Study Finds High Rates of Low-Value Care, But Hospitals Disagree

A study finding widespread and persistent delivery of low-value care services is based on incomplete data and omits important clinical details, according to the leading hospital professional group.

The American Hospital Association (AHA) wrote in an official blog post on May 7th that the study from the Lown Institute “attempts to make sweeping conclusions about hospital value based on data that are not only incomplete, but also not current.”

Published by the healthcare think tank on May 4th, the study found that hospitals in the US deliver a low-value test or procedure to an older adult every 80 seconds. The tests and procedures, defined as having little to no clinical benefit, are putting hundreds of thousands of patients at risk of harm, researchers said.

The study also ranked 3,100 hospitals based on their delivery of low-value care, with top hospitals like Mount Sinai in New York and Houston Methodist ranking poorly.

“Overuse in American hospitals is a pervasive problem that needs to be addressed,” Vikas Saini, MD, president of the Lown Institute, said in a press release. “Hospitals want to do better and these objective measures of performance can help them move forward.”

But the AHA is criticizing the study’s rankings, arguing that its only data source is Medicare billing data for just about a dozen services.

“[The services] represent only a portion of hospitals’ patient population and are not reflective of all the care hospitals provide,” Ashley Thompson, AHA’s vice president for public policy analysis and development, wrote in the blog post. “In addition, it is problematic to use only billing data to reach sweeping judgments about whether procedures are ‘unnecessary,’ let alone to construct a hospital ranking or rating.”

The decision to render a clinical procedure is based on a multitude of factors, Thompson added, including a physician’s judgment, the patient’s medical needs, and circumstances.

Moreover, the study lacks clinical and methodological details, such as whether hospitals can use rankings to improve care, Thompson stated. For example, the Lown Institute deemed all hysterectomies performed for reasons other than cancer as low-value care procedures despite the American College of Obstetricians and Gynecologists agreeing on several acceptable reasons for the service.

The Lown Institute study found that 64 percent of hysterectomies met criteria for overuse, followed by 44 percent of carotid endarterectomies and 24 percent of coronary stent procedures.

“America’s hospitals and health systems are constantly working to improve the quality and value of the care they provide, and have made important progress, but the narrow focus on Medicare patients, use of claims data and gaps in the methodology means this report will be of little value in these efforts,” Thompson stated.

Approximately a quarter of healthcare spending in the US is wasteful, according to a 2019 analysis from Humana and the University of Pittsburgh School of Medicine. At the time, that equated to between $760 billion to $935 billion of all healthcare spend.

Initiatives like Choosing Wisely are dedicated to avoiding wasteful spending while ensuring patients get the best clinical care possible. The efforts aim to prevent delivery of low-value services and procedures to accomplish its goals.

Adoption of low-value care guidelines from Choosing Wisely has increased significantly over the past couple of years and as such, utilization of key low-value care services like preoperative laboratory testing have decreased.

However, more work is still needed to be done in this arena. Just recently, RAND Corporation also published findings from an analysis of low-value care utilization in Medicare patients. The study found that low-value care spending among fee-for-service Medicare recipients dropped slightly from 2014 to 2018.

However, two of the three services that make up the majority of low-value healthcare spending—antibiotic and opioid prescriptions—increased despite a national campaign to promote value-based care.

“Given mushrooming deficits and the fact that the Medicare trust fund is running out of cash, there will be enormous pressure to find ways to trim spending in the Medicare program and making significant progress in reducing low value care needs to be a top priority,” said John N. Mafi, the study's lead author and an adjunct physician policy researcher at RAND.

But ranking hospitals based on low-value care—especially when evidence of utilization is based solely on billing data—is not the solution for reducing utilization, AHA’s Thompson said.

“[T]he precise approach for translating numerical scores into rankings is not clear. Instead, hospitals get a confusing hodgepodge of data points — an overall letter grade for overuse, a star rating for each procedure, an overall numerical ranking compared to other hospitals in their state and nationally and a percentile score,” Thompson wrote.

“Unfortunately, Lown does not provide any information on what data they use to assign a star rating or letter grade, nor do they describe how the procedure star ratings, letter grades or percentile score relate to one another,” Thompson continued.

According to the Lown Institute’s rankings, hospitals best at avoiding unnecessary tests and procedures include:

1. Scott County Hospital (Scott City, KS)
2. Beth Israel Deaconess Medical Center (Boston, MA)
3. West River Regional Medical Center (Hettinger, ND)
4. Highland Hospital (Rochester, NY)
5. Mayo Clinic Health System – Lake City (Lake City, MN)
6. Maine Medical Center (Portland, ME)
7. Sidney Regional Medical Center (Sidney, NE)
8. Mary Hitchcock Memorial Hospital (Lebanon, NH)
9. Healdsburg District Hospital (Healdsburg, CA)
10. Contra Costa Regional Medical Center (Martinez, CA)