Study finds racial disparities in low-value care, even within the same health systems

Low-value care, also known as overuse, refers to medical services that offer little or no clinical benefit to patients. These unnecessary services can range from imaging (eg. head CT for dizziness), to screening (eg. prostate cancer screening in men over age 75), to drugs (eg. antibiotics for cold), to surgeries (eg. stents for stable heart disease). Some of these low-value services are riskier than others, but all of them expose patients to potential harm and waste billions of dollars in unnecessary spending. 

Low-value care and equity

Given the health risks of overuse, it’s important to understand the impact of low-value care on health equity. Are people of color at higher risk of overuse than white patients, or vice versa? The evidence on this so far is mixed. A systematic review of studies looking at low-value care by race found that white patients were more likely to receive unnecessary care, but another more recent study found higher rates of overuse for certain low-value services in Black and Hispanic patients, such as feeding tubes for dementia. Clearly, there is a lot more to be studied on this issue.

Cue a new analysis from Harvard Medical School professor Dr. Ishani Ganguli and colleagues in The BMJ. This study looked at rates of 40 low-value services in nearly 10 million Medicare patients across 595 health systems. Ganguli and colleagues compared the likelihood of receiving low-value care between Black and white Medicare patients, including a comparison of patients within the same health system. Low-value services measured included screening tests, diagnostic tests, monitoring tests, drugs, and procedures.

Here are key takeaways from their study:

  • There were significantly different rates of low-value care for 29 of the 40 services measured, although most of the differences were small. Black patients had higher rates of nine low value services and white patients had higher rates of 20 low-value services. 
  • White Medicare patients were more likely to receive low-value screening tests such as prostate-specific antigen testing in men over 75 (31% v 26%) and cardiac screening (5% v 2%), as well as treatments such as antibiotics for cold or ear infection (37% v 33%), and vertebroplasty (5% v 3%) which is an injection of cement into the backbone.
  • Black Medicare patients were more likely to receive feeding tubes for advanced dementia (9% v 2%), two or more concurrent antipsychotic medications (8% v 5%), and certain low-value acute diagnostic tests, like imaging for uncomplicated headache (7% v 3%).
  • Differences in low-value care remained even when comparing patients within the same health system. That’s important, because it indicates differences in the way patients of different races are treated by the same providers–rather than just differences in culture between the health providers they frequent. 

Drivers of disparities in low-value care

What could explain these differences? The study authors suggest some potential reasons why Black patients could be more likely to receive low-value diagnostic tests:

“Mistrust in the healthcare system because of historical and present day racism might contribute to Black adults being more receptive to diagnostic testing when acutely ill—in this scenario, it is possible that a tangible test is more reassuring than a clinician’s words and might serve to lessen valid concerns about undertreatment.”

The authors also point out that structural barriers to care for Black patients can make it hard to access care earlier and result in them arriving to the ER sicker, which could prompt low-value testing. Additionally, if patients are more likely to seek care in the ER or urgent care as opposed to primary care, they may be subject to more low-value testing from doctors who don’t know them well. Why does this matter? Low-value diagnostic testing exposes patients to radiation exposure, out-of-pocket spending, and additional follow-up testing and procedures (known as “care cascades”).

Black patients were also more likely to receive feeding tubes in the setting of advanced dementia, a practice that does not help patients live longer, and is not recommended for these patients. Differences in rates of feeding tube usage may reflect lack of trust and communication between clinicians and patients; one study found that 14% of family members of patients with feeding tubes reported that there was no discussion about feeding tube insertion, and 42% reported a discussion that was shorter than 15 minutes.  

On the flip side, why are white patients more likely to receive certain low-value screenings and treatments? The authors suggest that white patients could be more likely to request these services, or clinicians might be more likely to offer them, perhaps because of implicit biases. Black patients are less likely than white patients to receive certain cancer screenings that are considered high-value, such as age-appropriate colonoscopies and mammograms, so it makes sense that they are also less likely to receive low-value ones. 

This study provides valuable information on the intersections between health equity and value, but there’s still much more to learn. The authors suggest that health systems measure use of low-value services stratified by racial group and sex, to identify potential disparities. “These results invite further exploration of differential access by race to routine, high value primary care, patient-clinician concordance, and trust,” they write.