9.3 Implications for practice
Economic evaluations are essential tools in the healthcare decision-making process, particularly in identifying low-value interventions – those that offer minimal benefits at disproportionate costs. Through methodologies such as cost-effectiveness analysis and cost-utility analysis, these evaluations compare the costs and outcomes of different healthcare interventions. An intervention is deemed low value if it incurs higher costs without corresponding improvements in health outcomes compared to alternatives. By highlighting interventions with minimal health benefits relative to their costs, economic evaluations guide healthcare systems in allocating resources more efficiently (Turner et al., 2021). They support the prioritisation of high-value care by identifying areas where spending can be reduced without compromising patient outcomes, thus enhancing the overall value delivered by healthcare services. This process aids not only optimising healthcare spending but also improving patient care by focusing resources on interventions that provide meaningful health improvements.
Identifying low-value healthcare interventions through economic evaluations is crucial for optimising resource allocation and improving patient care. Table 9.1 describes two case studies illustrating how economic evaluations have been instrumental in pinpointing such low-value interventions.
Table 9.1: Two economic evaluation case studies
| Case study | Economic evaluation | Findings | Outcome |
|---|---|---|---|
| Prostate-specific antigen (PSA) screening has been widely used to detect prostate cancer at early stages (Heijnsdijk et al., 2020; Paschen et al., 2022) | A comprehensive economic evaluation using CEA was conducted to assess the value of routine PSA screening versus no screening. The analysis considered direct medical costs (including the cost of the screening, follow-up diagnostics and treatments) and outcomes measured in QALYs. | The study found that routine PSA screening led to a marginal increase in life years gained but at a significantly high cost, with an ICER exceeding widely accepted thresholds for cost-effectiveness. Additionally, the screening led to a high rate of overdiagnosis and overtreatment, with associated harms and costs. | Based on the economic evaluation, PSA screening for prostate cancer was identified as a low-value intervention for the general population. The findings led to recommendations against routine PSA screening, suggesting that resources could be better allocated to high-value care areas. |
| Preoperative testing (such as blood tests, electrocardiograms and chest X-rays) before low-risk surgeries is a common practice intended to identify issues that might complicate surgery or anaesthesia (Berlin et al., 2021; Ferrando et al., 2005; Flamm et al., 2011) | A CEA estimated the costs associated with routine preoperative testing compared to selective or no testing for patients undergoing low-risk surgeries. The analysis looked at direct medical costs, including the cost of the tests and any follow-up care, and measured outcomes in terms of adverse surgical events avoided. | The evaluation demonstrated that routine preoperative testing for low-risk surgeries did not significantly reduce adverse surgical outcomes but led to increased healthcare costs due to unnecessary testing and follow-up interventions. The ICER for routine testing compared to selective or no testing was found to be substantially high, indicating low value. | The economic evaluation revealed that routine preoperative testing before low-risk surgeries is a low-value intervention. This has led to changes in clinical guidelines, advocating for a more selective approach to preoperative testing, thereby reducing unnecessary healthcare spending and focusing on interventions that genuinely improve patient outcomes. |
Challenges for economic evaluation
These case studies underscore the importance of economic evaluations in healthcare decision-making, guiding the shift away from low-value interventions towards more effective and efficient use of healthcare resources. However, they also highlight several challenges associated with identifying and addressing low-value interventions through economic evaluations:
- Data availability and quality: high-quality, comprehensive data are required to accurately assess the costs and outcomes associated with healthcare interventions. In both case studies, the availability of reliable data on long-term outcomes, patient quality of life, and direct and indirect costs was crucial for conducting robust economic evaluations. Data limitations can lead to uncertainty in the evaluation’s findings and recommendations.
- Overdiagnosis and overtreatment: a significant challenge, particularly evident in the PSA screening case, is the issue of overdiagnosis and the consequent overtreatment. These factors can inflate the perceived benefits of an intervention while understating its costs and harms, complicating the assessment of its value.
- Changing clinical practices and guidelines: both case studies illustrate the difficulty in changing established clinical practices and guidelines based on economic evaluation findings. Healthcare professionals and patients may have entrenched beliefs about the value of certain interventions, such as the importance of routine preoperative testing, making it challenging to shift towards evidence-based practices.
- Balancing cost, quality and access: economic evaluations aim to balance cost savings with the quality and accessibility of care. However, recommending the reduction or elimination of certain interventions, like routine PSA screening, can raise concerns about access to care and the potential for missing early disease detection, necessitating careful consideration and communication of the trade-offs involved.
- Stakeholder engagement and policy implementation: engaging a wide range of stakeholders (including clinicians, patients, policymakers and payers) in the process of identifying and eliminating low-value care is challenging. Achieving consensus on what constitutes low-value care and implementing changes in policy and practice based on economic evaluations requires coordinated efforts and clear communication of the evidence and its implications.
- Ethical and equity considerations: both case studies touch on ethical and equity issues, such as the risk of exacerbating health disparities by universally applying findings without considering population-specific factors. Economic evaluations must be sensitive to these concerns to ensure that recommendations do not inadvertently disadvantage certain patient groups.
Addressing these challenges requires a multifaceted approach, including improving data collection and analysis methods, enhancing stakeholder engagement, and fostering a culture of continuous learning and adaptation in healthcare practices based on the best available evidence.
Quantifying impacts
Quantifying the impact of low-value care on healthcare systems is crucial for understanding its economic burden and for guiding efforts to enhance efficiency and patient care quality. Low-value care, which encompasses interventions that offer little to no benefit to patients, can significantly drain healthcare resources, diverting funds away from more effective and necessary treatments (Cliff et al., 2021). The economic burden of such care includes not only the direct costs associated with the provision of unnecessary services – such as diagnostics, treatments and hospital stays – but also indirect costs like lost productivity due to unnecessary treatment or recovery time. Moreover, the allocation of resources to low-value care can lead to increased healthcare costs overall, contributing to financial strain on healthcare systems and potentially increasing out-of-pocket expenses for patients (Grimshaw et al., 2020).
The impact of low-value care extends beyond financial considerations, affecting resource allocation and healthcare quality. Allocating resources to low-value interventions limits the availability of those resources for high-value care that could significantly improve patient outcomes. For example, funds spent on widespread screening or tests that have been shown to offer minimal benefit could be redirected towards preventive care measures, research or treatments that have a substantial, evidence-based impact on health (Cliff et al., 2021). This misallocation can also lead to longer wait times for essential services, reducing the overall quality of care and patient satisfaction. Furthermore, the practice of delivering low-value care can erode trust in the healthcare system, as patients may question the necessity and effectiveness of the treatments they receive (Cliff et al., 2021). By identifying and reducing low-value care, healthcare systems can reallocate resources more effectively, improving access to high-quality, high-value healthcare services and enhancing patient outcomes. Reducing low-value care has the potential to decrease healthcare costs and to foster a more patient-centred approach to care, where interventions are tailored to deliver genuine value and benefit to patients.
Reduction strategies
Strategies for reducing low-value care through economic evaluations focus on leveraging the insights these analyses provide to inform policy decisions and clinical practice. Economic evaluations shed light on the cost-effectiveness of healthcare interventions, identifying those that do not provide sufficient value. Decision-makers, including policymakers and healthcare administrators, can use this information to develop policies that discourage the use of low-value interventions and instead encourage practices that offer better health outcomes per dollar spent. For instance, reimbursement policies can be adjusted to favour high-value care, and incentives can be created for providers who minimise low-value practices. Furthermore, integrating the findings of economic evaluations into clinical guidelines is a vital strategy. By embedding cost-effectiveness data into guidelines, healthcare providers are equipped with evidence-based recommendations that prioritise high-value care. This integration helps ensure that clinical decisions are not only medically sound but also economically prudent, aligning healthcare delivery with the best interests of patients and the sustainability of the healthcare system. Through these strategies, economic evaluations become a cornerstone of efforts to enhance the efficiency and effectiveness of healthcare, guiding the allocation of resources towards interventions that truly improve patient outcomes and system-wide health quality.
Challenges and limitations
Addressing the challenges and limitations inherent in economic evaluations of healthcare interventions requires careful consideration, particularly when it comes to ethical considerations and the limitations of current methodologies. Ethically, there’s a fine balance between cost-efficiency and ensuring equitable access to care for all patients. Economic evaluations might inadvertently prioritise efficiency over equity, potentially marginalising certain patient groups or undervaluing interventions that are critical for less common but severe conditions. Methodologically, current economic evaluations may not fully capture the complexity of healthcare interventions and their impacts on diverse patient populations. These methodologies often rely on averages that may not reflect individual patient needs and outcomes, leading to a one-size-fits-all approach in healthcare decision-making.
Most economic evaluations are constrained by the quality and availability of data and the means to estimate outcomes or effect size, particularly long-term health outcomes and real-world effectiveness of interventions. There’s also a need for improvement in how these evaluations incorporate patient-reported outcomes and quality of life measures, ensuring that the value of healthcare interventions is assessed holistically. Addressing these challenges requires ongoing methodological innovation, greater inclusivity in evaluation processes, and a commitment to balancing efficiency with ethical considerations in healthcare policy and practice.
Future directions
The future of economic evaluations in healthcare lies in embracing innovative approaches and harnessing the power of technology and data analytics to refine the identification of low-value care. Advancements in big data, artificial intelligence and machine learning offer unprecedented opportunities to analyse vast datasets, revealing insights into the effectiveness and efficiency of healthcare interventions across diverse populations. These technologies can enable more personalised economic evaluations, taking into account patient-specific factors to determine the true value of interventions on an individual level.
Additionally, the integration of real-world evidence gathered from electronic health records, patient registries and wearable devices will enhance the accuracy and relevance of economic evaluations. This shift towards more dynamic and data-driven analyses promises to uncover nuances in healthcare delivery and outcomes that traditional methodologies might overlook. By leveraging these technological advancements, future economic evaluations can provide a more subtle understanding of value in healthcare, guiding the allocation of resources towards interventions that genuinely improve patient health and wellbeing while minimising waste and inefficiency. This evolution in economic evaluations will play a critical role in shaping more effective, efficient and patient-centred healthcare systems.
