When the Choosing Wisely campaign launched in 2012, it set the stage for broader discussions about low value care. We know from a systematic review that multicomponent interventions that focus on both the patient and the clinician have the greatest potential to reduce low-value care. Furthermore, we know the characteristics of some physicians who order a high frequency of low-value care screening tests.

The problem of overuse, unnecessary care, or low-value care is increasingly a focus of the national health policy conversation. Estimates suggest that as much as one-third of health care spending in the United States is of low-value or wasteful. Many factors contribute to the problem, including increased patient demand, information asymmetry, perverse financial incentives for providers, and a culture of “more is better than less.”

Despite our growing knowledge, defining and measuring low-value care remains challenging and has led to important questions about the care we deliver.

Nonobvious low-value care

Targeting the most obvious tests and treatments that did not provide a meaningful benefit for patients seemed reasonable, noncontroversial, and perhaps achievable. However, a greater opportunity may exist among the nonobvious low-value care.

A recent article in JAMA Cardiology provided a great example of nonobvious low-value care. Large savings of more than $5,000 US dollars per case could be realized by discharging patients the same day after elective percutaneous coronary intervention (PCI). In addition, this article showed substantial hospital variation for same day discharge (SDD) after elective PCI from 0-83 percent. After reading this article, we were immediately reminded of an article by Chalmers et al where the authors suggested that most surgical procedures should be a day surgery and “variation in the use of day surgery for specific operations should be measured.” It should go without saying that not going home the same day after most elective procedures is low-value care.

Such focus on efficiency and throughput requires physician buy-in, consistent criteria, patient/family engagement, and infrastructure in place to enable optimal SDD workflows. In addition, a successful SDD strategy should be paired with a monitoring system that permits clinicians and administrators to ensure a safe SDD paired with patient education aimed at increasing SDD awareness.

Indeed, additional SDD derived savings may come from other procedures. Data from cohort studies in Europe have shown that SDD after cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillators (ICDs) resulted in decreased length of stay without increasing complications. Similarly, Darda et al. reported savings of $5,590 US dollars per patient with the use of a SDD strategy versus overnight observation post-ICD implant.

Think big, act bigger

With researchers from different parts of the world demonstrating the feasibility, safety, and cost-effectiveness of SDD across a variety of procedures from interventional cardiology to hip and knee arthroplasties, we need a loud voice to motivate us to embrace change and move from thinking big to acting bigger. National consensus for SDD, analogous to Choosing Wisely recommendations, would advance our ability to eliminate waste, improve quality, and enhance patient experience.

The opinions expressed in this blog post are the authors’ own and do not necessarily reflect the view of AcademyHealth.

Jose serves on the Advisory Committee for the Research Community on Low-Value Care, a professional network for research producers and users who are working on this topic both here in the U.S. and abroad. The community, hosted by AcademyHealth, the ABIM Foundation, and the Donaghue Foundation, is comprised of more than 300 members to date and includes researchers in academic and other settings, health system representatives, patients/consumers, clinicians, health plans, and policymakers. We are continuing to grow the community, so if you are interested in joining or would like to learn more, please fill out this brief form or email RC-LVC@AcademyHealth.org.

 

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Author, Member

Jose Benuzillo, M.A., M.S.

Senior Program Evaluation Consultant - Kaiser Permanente - Center for Health Research - Kaiser Permanente

Jose Benuzillo, MA, MS is the Senior Program Evaluation Consultant at Kaiser Permanente Center for Health Rese... Read Bio

Lucy Savitz
Board Member

Lucy A. Savitz, Ph.D., M.B.A.

Vice President for Health Research - Kaiser Permanente - Northwest Region

Dr. Savitz is currently Vice President for Health Research in the KP Northwest Region where she directs the C... Read Bio

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It's crucial that family members and home support are willing and able to take on a patient's recovery at home.  Their input should not be treated as costless.  See https://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/home-alone-family-caregivers-providing-complex-chronic-care-rev-AARP-ppi-health.pdf.

Submitted by Christine E Bishop on Tuesday, December 18th, 2018 at 10:35 am

Thank you for your comment. It gives us one more opportunity to reiterate that a successful same day discharge strategy will have to include family caregivers. Partnering with patients and their families can play an important role in safety and it has the potential to reduce 30-day hospital readmission. https://www.ncbi.nlm.nih.gov/pubmed/29406225

Submitted by Jose Benuzillo on Wednesday, December 26th, 2018 at 12:45 pm