A new article, published in BMJ Quality & Safety, addresses the challenges with quantifying and studying low-value healthcare. The authors, led by Kelsey Chalmers, a doctoral candidate at the University of Sydney, discuss three different ways to express rates of low-value care and how each may paint a very different picture. The authors write:
“It is curious that low-value lists abound, yet the world over we have but a cursory understanding of the scale and scope of low-value care due to the general lack of measurement.”
The authors define low-value care as “care that is inappropriate for a specific clinical indication, inappropriate for a clinical indication in a specific population or an excessive frequency of services relative to expected benefit.” The overuse of low-value treatments is gaining increasing attention. For example, Choosing Wisely is an international campaign aimed at addressing low-value care.
“Interventions targeting the reduction of low-value or no-value care offer the dual benefit of improving safety and quality and making inroads into escalating healthcare expenditure,” write the authors. However, in order develop appropriate solutions, researchers need to identify the scope of the problem. This is difficult when researchers are using different measures. The authors identify three ways researchers are measuring low-value care:
- Patient-Indicator (patient-oriented): Measures the number of patients who received a low-value service out of the total number of patients who have the same diagnosis/indication. Example: A knee arthroscopy to treat osteoarthritis is considered a low-value service. The percentage of osteoarthritis patients who received knee arthroscopy out of a cohort of patients with osteoarthritis was 4%.
- Patient-Population (patient-oriented): Measures the number of patients who received a low-value service out of an entire population. Example: The percentage of patients with osteoarthritis who received knee arthroscopy out of all Medicare beneficiaries was 2%.
- Service (service-oriented): Measures the number of times a treatment was performed as a low-value service out of all the times that treatment was performed. Example: The percentage of arthroscopies performed for a diagnosis of osteoarthritis out of all arthroscopies performed was 57%.
These three measures give vastly different portrayals of how often knee arthroscopy for osteoarthritis is performed. Using the patient-population indicator, this low-value service only happens for 0.2% of Medicare patients, and therefore may not seem very concerning. However, it is far more alarming to learn that that 57% of arthroscopies are considered low-value care.
In a previous study, the authors reviewed 40 published papers measuring low-value care. The researchers found that patient-centric measures (i.e., patient-indication, patient-population) are much more common than service-centric measures. The authors acknowledge that different measures may be most relevant for different research studies, or for specific audiences.
For example, clinicians may be more interested in the patient-indication measure in order to know how many patients with a specific diagnosis are receiving low-value care. However, policymakers or those responsible for resource allocation would be more interested in the service measure in order to know the proportion of services that are low-value. Therefore, each measurement has merit in different situations. The problem arises when researchers attempt to examine the prevalence of low-value care across studies. The authors write:
“This has very real implications for the extensive audiences of this work, including clinicians, researchers and policy/payer stakeholders, in that they cannot always make comparisons for the same low-value services and thus one cannot, in fact, compare apples and oranges.”
Therefore, the authors recommend that whenever possible, “researchers report using both lenses and all three measures, to describe the full picture of low-value care practice.” This will aid future researchers, clinicians, and policymakers to more accurately understand the prevalence of low-value, which will improve efforts to reduce its occurrence.
Chalmers, K., Pearson, S. A., & Elshaug, A. G. (2017). Quantifying low-value care: A patient-centric versus service-centric lens. BMJ Quality & Safety. Advance online publication. doi:10.1136/bmjqs-2017-006678 (Link)