Hospital overuse linked to thousands of adverse events each year

Every 80 seconds, an older patient receives a low-value service at a hospital, putting hundreds of thousands at risk of harm. Low-value care–also known as overuse–is the delivery of tests and procedures that provide little clinical benefit, increase health care spending without improving health outcomes, or risk patient harm in excess of potential benefits. Unfortunately, low-value care is incredibly common among Medicare beneficiaries, with an estimated 42% of beneficiaries receiving at least one low-value service.

Most research on the impact of low-value care has focused on the cost to the health care system, but the potential harm to patients is an arguably more motivating factor for both clinicians and patients to avoid unnecessary services. All procedures, particularly invasive procedures in hospitals, carry some risk — and the risk of harm to patients is the same regardless of whether or not the procedure is necessary. However, there is little research on the prevalence and impact of harms related to low-value care.

“Framing overuse as a problem of cost or resource utilization has yet to move clinicians and patients to avoid it in any meaningful way.”

Shannon Brownlee and Deborah Korenstein, The BMJ

In a recent study in JAMA Health Forum, Lown Institute researchers Kelsey Chalmers, Valérie GopinathShannon BrownleeVikas Saini, and professor of health policy at the Melbourne School of Population and Global Health Adam Elshaug investigate the relationship between low-value hospital services and hospital-acquired infections and patient safety events. This study was funded by Arnold Ventures, as part of a suite of low-value care projects in partnership with the Lown Institute.

The research team looked at seven low-value procedures commonly delivered at hospitals to Medicare patients: Knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. (For more about each of these services, check out the Lown Hospitals Index research on overuse!)

From 2016 to 2018, there were nearly 200,000 inpatient Medicare claims for these low-value procedures. These instances of low-value care were associated with 1,995 adverse events: 231 hospital-acquired conditions (HACs) and 1764 patient safety events. The most common HACs were urinary tract infections and and falls/trauma, and the most common patient safety events were bleeding and blood clots.

About one in 100 inpatient low-value procedures resulted in an adverse event. These adverse events led to Medicare beneficiaries spending an additional 4,201 days in the hospital — cumulatively 11.5 years.

More than half of the adverse events were associated specifically with low-value spinal fusion.

However, these adverse events were not allocated equally. More than half of the HACs and patient safety events were associated specifically with low-value spinal fusion. Spinal fusion was by far the most common low-value procedure of the seven, so it follows that the number of adverse events would be highest. Vertebroplasty (injection of cement into the spine) had the highest rate of HACs (2.5 per 1000 procedures). Renal stenting (placing a stent or balloon in the renal artery artery) had highest rate of patient safety events (13.4 per 1000 procedures), although spinal fusion and carotid endarterectomy also had high rates (10 events per 1000 procedures).

The authors note that the rate of patient safety events for these low-value services is actually lower than rates in the overall Medicare population, which may be because patients receiving low-value procedures tend to be healthier than the general inpatient population.

Although this study examines just seven procedures, this is an important first step toward estimating the harms from low-value care. This should also be a wake-up call for hospitals to crack down on low-value services, for the sake of their patients. Currently, there are few incentives for hospitals to reduce low-value care–in fact, most hospitals get paid more for doing more procedures, whether or not they are necessary.

This should be a wake-up call for hospitals to crack down on low-value services, for the sake of their patients.

It’s also important to recognize that this study likely underestimates the harms of low-value procedures, because it measures only certain physical harms. As other experts have pointed out, physical impairment is just one of the many potential harms from low-value care, including psychological distress, social disruption, loss of trust in the health system, treatment burden, and financial toxicity. These elements are even harder to measure than adverse events, but should be taken into consideration when discussing the overuse harms.

The authors hope that this study and future research on overuse harms will “help frame the issue of avoiding low-value care as a patient safety issue and encourage efforts to promote high-value care.”