Reducing low-value care: Awareness, education efforts need to evolve

Although discussions about reducing health care costs often focus on high-value care, so-called low-value care may be overlooked. However, low-value care, which is defined as services that provide no or minimal benefit to patients in specific clinical situations, costs an estimated $76 billion to $101 billion annually in the United States.

In 2012, the physician-led Choosing Wisely campaign began to encourage awareness, measurement, physician accountability and intervention around this problem. Nine years later, the U.S. Choosing Wisely compendium of recommendations for tests and treatments to avoid has grown from 45 to more than 600. But despite the wide reach of the Choosing Wisely campaign and its success at raising awareness, progress in reducing low-value care use and spending has been modest at best.

A new study reported in JAMA Internal Medicine analyzed all Choosing Wisely recommendations by U.S.-based physician societies from 2012 to 2021 to assess the services, clinical contexts and consequences of low-value services. Among the findings:

• Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging and laboratory studies in the context of chronic conditions and healthy patients with risk factors alone.
• Most of the identified low-value services were revenue-neutral for the recommending society, and the plurality were low cost.
• Low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations.
• Nearly half of recommendations identified services with high direct harm potential, and 388 identified those with high potential for triggering downstream services, or cascades.

“Taken together, the results of this qualitative study point to the successes of Choosing Wisely to date, as well as an opportunity to explicitly prioritize future recommendations and interventions to maximize impact across the dimensions of spending across populations, direct harms and cascades,” according to the report. “Current recommendations do identify many potentially high-impact, low-value services. Clinical leaders, payers and policymakers might use the coded recommendations to target such services for intervention based on individual priorities.”

As the Choosing Wisely compendium evolves with professional societies contributing new and updated recommendations, a broader coalition of stakeholders could define recommendation standards based on these dimensions of impact, given the financial conflicts that affect these societies. Writing and updating these recommendations also will require robust evidence on the spending, utilization, direct harms and cascades associated with the services.

“Most importantly, eliminating low-value care must extend beyond better lists,” the report concluded. “We need scalable local, regional and national multistakeholder efforts to leverage recommendations into meaningful improvements. Choosing Wisely has been a helpful tool for raising awareness, but it cannot be the final word.”