Caring African American female nurse in hospital uniform scrubs with wheelchair patient in medical center

A previous Health Affairs blog post explored the challenges of identifying and addressing the provision of low value care to traditionally underserved populations. While low-value care is a well-documented and pervasive  feature of healthcare in the US and internationally, too few efforts have examined the unique obstacles of trying to reduce use of care when the dominant paradigm driving care for vulnerable populations has been poor access and underutilization.  

What is Low-Value Care?

Pre-operative cardiac testing before cataract surgery for a low-risk patient, imaging for minor head trauma in children, PSA screening for men over 70 - These  are all examples of low-value care; commonly defined as care in which the potential for harm exceeds the possible benefits. While harm has historically been defined by clinical consequence, the significant financial and psychological impacts are being increasingly recognized. Nevertheless, a recent review demonstrated that $75.7 billion to $101.2 billion is spent on overtreatment and low-value services each year. These services are unnecessary, wasteful and can even cause harm.

Despite over a decade of calls to reduce low-value services, good progress in identifying which services are usually, or are almost always low value care in a way that is clinically nuanced and sensitive to context, numerous health system initiatives, and a growing evidence base of which interventions are effective,  there is far too little evidence that such services have been systematically reduced in a sustained way.

Less is More? De-implementing Low-Value Care Services

Eliminating known low-value services is challenging when the practice has long been established and/or when system practices (e.g. workflows or standing orders) promote their continued use.  This process of elimination is called de-implementation, has become a more recently studied phenomenon, and was the topic of a recent webinar hosted by the Research Community on Low-Value Care.  As a systematic review of the topic elucidated, de-implementation is particularly challenging due to contradictory evidence of certain practices and limited literature on how to effectively de-implement these low-value services.  

Another challenge to de-implementation is that our current payment model - fee-for-service - continues to reward the volume of services rendered. Indeed, ordering an unnecessary test is far less time consuming than spending valuable minutes convincing a patient the service is not necessary. Moreover, the evidence is mounting that many recent value based payment initiatives are falling short in their effectiveness at reducing costs or improving outcomes. Finally,  85% of physicians continue to cite fear of malpractice as a key reason they provide unnecessary services.

A final component to successful de-implementation is effective patient engagement in decision-making. As Colla’s 2016 review noted, shared decision-making between patients and clinicians is an important component of effective interventions to reduce low value care.  Such communications are most effective when trust has been established, so that patients are partners in the decision and understand a physician’s recommendation to not do a test or provide a service. As the Health Affairs blog post notes, vulnerable populations, who already struggle to access even basic care, may perceive such de-implementation efforts that result in withholding of a service as particularly inappropriate or discriminatory. Moving forward, evidence-based communication strategies need to be developed to examine how doctors and patients can both feel comfortable with deciding that less is truly more when it comes to low-value care.

Looking to Patient Input to Reduce Low-Value Care

In order to effectively communicate the message that “less is more,” the authors of the Health Affairs blog post emphasized the history of success of multifaceted interventions that incorporated key stakeholder and community partner input to improve preventive and chronic disease care. This is important to remember, especially taking into consideration that key stakeholders and community partners will vary geographically and demographically. For instance, as highlighted in another webinar by the Research Community on Low-Value Care, the senior population has unique needs when it comes to low-value care. Seniors have different health concerns and risk profiles than the rest of the population. As noted earlier, there is consensus that men over 70 do not benefit from Prostate-Specific Antigen (PSA) screening, making it a well-recognized low value service. Any decision about how to relay this message to seniors and their families must be communicated in an effective manner and more research on building trust and effective patient-engaged research needs to be conducted in this and other clinical areas to foster an environment of high-value clinical care that respects and engages both patients and physicians.

Join the Research Community on Low-Value Care

The AcademyHealth, ABIM Foundation, and Donaghue Foundation Research Community on Low-Value-Care is a professional hub for various stakeholders working to eliminate Low-Value Care. If you are interested in learning more about research on low value care, joining webinars and thematic working groups, hearing about funding opportunities, and participating in a community engaged with the topic, consider joining today.

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