Low-value healthcare services (LVHS) are defined as tests and procedures that deliver little or no clinical benefit, increase healthcare spending without improved health outcomes, carry risk of patient harm outweighing benefits, and are unlikely to have an impact on clinician decisions.1–6 Performing healthcare services that are unnecessary or low-value increases burden on the system as well as payers, and can also lead to false positives, unnecessary follow-ups, increased patient anxiety along with decreased satisfaction, and poor outcomes. Currently, LVHS contribute significantly to the growing problems of overuse, over diagnosis, and overtreatment in healthcare. Medical overuse is defined as unwarranted/unnecessary delivery of care in which the risks of harm exceed the benefits7–9; care unlikely to improve outcomes4,10–12; or services an average patient would opt to forego given choices.12,13 over diagnosis, diagnosis of a condition that will never cause patient symptoms or death, and overtreatment, treatment targeting an overdiagnosed condition offering little benefit, are both common.9,14,15
Overuse of LVHS is prevalent in the United States, contributing to unsustainable rising costs. In 2012, United States healthcare spending totaled $2.87 trillion, comprising over 18% of the gross domestic product, yet research indicates that up to 30% of this spending does not improve patient health.2,5,16–18 The United States currently spends about $8,000 per capita on care, up to 50% more than most other industrialized nations,19 many of which have better patient outcomes.16–18 Furthermore, estimates place the annual cost of healthcare waste at $700 billion,8,20–22 with an estimated 40% ($280 billion) from overuse of LVHS.8 Thus concerns about appropriate utilization, improved care quality, and cost containment have become priorities for healthcare organizations and policy makers.
Physicians and payers recognize the need to identify “high-value, cost-conscious” care or services that provide benefits to the patient.23 Existing quality measures address the underutilization of necessary high-value services; however, validated measures currently do not exist strictly for overuse.4,8,10,24,25 The development of specific overuse measures may allow further research into the factors that contribute to overuse and its subsequent effect on costs and quality.25
Statement of Purpose
Our primary purpose in this commentary is to: (1) examine the overuse of LVHS and its effect on quality of care delivery and (2) propose factors to consider in developing related quality measures to help reduce overuse and waste and to help improve patient outcomes. To accomplish this purpose, we will describe a limited review of research to provide background information and to support our position in this commentary.
Our primary purpose was to examine the growing problem of LVHS overuse and impacts of this overuse. In addition, we propose factors to consider in developing or improving measures to help reduce unnecessary overuse and waste associated with these services. Thus to describe background information and to further support our position, we conducted a limited review of the scientific literature, which was sufficient to meet our purpose. No human subjects were used, and therefore, no institutional review board approval was required or obtained.
Our literature search methods were restrictive to meet our stated purpose and to concisely support our position. Specifically, our key criterion was whether each published article pertained to the problem of overuse, LVHS, and/or the need to address overuse of LVHS and resulting healthcare waste. We used online search engines, primarily PubMed, Medline, Google Scholar, and a mainstream Google search, to identify research studies describing these topics. We searched for publications reporting relevant studies using multiple search terms and phrases, including: overuse, overuse in healthcare, effects of overuse/healthcare overuse, costs of overuse/healthcare overuse, low-value services/high-cost services, waste/healthcare waste, and overuse measures/quality measures.
Each search term returned a number of results too large to review individually. Thus, we narrowed our results by using advanced features to search exact phrases. This allowed us to better identify research most closely aligned with our purpose and directly related to our areas of interest. Finally, we eliminated studies very general or broad in scope; those only examining overuse of medications (our primary interest was in services); those detailing very specific quality measures in various disciplines (as we were primarily interested in the need for general improvement in quality measures for overuse); and those detailing measurement tools.
Among the studies relevant to our purpose, most articles were published in 2009 or later. However, we also included select articles providing definitions or background content published earlier. Furthermore, we selected studies conducted in the United States and written in English, as this commentary focuses on issues within the United States healthcare system.
PubMed was our primary resource and provided the vast majority of publications selected for review. For brevity, search results are summarized here for only the primary main terms, grouped into appropriate categories, used to gather and select research. Overuse/overuse in healthcare returned over 9,500 results; effects of overuse/healthcare overuse returned approximately 70 results; costs of overuse/healthcare overuse returned approximately 815 results; low-value services/high-cost services returned nearly 3,000 results; waste/healthcare waste returned over 2,000 results; and overuse measures/quality measures returned over 92,000 results. These results were too numerous to review individually, and included many overlapping results across different topic categories and publications in areas not useful for this commentary. Therefore, we narrowed these initial results using advanced search features as previously described.
The following numbers of publications selected for inclusion within each main category are as follows: overuse/overuse in healthcare: 12; effects of overuse/healthcare overuse and/or costs of overuse/healthcare overuse: 9; LVHS/high-cost healthcare services: 12; waste/healthcare waste: 5; and overuse measures/quality measures: 10. The final total number of references ultimately used as support for this commentary totals 48. Of these, 43 were published in 2009 or later, with the remaining 5 published in 2008 or earlier, demonstrating an increasing focus in more recent years on the growing problem of healthcare overuse and waste. The resulting commentary is based on this limited literature review, which was sufficient to support our primary purpose and position.
The results of our limited review may not reflect all LVHS that are commonly overused within the United States. However, publications selected as support for this commentary provide sufficient evidence of the ongoing concerns and effects associated with overuse of LVHS. Meanwhile, because the reasons for overuse of LVHS are poorly understood and its direct impact on certain patient outcomes remains somewhat unclear, it was impossible to discuss all potential contributing factors or to compile total numbers of all exact costs and patients who had impact by overuse of these services. However, the primary intent of this commentary was to provide an overview of the problem and suggest the need for ongoing work in this area.
Low-Value Healthcare Services
In a 2012 report, The Joint Commission and American Medical Association (AMA) described the overuse of LVHS as a patient safety and quality concern, confirming the need for a shift to value-based care.19 This report aimed to highlight, as examples, 5 areas of particular concern: antibiotics to treat upper respiratory infections; blood transfusions; early-term elective deliveries; tympanostomy tubes for acute otitis media; and elective percutaneous coronary interventions.19 Although not a comprehensive list of all LVHS contributing to waste, these 5 areas have been among the most overused, generating wide concern across the industry.
Because many widely used screening/diagnostic tests are significant cost-drivers, these services have also been highlighted as low-value care and as targets of initiatives to reduce waste.23,26–28 The American College of Physicians (ACP) has identified tests that physicians believe to be among the most overused, resulting in a list of 37 services considered low-value that do not adhere to clinical use guidelines.23 These include repeated screening ultrasound for abdominal aortic aneurysms, coronary angiography for angina with well-controlled symptoms, echocardiograms for asymptomatic heart murmurs, and others, summarized in Table 1. In addition, Table 1 includes several of the LVHS identified by The Joint Commission and AMA report.19 Among them are various imaging procedures, which have been identified as a main category of LVHS, especially since imaging has expanded by 85% in recent years and contributes significantly to healthcare spending.10,19,29–32 In fact, about 40% of over 300 procedures identified as the most overused and high-cost involve imaging; imaging has also been identified as one category with the most potential opportunities for improved overuse measures.2,3,6,10,29,33 Furthermore, imaging can lead to the “cascade effect” of unnecessary follow-up testing and patient exposure to radiation, creating potential risk of harm.30,32,34
Elsewhere, related studies suggest that LVHS are commonly provided without clear indication of need, such as repeated colonoscopies for those who have had a negative screening colonoscopy within a time interval of <10 years.35 These findings suggest that many physicians make recommendations inconsistent with established guidelines.35,36
Impact on Outcomes
Research demonstrates that the widespread use of LVHS leads not only to financial consequences but also have impacts on care quality and patient outcomes including risk of harm.10,19 Antibiotic use and advanced imaging, in particular, carry significant risks, yet continue to be overused.10 In addition, high spending has not been associated with improved outcomes.2,5,17 Efforts to reduce spending highlight the need to focus on each patient's situation,23 as some high-cost services may positively have an impact on outcomes enough to justify their costs. However, services providing little benefit, regardless of whether low or high cost (i.e., cervical cancer screenings; computed tomography use for common chest symptoms), should be carefully considered.23,37
Other findings demonstrate the need to consider patient outcomes in care decisions. Many early elective deliveries, for example, are done for provider or patient convenience without medical merit, yet increase the risk of complications and likelihood of cesarean section.19,38,39 One study reported that among cesarean sections performed at 19 United States academic centers over 3 years, more than one-third did not follow American Congress of Obstetricians and Gynecologists' (ACOG) guidelines; early deliveries were associated with increased complications.19,38,39 Elsewhere, studies demonstrate that sedation by anesthesiologists (versus endoscopists) during routine endoscopic procedures is tied to higher risk for complications without benefits.40 These studies demonstrate that the procedures delivered do not always align with evidence-based guidelines to achieve optimal health outcomes.41
Unnecessary overuse of LVHS is prevalent, contributing significantly to healthcare waste and rising care costs. Furthermore, evidence is lacking that overspending from overuse improves health outcomes; in fact, delivery of services when benefits do not outweigh the risks can be harmful. Thus, healthcare stakeholders and providers have recognized the need to address overuse and move toward value-based care to achieve improved quality and outcomes.23
Research confirms that overuse of LVHS is growing.6,22 However, the reasons are multidimensional and poorly understood, involving not only financial interests and payment incentives but also referral patterns, attribution of services (facility vs. provider), patient expectations, malpractice concerns, and a trend toward using technology, such as imaging, simply because it is available.30–33 In addition, concern over potential litigation threats may drive providers to recommend treatments and order procedures that are unnecessary to ensure that they are as thorough as possible. Overuse can be patient-driven when the patient has a preference for a treatment or needs the reassurance a procedure may provide.33 However, in some instances a patient may be requesting clarification or guidance that the provider interprets as preference for a service.42 Furthermore, patients who do not understand procedures are unlikely to question a physician's recommendation, whereas physicians are also unlikely to question specialists' recommendations.33 Developing specific overuse measures may help to curb wasteful patterns and the subsequent effect on costs and quality.
Meanwhile, research indicates that United States physician practices spend an average of over 15.1 hour per physician per week dealing with issues related to quality measures, including data tracking, collection, recording, and transmission.25 Furthermore, the cost to physician practices of dealing with quality measurement has been estimated at over $15 billion a year.25 As such, healthcare stakeholders, such as the Centers for Medicare & Medicaid Services (CMS), Blue Cross Blue Shield (BCBS), and the National Priorities Partnership (NPP), as well as initiatives such as Choosing Wisely, have begun to move toward development of quality measures focused on common LVHS.10
In response to growing concerns regarding overuse, the American Board of Internal Medicine (ABIM) Foundation developed and launched the Choosing Wisely initiative in 2012, recommending discussions between providers and patients about the necessity of services as they make care decisions.2,6,22,29 As part of Choosing Wisely, over 60 professional medical societies have identified lists of “Five Things Physicians and Patients Should Question,” encompassing over 300 of the most commonly overused and expensive procedures.2,3,6,29 Choosing Wisely is valuable in its aim to start conversations about LVHS and to encourage collaboration between physicians and patients regarding treatment decisions. Choosing Wisely has also guided specialists regarding common strategies to address overuse in their practices. However, the specific services that repeatedly contribute to excessive spending are difficult to identify,24 and translating lists of services into quality measures that can be effectively applied remains challenging. Despite these limitations, Choosing Wisely is one initiative drawing attention to healthcare waste and encouraging physicians to work toward solutions.
Expanding Quality Measures
Most existing quality measures are designed to address the underuse of high-value services, with little attention to overuse and no comprehensive tool to measure LVHS.4,8,10,24 The National Quality Forum (NQF) sets standards for healthcare measurement through committees that evaluate quality measures before endorsement. The NQF advises government and private payers regarding measures to use for accountability; by 2017, 90 percent of all Medicare payments will be performance-based according to NQF guidelines.43 Providers and payers routinely measure high-value services, such as preventive care and chronic disease medications, yet most measures designed to address underuse of high-value care do not specifically apply to overuse.1,8 In addition, current standards within each specialty differ greatly and exist independently, so it is challenging to address their effectiveness and limitations.
One review of quality measures found that only 37 of the 160 measures identified had clear definitions of overuse.10 In addition, the specific measures focus on common health conditions (i.e., cancer, coronary artery disease, back pain, acute bronchitis, headache) but not commonly overused LVHS. For various services (i.e., mammography, endoscopy, bone scans, cardiac stress testing), these measures examine the frequency and intensity of performance and the population and indications for which each is used, but lack further specificity. Furthermore, only 27 of the 37 measures are NQF endorsed (Table 2). For instance, overuse is common and problematic for follow-up diagnostic mammography or ultrasound within 45 days of a screening exam and for 2 or more cardiac stress tests within 12 months for those with coronary artery disease but no evidence of unstable angina.10 However, no NQF-endorsed measures exist for these tests.
Growing emphasis on the overuse of LVHS demonstrates a need for specific measures to identify and address common LVHS; track overuse; establish attribution; and support interventions to reduce overuse and spending. Most existing measures do not combine all of these capabilities or have the potential to directly have an impact on outcomes and overspending because of overuse. Even quality measures that consider combined healthcare claims as episodes of care based on dates and diagnosis or procedure codes are used essentially as surrogates for quality but do not represent true quality measurement.30,44–47 Thus development of specific measures or revision of existing measures to focus on overuse could help to fill this gap. Overuse measures for specific LVHS would need to consider accurate attribution to the ordering provider, overall costs of common tests and procedures, and the ability to compare practice patterns across providers.
Research also suggests that quality measures for overuse should be based on appropriate use, or evidence of whether a service is likely to lead to improved outcomes outweighing potential risks.1,4 Researchers have described principles for developing quality measures intended to reduce overuse while also considering the unintended consequences of service limitation, such as the likelihood of adverse outcomes if a procedure could be helpful and appropriate in specific cases.4 Quality measures should be supported by strong evidence, such as that from randomized controlled trials with sufficient sample sizes, and must be able to assess the value of procedures both for individual patients and within specific populations.4 In addition, Chan et al10 suggest 4 categories of overuse requiring attention with more direct measures: inappropriate for a specific indication; inappropriate for a clinical indication in a specific population; excessive service intensity given the expected benefits; and excessive frequency given the expected benefits. Standard clinical guidelines, clear evidence of the lack of value of a service, identification of appropriate patient denominators, and access to large amounts of clinical data will also be critical aspects of improving quality measures. Considering the limitations of existing quality measures, demand is growing for overuse measures to not only measure quality, but also to assign accountability and reduce the use of LVHS. Finally, improved communication and education for patients is imperative to help reduce overuse, especially as the message that more treatment is not always better can be difficult to understand.48 Patients should have an active role in the decision process but need adequate information to weigh both the benefits and risks of a recommended procedure.
Overuse of LVHS continues to be prevalent within the United States healthcare system, significantly contributing to unsustainable rising costs of care and the burden of providers. The need for a broader set of overuse measures to capture a larger scope of LVHS has been demonstrated in this commentary and supporting research elsewhere. Improving and implementing overuse measures will be challenging, but may help to enhance understanding of the various factors, connect procedures to ordering providers, inform initiatives to reduce the use of LVHS, and subsequently help to reduce waste.
Potential implications include not only cost containment but also improved care quality, patient outcomes, and satisfaction as well as increased efficiency in care patterns, improved patient-provider communication, and better patient understanding of benefits and risks. Thus continued research is warranted.
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Stephanie MacLeod, MS, Senior Medical Writer, Advanced Analytics, Optum, Ann Arbor, MI. As Senior Medical Writer with Advanced Analytics, Stephanie MacLeod leads all dissemination efforts for health services research projects, including drafting manuscripts for publication.
Shirley Musich, PhD, Senior Research Director, Advanced Analytics, Optum, Ann Arbor, MI. As Senior Research Director in the Advanced Analytics group, Dr. Musich is responsible for providing decision support to lead employers and other clients through health evaluation, strategy design, intervention, measurement, and evaluation processes.
Kevin Hawkins, PhD, Vice President, Advanced Analytics, Optum, Ann Arbor, MI. As former Vice President of the Advanced Analytics group, Dr. Hawkins has conducted and overseen a variety of research and evaluation projects, specifically health-economic, quality-of-life, disease burden, pharmacoeconomics, and retrospective database analyses.
Kay Schwebke, MD, Medical Director, Quality Measurement, Optum, Minnetonka, MN. Dr. Schwebke is the Medical Director of Quality Measurement at Optum (Minnetonka, MN). Board certified in Internal Medicine and Infectious Diseases, she has extensive patient care and quality measurement experience. In addition to her work at Optum, she has a clinical practice at Hennepin County Medical Center (HCMC), in Minneapolis, Minnesota.