedures, more conversations, may lead to better outcomes.

September 2022 – The Journal of Healthcare Contracting

Less is more: Is it true regarding healthcare services and procedures? Many clinicians think so but have found that eliminating “low-value care” is more difficult than it sounds.

Research shows that fear of malpractice, patient demands and old med school habits continue to drive physicians to provide diagnostic, imaging and pharmacological services that do little good for their patients, and at worst, lead to poorer health outcomes. It’s called low-value care and has been defined as services that are of limited to no benefit to patients, may cause patients harm, and lead to waste of healthcare resources.

“The potential negative consequences of medical overuse include adverse effects of treatments and procedures, invasive and dangerous follow-up tests and treatments, overdiagnosis, psychological harm, treatment burden, social consequences, and dissatisfaction with health care,” concludes Niloofar Latifi, M.D., of John Hopkins School of Medicine, writing in a JAMA Internal Medicine editorial in December 2021. For example, routine preoperative electrocardiograms before cataract surgery have been associated with a cascade of testing, treatment, and specialist referral at an estimated annual cost for Medicare of $35 million, she says. Low-value testing in annual health examinations has been associated with more specialist visits and additional noninvasive and invasive testing.

Choosing Wisely®

Based on the principle of avoiding services with no or minimal benefit to patients, the American Board of Internal Medicine Foundation in 2012 helped launch the Choosing Wisely® campaign. The program calls for professional societies to create lists of low-value services that physicians should avoid and encourages physicians to engage in conversations about overuse.

The campaign started with lists from nine medical societies and has since grown to include lists from more than 80 societies, citing more than 600 procedures in total. In addition, the program has spread beyond U.S. borders to 25 other countries, including Canada, the United Kingdom, Germany, and Japan.

In a Perspective piece in the New England Journal of Medicine in April, internist Elizabeth J. Rourke, M.D., of Brigham and Women’s Primary Care in Boston, raised questions about Choosing Wisely, calling it an “immediate public relations win for the medical profession in 2012, demonstrating that doctors were stepping up to address low value and high costs in medicine.” But, she continues, “[t]en years later, it’s clear that making lists and publicizing them are not sufficient to reduce low-value care.” Medical services that do not improve patients’ health continue to account for an estimated 10% to 20% of health care provided in the United States, costing $75 billion to $101 billion per year, she says.

“In a capitalist economy oriented toward growth, more has always been more, and newer has always been better. In this context, parsimony is a hard sell. In addition, cognitive biases such as the therapeutic illusion that leads us to overestimate benefits and underestimate harms are present in both doctors and patients.”

Physicians who want to reduce low-value care should begin by listening to their patients’ wishes, Rourke says. “My experience mirrors the findings of a 2015 study that used surveys, interviews, and focus groups to assess how patients understood low-value care. The study found ‘quite powerfully’ that patients favored ‘replacing excessive tests with time for clinicians to talk, listen and personalize’ and that ‘the vast majority of Americans who currently view reducing low-value care in a positive light do so because they see it as a means to improve communication with their clinicians.’ In short, these patients – and I – want more of the conversations that the [American Board of Internal Medicine] set out to promote in 2012.”

Time to talk

Daniel B. Wolfson, executive vice president and COO of the ABIM Foundation told Repertoire, “After a decade of Choosing Wisely we know what helps in addressing low-value care and have worked with specialty societies to create many valid and meaningful recommendations. But we completely agree that now is the time for delivery systems and other entities to use multiple interventions to promote value-based care.

“Our role was in starting the movement, and we always knew it would take others joining us to create projects and interventions that would help ensure reductions of low-value care. Beginning with awareness, cultural changes, and prioritizing low-value care, the next phase would be multiple efforts to de-implement care.”

Wolfson points out that this is already occurring in pockets of the healthcare system, including among 14 large healthcare systems whom the Foundation worked with under a grant from the Robert Wood Johnson Foundation. That effort led to a 20% to 30% reduction in the use of antibiotics, he says. In another example, Cedars-Sinai Health System used its decision support tool in Epic to alert physicians when their care instructions deviated from Choosing Wisely’s evidence-based guidelines during inpatient visits. “An alert was triggered, for example, if a physician tried ordering a sedative for a sleepless older patient, as sedatives can put seniors at risk for falls and more,” he says. “Physicians could choose to follow the suggestion or override it. The study found a significant difference in health outcomes and costs between those that followed the suggested alerts and those that didn’t.

“The conversations we ignited continue, with many physicians reporting that Choosing Wisely conversations occur daily in their hospitals and clinical practices,” says Wolfson. “Multiple journals, including the Journal of Hospital Medicine and JAMA Internal Medicine, feature regular sections on Choosing Wisely and/or overuse. Specialty society meetings have tracks on overuse and their Choosing Wisely recommendations. And conversations also occur in medical education and training through the Costs of Care’s STARS program,” which provides training for medical students to lead value improvement initiatives at their own medical schools.

Value-based care

Mary Campagnolo, MD, MBA, FAAFP, a board member of the American Academy of Family Physicians, believes that “at its core, the [Choosing Wisely] campaign shares a major theme with family medicine – encouraging conversations and shared decision-making between physicians and patients regarding the risks, benefits and necessity of common tests and procedures.” But those types of conversations can be difficult in today’s fee-for-service system.

“Fee-for-service payment models incentivize ‘sick’ care by rewarding physicians for ‘doing things to people,’ i.e., tests and procedures,” she says. “In contrast, value-based payment models prioritize primary care and wellness.

“Value-based payment rewards efficiency while maintaining sensitivity to patients’ physical, emotional and social needs. For example, value-based care incentivizes reduced emergency department visits or unnecessary hospitalizations by focusing on prevention for patients at high risk. Similarly, value-based care encourages practices to work with local social service agencies to address social or emotional needs that may be affecting the patient’s health.

“We firmly believe that value-based payment models, which base physician payment on outcomes as opposed to the number and type of services, enables physicians to provide person-centered, proactive care that better serves patients.”

Says Wolfson, “Change in health care is often slower than we’d like, especially in reducing low-value care, as we’re continually working against the perception that more is better. Choosing Wisely helped change that conversation, and we believe that the vast majority of the clinical recommendations from the campaign advanced our goals of promoting conversations between clinicians and patients about reducing overuse.

“We’re certainly not all the way there yet, but there is greater awareness of these issues amongst clinicians and patients than when we started.”

Spending on low-value care

Despite the efforts of the medical societies participating in the American Board of Internal Medicine’s Choosing Wisely® initiative, success in reducing low-value care and spending has been modest at best, concluded researchers reporting in JAMA Internal Medicine in December. The reason could lie in the characteristics and expected impact of the services identified in Choosing Wisely recommendations. Some of their findings:

  • Low-value services identified in the 626 Choosing Wisely recommendations largely cover imaging (26.8% and laboratory studies (24.9%).
  • Nearly half (45.4%) of recommendations identify services that are low cost (<$200), such as serum vitamin D tests or electrocardiograms.
  • Most recommendations (43.8%) identify low-value services that cover common clinical scenarios, such as low back pain, pregnancy, or acute respiratory tract infection, or uncommon clinical scenarios, such as pediatric nephrolithiasis (38.5%).
  • Nearly half (44.8%) of identified low-value services have high potential for direct harm (e.g., central venous catheter placement), while 62% have high potential for cascades (e.g., opioid treatment, preoperative electrocardiogram, and prostate specific antigen test).
  • Most services with low direct harm nevertheless have high cascade potential and 19.2% of recommendations name services with high direct harm and high cascade potentials.

A ‘Choosing Wisely’ list

Following are the American Academy of Family Physicians’ clinical recommendations for the American Board of Internal Medicine’s Choosing Wisely® initiative.

  1.  Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
  2.  Don’t routinely prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable.
  3.  Don’t routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes mellitus and are not using insulin.
  4.  Don’t use dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis in women under age 65 or men under 70 with no risk factors.
  5.  Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks.
  6.  Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
  7.  Don’t perform Pap smears on women under the age of 21 or women who have had a hysterectomy for non-cancer disease.
  8.  Do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications.
  9.  Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.
  10. Don’t transfuse more than the minimum of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable patients).
  11. Don’t screen for carotid artery stenosis in asymptomatic adult patients.
  12. Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
  13. Don’t screen for genital herpes simplex virus infection in asymptomatic adults, including pregnant women.
  14. Don’t screen for testicular cancer in asymptomatic adolescent and adult males.
  15. Don’t perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline-appropriate screening for cervical cancer. 
  16. Don’t perform voiding cystourethrogram (VCUG) routinely in first febrile urinary tract infection (UTI) in children aged 2-24 months.
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