8.1 Low-value care evaluation

The primary goal of healthcare is to benefit patients. Evaluations help ensure that care being provided is beneficial and not harmful (Owens et al., 2011). In the context of low-value care, where risks can outweigh benefits, this is critical. Effective evaluation helps to refine healthcare interventions to maximise patient safety and treatment efficacy. Low-value care refers to medical tests, procedures and treatments that provide little or no benefit to patients in specific clinical scenarios and, in some cases, may even cause harm (Colla et al., 2017). This concept extends to interventions that, when weighed against their potential risks, costs and the availability of more effective alternatives, are deemed unnecessary or inefficient. Low-value care can arise from overdiagnosis, underdiagnosis, overtreatment, undertreatment or practices that have been superseded by newer, evidence-based approaches.

Prevalence and types

Low-value care encompasses a broad spectrum of services, including diagnostic tests, medical treatments and surgical procedures (see Table 8.1). The prevalence of low-value care varies widely depending on the healthcare system, the specific types of care considered and the methodologies used for measurement.

Table 8.1: Types and examples of low-value care

Studies across different countries and healthcare settings have reported varying rates of low-value care. For example, in the US it’s estimated that a significant portion of healthcare spending is on services that do not improve patient outcomes (Owens et al., 2011).

The prevalence of low-value care in Japan was examined in a multicentre observational study involving 345,564 patients seeking care at acute care hospitals in 2019 (Miyawaki et al., 2022). The study identified 33 low-value care services occurring in 7.5 per cent of the population, which resulted in 0.5 per cent of overall annual healthcare spending. The study estimated that at least ¥100 billion (approximately US$650 million) of medical overuse occurs annually in Japan, highlighting the considerable resources consumed by and economic impact of low-value care in the universal healthcare system.

A study in the US that focused on the prevalence of low-value prostate cancer screening in primary care clinics aimed to identify the proportion of primary care visits where low-value prostate-specific antigens (PSAs) and digital rectal exams (DREs) are ordered, as well as the characteristics associated with this practice (Gillette et al., 2023). The study found that the use of low-value PSAs and DREs was significant during the observed period, and the number of services ordered by primary care providers increased the likelihood of ordering low-value PSAs and performing low-value DREs. The study suggested that organisations looking to reduce the use of low-value prostate cancer screening should focus interventions on providers who order a high number of tests (Gillette et al., 2023).

Similarly in Germany a study that looked at the prevalence of low-value care in people with dementia found that the prevalence of low-value care was high , with 31 per cent of the study population receiving low-value care (Platen et al., 2021). The study also found that patients with dementia who received low-value care had a significantly low quality of life and were more likely to be hospitalised compared to those who did not receive low-value care.

In Australia, one study identified 156 potentially ineffective or unsafe non-pharmaceutical services listed on the Australian Medicare Benefits Schedule (Elshaugh et al., 2012). This effort, aimed at evaluating low-value care, used a multiplatform approach, including literature reviews and expert consultations. The findings serve as a basis for further clinical evaluation and prioritisation within health technology reassessment initiatives, emphasising the need for a systematic and evidence-based approach to identifying and reducing low-value care in the healthcare system.

Recent studies in New South Wales (NSW), Australia, have contributed significantly to the understanding of low-value care in public hospitals (Badgery-Parker et al., 2019a). One study analysed hospital-admitted patient data across seven financial years (2010–2011 to 2016–2017), focusing on 27 procedures identified as potentially low value based on international and Australian recommendations. This study found that in the financial year 2016–2017 between 5,079 and 8,855 episodes of care were deemed low value, accounting for 11.0 per cent to 19.2 per cent of all procedures analysed. The total cost associated with these episodes of low-value care was estimated to be between A$49.9 million and A$99.3 million, indicating a significant financial impact on the healthcare system.

Another study investigated hospital characteristics associated with low-value care, aiming to understand factors contributing to variation in its provision (Badgery-Parker et al., 2019b). This research, which focused on seven low-value procedures, found little association between hospital characteristics and rates of low-value care, suggesting that low-value care is not a general property of hospitals in NSW. Instead, variations by procedure within hospitals were observed. The study highlighted the complexity of addressing low-value care and suggested that understanding its drivers might require examining the knowledge and attitudes of the clinicians who provide these procedures.

These findings underscore the prevalence and financial implications of low-value care for healthcare systems, providers and patients. The studies also emphasise the importance of considering procedure-specific variations and clinician-related factors in efforts to reduce low-value care.

Implications for healthcare systems, providers and patients

• Healthcare systems: Low-value care contributes to escalating healthcare costs without corresponding improvements in patient outcomes. It diverts resources away from high-value, necessary care, affecting the overall efficiency and sustainability of healthcare systems (Schwartz et al., 2014). Additionally, low-value care can exacerbate issues related to healthcare access and equity, as funds wasted on low-value care could be better used.
• Providers: For healthcare providers, engaging in low-value care can lead to professional dissatisfaction, especially when practitioners are aware of the mismatch between the care provided and the best evidence-based practices (Colla et al., 2015). It may also expose providers to increased risk of legal liability and damage to their professional reputation, especially in cases where low-value care results in patient harm.
• Patients: From the patient perspective, low-value care can lead to unnecessary financial burden due to out-of-pocket expenses for ineffective treatments (Colla et al., 2017). More importantly, it poses health risks, including potential side effects from unnecessary medication, complications from unwarranted procedures, and the psychological impact of overdiagnosis (Schwartz et al., 2014). It can also lead to misallocation of the patients’ time and focus away from interventions that could genuinely improve their health outcomes.