Low-value care can be dangerous to patients; researchers are working on solutions

Key takeaways:

• Low-value care causes both physical and psychological harms.
• These services often include prostate cancer screening and back pain imaging.
• The problem is complex, although some interventions have shown success.

Low-value care can result in significant harm and costs to patients, although interventions involving patient and clinician education could help reduce these services, an expert said.

Speaking to Healio, Thomas Radomski, MD, MS, an assistant professor of medicine and health services researcher at the University of Pittsburgh, explained that even though the United States spends twice as much on health care compared with other developed countries, “we're actually doing worse across a whole host of outcomes.”

Among the key drivers of these expenses is low-value care, a service where the potential costs or harms outweigh its possible benefits.

A 2019 JAMA study reported that low-value care is estimated to account for 0.6% to 2.7% of annual U.S. health care spending, equivalent to $75.7 billion to $101.2 billion annually.

“On a very basic level, it’s all downside and not much upside for the delivery of one of these types of services,” Radomski said

Harms of low-value care

According to Radomski, the harms of low-value care can manifest in different ways.

“For example, maybe you're undergoing a procedure, and you have a complication related to that procedure,” he said. “Maybe you develop an infection because of a procedure that you didn't necessarily need.”

Harms can also be psychological — with unnecessary services potentially causing anxiety in patients — whereas the financial costs can be significantly burdensome to many, “especially older adults who are on a fixed income,” Radomski noted.

“Taking this all together, it can really erode trust in the health care system and crowd out care that patients — either that individual patient or another patient — needs,” he said.

Among the most common low-value care services is low back imaging, such as MRIs, X-rays or CT scans, which are ordered too early in the patient’s progression of their back pain.

“Most back pain will resolve either on its own or with what we would call conservative treatment,” Radomski said.

Another overused service is prostate-specific antigen testing for prostate cancer among older adults who do not fit the criteria for screening.

“The current guidelines would recommend we stop screening for prostate cancer at the age of 70 years — the reason being is because above that age, it's very unlikely that an older man will be diagnosed with prostate cancer and that it will result in his lifespan being shortened,” Radomski explained.

Why providers reach for low-value services

Radomski said the fee-for-service payment system is one of several reasons why low-value care services continue to be used, despite the clear lack of benefits.

“There's no reason to dissuade doctors from ordering tests and procedures,” he said. “If they're going to make more money from it, they might not encourage it, but they also don't actively dissuade against it.”

Another factor is a provider’s potential fear of missing something serious or being sued.

“Someone comes in with a headache. You think it’s innocent, but what if it's an aneurysm that is ruptured? What if it’s that worst-case scenario?” Radomski said. “Maybe you did miss something in the past, and you live with that regret. So, you might have a lower threshold to order a CT scan of someone's head, even though 99% of the time that scan will be normal.”

Interventions to reduce reliance on low-value care

The ABIM’s Choosing Wisely campaign has become one of the most recognizable and largest initiatives aimed at reducing overused and unneeded care.

However, “what we’ve seen in studies is that the advent of this campaign unto itself, and disseminating that knowledge, hasn't been shown to result in decreases in low-value care over time,” Radomski said. “So, broad-based knowledge is likely insufficient to reduce low-value care.”

He said there is not a single best approach to addressing low-value care, “and that’s in part because there are different drivers of why low-value care happens based upon the service that we’re talking about, the health system that you’re in and the set-up of the system, and the local culture that exists surrounding the delivery of care.”

Still, multiple interventions — aimed at either the patient, clinician or overall health system — have shown some success.

Effective interventions centered around patient education include those aimed at reducing inappropriate or harmful prescribing, “where patients were sent pamphlets saying, ‘you're on a medication that could increase your risk of falls or increase your risk of confusion,’” Radomski explained.

“Initiatives such as that have been helpful at inducing conversations between patients and their clinicians and have resulted in some deprescribing of those harmful medications,” he said.

Radomski highlighted another recent study in which researchers created an intervention based on behavioral economics. Clinicians were asked to commit to following Choosing Wisely recommendations and offered education on alternatives to low-value care. The intervention ultimately led to a reduction in the use of low-value services, and it increased the odds of deintensification of hypoglycemic medications for diabetes.

At the system level, Radomski recommended involving an interprofessional health care team to tackle the problem of overreliance on low-value care.

"A good example for unnecessary or inappropriate medication use is involving clinical pharmacists to initiate a conversation with patients about potentially harmful medications and alleviate the time burden placed on the physician to engage in that conversation on their own and try and get the patient to stop medications that might be inappropriate,” he said.

References:

• Choosing Wisely. https://abimfoundation.org/what-we-do/choosing-wisely. Accessed Feb. 8, 2024.
• Choosing Wisely. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/choosing-wisely.html. Accessed Feb. 8, 2024.
• Oakes A, Radomski T. JAMA. 2021;doi:10.1001/jama.2021.3308.
• Park S, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.1762.
• Shrank WH, et al. JAMA. 2019;doi:10.1001/jama.2019.13978.