Measuring low-value care throughout the health system

Last month, we launched the 2021 results of the Lown Hospitals Index, which evaluates more than 3,000 hospitals on how well they avoid 12 common low-value services. Our research on low-value hospital care showed that hospitals in the South, for-profit hospitals, and nonteaching hospitals were associated with the highest rates of overuse. We also found that head imaging for fainting was the highest-volume low-value service (making up the largest proportion of all overuse measured), while hysterectomy had the highest rate of overuse (most hysterectomies measured were for benign disease).

Now, Dr. Ishani Ganguli, researcher and assistant professor at Harvard Medical School, along with researchers at The Dartmouth Institute for Health Policy and Clinical Practice have expanded this research to include both hospital and non-hospital settings, evaluating 556 health systems on 41 low-value services. Their research was recently published in JAMA Internal Medicine.

Many of the patterns Dr. Ganguli and colleagues found among health systems are similar to patterns among hospitals. For example, they found that health systems without a major teaching hospital and hospitals in the South and West had more overuse. They also found that health systems with a smaller proportion of primary care physicians delivered more low-value care, a result that corroborates previous research as well.

The most common low-value services among the 41 they studied were preoperative laboratory testing, prostate-specific antigen testing in older men, and use of antipsychotic medications in patients with dementia. Testing is one of the most common types of low-value services, often because both clinicians and patients believe that it’s better to do a test “just to be safe” even when there is a risk of cascade events and overtreatment. Overmedication for older adults is another incredibly common form of low-value care that also puts patients at significant risk for adverse events, particularly for older adults with cognitive decline.

Another interesting finding from Dr. Ganguli and colleagues is that low-value care was more prevalent among health systems serving more people of color. On the Lown Index, we don’t see a similar pattern; in fact, major teaching hospitals with the highest racial inclusivity scores had better rankings and grades on avoiding overuse, compared to major teaching hospitals with the lowest scores on racial inclusivity. Perhaps low-value care at more inclusive health systems is happening more often in primary care clinics or other non-hospital settings.

Now more than ever, hospitals and health systems have the tools and opportunity to track their low-value care and make improvements. These tools can also help hold health systems accountable for providing high-value care, and their findings can support policies to shift incentives for health systems toward value rather than volume.