Dataset Information

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

ABSTRACT:

Background

Low-value care, typically defined as health services that provide little or no benefit, has potential to cause harm, incur unnecessary costs, and waste limited resources. Although evidence-based guidelines identifying low-value care have increased, the guidelines differ in the type of evidence they cite to support recommendations against its routine use.

Objective

We examined the evidentiary rationale underlying recommendations against low-value interventions.

Design

We identified 1167 "low-value care" recommendations across five US organizations: the US Preventive Services Task Force (USPSTF), the "Choosing Wisely" Initiative, American College of Physicians (ACP), American College of Cardiology/American Heart Association (ACC/AHA), and American Society of Clinical Oncology (ASCO). For each recommendation, we classified the reported evidentiary rationale into five groups: (1) low economic value; (2) no net clinical benefit; (3) little or no absolute clinical benefit; (4) insufficient evidence; (5) no reason mentioned. We further investigated whether any cited or otherwise available cost-effectiveness evidence was consistent with conventional low economic value benchmarks (e.g., exceeding $100,000 per quality-adjusted life-year).

Results

Of the identified low-value care recommendations, Choosing Wisely contributed the most (N=582, 50%), followed by ACC/AHA (N=250, 21%). The services deemed "low value" differed substantially across organizations. "No net clinical benefit" (N=428, 37%) and "little or no clinical benefit" (N=296, 25%) were the most commonly reported reasons for classifying an intervention as low value. Consideration of economic value was less frequently reported (N=171, 15%). When relevant cost-effectiveness studies were available, their results were mostly consistent with low-value care recommendations.

Conclusions

Our study found that evidentiary rationales for low-value care vary substantially, with most recommendations relying on clinical evidence. Broadening the evidence base to incorporate cost-effectiveness evidence can help refine the definition of "low-value" care to reflect whether an intervention's costs are worth the benefits. Developing a consensus grading structure on the strength and evidentiary rationale may help improve de-implementation efforts for low-value care.

SUBMITTER: Kim DD

PROVIDER: S-EPMC8606489 | biostudies-literature | 2021 Nov

REPOSITORIES: biostudies-literature

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Publications

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

Kim David D DD Do Lauren A LA Daly Allan T AT Wong John B JB Chambers James D JD Ollendorf Daniel A DA Neumann Peter J PJ

Journal of general internal medicine 20210223 11

<h4>Background</h4>Low-value care, typically defined as health services that provide little or no benefit, has potential to cause harm, incur unnecessary costs, and waste limited resources. Although evidence-based guidelines identifying low-value care have increased, the guidelines differ in the type of evidence they cite to support recommendations against its routine use.<h4>Objective</h4>We examined the evidentiary rationale underlying recommendations against low-value interventions.<h4>Design ...[more]

PMID: 33620623

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Project description:BackgroundPlenty 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.MethodsInformed 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.FindingsLow-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).InterpretationDespite 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.FundingThe 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).

Project description:BackgroundAccumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings.MethodsWe systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care.ResultsOut of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers' behavior, and 1 de-implementation intervention focused on changing the patients' behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias.ConclusionsThis review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).

Project description:ObjectivePoint-of-care testing (POCT) has become an essential diagnostic technology for optimal patient care. Its implementation, however, still falls behind. This paper reviews the available evidence on the health economic impact of introducing POCT to assess if poor POCT uptake may be related to lacking evidence.Study designThe Scopus and PubMed databases were searched to identify publications describing a health economic evaluation of a point-of-care (POC) test. Data were extracted from the included publications, including general and methodological characteristics as well as the study results summarized in either cost, effects or an incremental cost-effectiveness ratio. Results were sorted into six groups according to the POC test's purpose (diagnosis, screening or monitoring) and care setting (primary care or secondary care). The reporting quality of the publications was determined using the CHEERS checklist.ResultsThe initial search resulted in 396 publications, of which 44 met the inclusion criteria. Most of the evaluations were performed in a primary care setting (n = 31; 70.5%) compared with a secondary care setting (n = 13; 29.5%). About two thirds of the evaluations were on POC tests implemented with a diagnostic purpose (n = 28; 63.6%). More than 75% of evaluations concluded that POCT is recommended for implementation, although in some cases only under specific circumstances and conditions. Compliance with the CHEERS checklist items ranged from 20.8% to 100%, with an average reporting quality of 72.0%.ConclusionThere were very few evaluations in this review that advised against the implementation of POCT. However, the uptake of POCT in many countries remains low. Even though the evaluations included in this review did not always include the full long-term benefits of POCT, it is clear that health economic evidence across a few dimensions of value already indicate the benefits of POCT. This suggests that the lack of evidence on POCT is not the primary barrier to its implementation and that the low uptake of these tests in clinical practice is due to (a combination of) other barriers. In this context, aspects around organization of care, support of clinicians and quality management may be crucial in the widespread implementation of POCT.

Project description:BackgroundDe-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research.MethodsWe searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool.ResultsWe screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%).ConclusionDe-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers.Trial registrationOSF (Open Science Framework): https://osf.io/ueq32 .

Project description:BACKGROUND:It is unknown to what extent Choosing Wisely recommendations about income-generating treatments apply to members of the society generating the recommendations. The primary aim of this study is to determine the proportion of Choosing Wisely recommendations targeting income-generating treatments, and whether recommendations from professional societies on income-generating treatments are more likely to target members or non-members. The secondary aim is to determine the prevalence of qualified statements, and whether qualified statements are more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members. METHODS:We performed a content analysis of all Choosing Wisely recommendations, with data extracted from Choosing Wisely websites. Two researchers coded recommendations as test or treatment-based, for or against a procedure, containing qualified statements, income-generating and applying to members. Disagreements were resolved by discussion or consultation with a third researcher. A Chi-squared test evaluated whether society recommendations on income-generating treatments were more likely to target members or non-members; and whether qualified statements were more likely to appear in recommendations targeting income-generating or non-income-generating treatments that apply to members. RESULTS:We found 1293 Choosing Wisely recommendations (48.3% tests and 48.6% treatments). Ninety-eight treatment recommendations targeted income-generating treatments (17.8%), and recommendations on income-generating treatments were less likely to target members compared to non-members (15.6% vs. 40.4%, p < 0.001). Nearly half of all recommendations were qualified (41.9%), with a similar proportion of recommendations targeting income-generating and non-income-generating treatments that apply to members containing qualified statements (49.4% vs. 42.0%, p = 0.23). CONCLUSIONS:Many societies provide Choosing Wisely recommendations that minimise impact on their own members. Only 20% of treatment recommendations target income-generating treatments, and of these recommendations mostly target non-members. Many recommendations are also qualified. Increasing the number of recommendations from societies that are unqualified and target member clinicians responsible for de-implementation of low-value and costly treatments should be a priority.

Project description:ObjectiveTo assess barriers and facilitators to de-implementation.DesignA qualitative evidence synthesis with a framework analysis.Data sourcesMedline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched.Eligibility criteriaWe included studies that primarily focused on identifying factors influencing de-implementation or the continuation of low-value care, and studies describing influencing factors related to the effect of a de-implementation strategy.Data extraction and synthesisThe factors were classified on five levels: individual provider, individual patient, social context, organisational context, economic/political context.ResultsWe identified 333 factors in 81 articles. Factors related to the individual provider (n=131; 74% barriers, 17% facilitators, 9% both barrier/facilitator) were associated with their attitude (n=72; 55%), knowledge/skills (n=43; 33%), behaviour (n=11; 8%) and provider characteristics (n=5; 4%). Individual patient factors (n=58; 72% barriers, 9% facilitators, 19% both barrier/facilitator) were mainly related to knowledge (n=33; 56%) and attitude (n=13; 22%). Factors related to the social context (n=46; 41% barriers, 48% facilitators, 11% both barrier/facilitator) included mainly professional teams (n=23; 50%) and professional development (n=12; 26%). Frequent factors in the organisational context (n=67; 67% barriers, 25% facilitators, 8% both barrier/facilitator) were available resources (n=28; 41%) and organisational structures and work routines (n=24; 36%). Under the category of economic and political context (n=31; 71% barriers, 13% facilitators, 16% both barrier/facilitator), financial incentives were most common (n=27; 87%).ConclusionsThis study provides in-depth insight into the factors within the different (sub)categories that are important in reducing low-value care. This can be used to identify barriers and facilitators in low-value care practices or to stimulate development of strategies that need further refinement. We conclude that multifaceted de-implementation strategies are often necessary for effective reduction of low-value care. Situation-specific knowledge of impeding or facilitating factors across all levels is important for designing tailored de-implementation strategies.

Project description:ImportanceOvertreatment of early-stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing Wisely campaign identified 4 breast cancer operations as low value: (1) axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiation, (2) re-excision for close but negative lumpectomy margins for invasive cancer, (3) contralateral prophylactic mastectomy in patients at average risk with unilateral cancer, and (4) sentinel lymph node biopsy in women 70 years or older with hormone receptor-positive cancer.ObjectiveTo evaluate the extent to which these procedures have been deimplemented, determine the implications of decreased use, and recognize possible barriers and facilitators to deimplementation.Evidence reviewA systematic review of published literature on use trends in breast surgery was performed in accordance with PRISMA guidelines. The Ovid, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for original research with relevance to the Choosing Wisely recommendations of interest. Eligible studies were examined for data about use, and any patient-level, clinician-level, or system-level factors associated with use.FindingsConcordant with recommendations, national rates of axillary lymph node dissection for patients with limited nodal disease have decreased by approximately 50% (from 44% in 2011 to 30% to 34% in 2012 and 25% to 28% in 2013), and national rates of lumpectomy margin re-excision have decreased by nearly 40% (from 16% to 34% before to 14% to 18% after publication of a consensus statement). Conversely, national rates of contralateral prophylactic mastectomy continue to rise each year, accounting for up to 30% of all mastectomies for breast cancer (range in all mastectomy cases: 2010-2012, 28%-30%; 1998, <2%), and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer are persistently greater than 80% (range, 80%-88%). Factors associated with high rates of contralateral prophylactic mastectomy use are younger age, white race, increased socioeconomic status, and the availability of breast reconstruction; limited data exist on factors associated with high rates of sentinel lymph node biopsy in women 70 years or older. Successful deimplementation of axillary lymph node dissection and lumpectomy margin re-excision were associated with decreased costs and improved patient-centered outcomes.Conclusions and relevanceThis review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.

Project description:BackgroundThe benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools.ObjectiveThis paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist.MethodsA systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering.ResultsThe review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits.ConclusionsThe research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base.

Project description:BackgroundThe use of low-value care (LVC) is a persistent challenge in health care. Health technology reassessment (HTR) assesses the effects of technologies currently used in the health care system to guide optimal use of these technologies. Consequently, HTR holds promises for identifying and reducing, i.e., de-implementing, the use of LVC. There is limited research on how HTR is executed to support the de-implementation of LVC and whether and how HTR outcomes are translated into practical application. The aim of this study is to investigate how HTR is conducted to facilitate de-implementation of LVC and to investigate how the results of HTR are received and acted on in health care settings.MethodsThis study is a qualitative interview study with representatives from health technology assessment agencies (n = 16) that support the regional health care organizations in Sweden and with representatives from the health care organizations (n = 7). Interviews were analysed with qualitative content analysis.ResultsWe identified three overarching categories for how HTR facilitates de-implementation of LVC and how the results are received and acted on in health care settings: (1) involving key stakeholders to facilitate de-implementation of LVC in identifying potential LVC practices, having criteria for accepting HTR targets, ascertaining high-quality reports and disseminating the reports; (2) actions taken by health care organization to de-implement LVC by priority setting and decision-making, networking between health care organizations and monitoring changes in the use of LVC practices; and (3) sustaining use of LVC by not questioning continued use, continued funding of LVC and by creating opinion against de-implementation.ConclusionsEvidence is not enough to achieve de-implementation of LVC. This has made health technology assessment agencies and health care organizations widen the scope of HTR to encompass strategies to facilitate de-implementation, including involving key stakeholders in the HTR process and taking actions to support de-implementation. Despite these efforts, there can still be resistance to de-implementation of LVC in passive forms, involving continued use of the practice and more active resistance such as continued funding and opinion-making opposing de-implementation. Knowledge from implementation and de-implementation research can offer guidance in how to support the execution phase of HTR.

Dataset Information

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

Background

Objective

Design

Results

Conclusions

Publications

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

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