An Evidence Review of Low-Value Care Recommendations: Inconsistency and Lack of Economic Evidence Considered

Abstract

Background

Low-value care, typically defined as health services that provide little or no benefit, has potential to cause harm, incur unnecessary costs, and waste limited resources. Although evidence-based guidelines identifying low-value care have increased, the guidelines differ in the type of evidence they cite to support recommendations against its routine use.

Objective

We examined the evidentiary rationale underlying recommendations against low-value interventions.

Design

We identified 1167 “low-value care” recommendations across five US organizations: the US Preventive Services Task Force (USPSTF), the “Choosing Wisely” Initiative, American College of Physicians (ACP), American College of Cardiology/American Heart Association (ACC/AHA), and American Society of Clinical Oncology (ASCO). For each recommendation, we classified the reported evidentiary rationale into five groups: (1) low economic value; (2) no net clinical benefit; (3) little or no absolute clinical benefit; (4) insufficient evidence; (5) no reason mentioned. We further investigated whether any cited or otherwise available cost-effectiveness evidence was consistent with conventional low economic value benchmarks (e.g., exceeding $100,000 per quality-adjusted life-year).

Results

Of the identified low-value care recommendations, Choosing Wisely contributed the most (N=582, 50%), followed by ACC/AHA (N=250, 21%). The services deemed “low value” differed substantially across organizations. “No net clinical benefit” (N=428, 37%) and “little or no clinical benefit” (N=296, 25%) were the most commonly reported reasons for classifying an intervention as low value. Consideration of economic value was less frequently reported (N=171, 15%). When relevant cost-effectiveness studies were available, their results were mostly consistent with low-value care recommendations.

Conclusions

Our study found that evidentiary rationales for low-value care vary substantially, with most recommendations relying on clinical evidence. Broadening the evidence base to incorporate cost-effectiveness evidence can help refine the definition of “low-value” care to reflect whether an intervention’s costs are worth the benefits. Developing a consensus grading structure on the strength and evidentiary rationale may help improve de-implementation efforts for low-value care.

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Funding

This project was supported by a research grant from Arnold Ventures (formerly, the Laura and John Arnold Foundation).

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Correspondence to David D. Kim PhD.

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Conflict of Interest

All of the authors are supported by a research grant from Arnold Ventures. DDK, LAD, ATD, JDS, DAO, and PJN are employees of the Center for the Evaluation of Value and Risk in Health (CEVR) at Tufts Medical Center, which maintains the CEA Registry used as a data source. The CEA Registry is supported by subscription revenue from academic institutions, government agencies, and pharmaceutical and device companies. Dr. Wong is a member of the US Preventive Services Task Force.

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Kim, D.D., Do, L.A., Daly, A.T. et al. An Evidence Review of Low-Value Care Recommendations: Inconsistency and Lack of Economic Evidence Considered. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-021-06639-2

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KEYWORDS

  • low-value care
  • guidelines
  • cost-effectiveness
  • evidence