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October 2, 2020

De-adopting Low-Value Care: Evidence, Eminence, and Economics

Author Affiliations
  • 1Humana Inc, Louisville, Kentucky
  • 2SCAN Group and Health Plan, Long Beach, California
  • 3Stanford University, Palo Alto, California
JAMA. 2020;324(16):1603-1604. doi:10.1001/jama.2020.17534

An often cited shortcoming of the US health care system is the slow pace with which new innovations are adopted into routine clinical practice.1 A parallel problem receives comparably less attention: the US and other countries are slow to abandon practices that provide little or no benefit to patients. Despite robust research cataloguing common practices that confer little or no value,2,3 these practices remain widespread, accounting for an estimated $67 billion in spending annually.4 For example, estimates suggest that the Centers for Medicare & Medicaid Services (CMS) spends more than $274 million annually on carotid artery disease screening for asymptomatic patients and more than $111 million annually on cervical cancer screening for women older than 65 years.2 The concept of de-adopting these and other low-value services is embedded in the Less Is More series in JAMA Internal Medicine5 and in the Choosing Wisely campaign from the American Board of Internal Medicine.6

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    2 Comments for this article
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    Two Cheers for Choosing Wisely
    Dena Davis, PhD | Lehigh University
    As a health consumer (aka patient) I try to follow guidelines, e.g. from Choosing Wisely, to avoid low-value and potentially harmful "care." It is exceptionally frustrating. A few years ago I needed cataract surgery, and for various reasons I needed it from a highly sophisticated practice, the only one in my geographical area. I found a surgeon I liked and trusted, who did the best job of eliciting informed consent I have ever seen. I made an appointment for surgery, was handed a sheaf of papers, and sent on my way. Only once I got home did I discover that I was expected to visit my PCP for an EKG within 30 days of surgery--a "standard practice" disavowed by the Am Acad of Ophthalmology. My telephone calls to the practice were all stonewalled when I explained why I wanted to talk to my surgeon--this was routine and therefore there was no point in discussing it. My PCP was also stonewalled when she called. I finally sent a letter to the surgeon, marked "Personal and Confidential" so I knew he would get it. He called me--Yup, he knew I was right, the EKG was unnecessary, but he claimed his hands were tied by the surgery center where he practiced. Eventually, fuming mad, I got the EKG--and of course my insurance paid for it! All that this experience had done was to make me feel angry and powerless, and adversarial to someone who was about to put sharp objects in my eye.
    CONFLICT OF INTEREST: None Reported
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    Value Starts With Diagnosis
    Tim Germon, BSc, MBChB, MD, FRCS(SN) | University Hospitals Plymouth, UK
    I absolutely agree with the sentiments expressed by the authors. However, the fundamental problems may be far more embedded within the medical establishment than it might at first appear. As a spinal surgeon, I see people who present with pain related to their spine. This is very common, but most cases will resolve without intervention and very few are a consequence of inevitably progressive disease. However, if a person is suffering pain which is intrusive enough that they seek professional help it seems reasonable to expect advice to be based on a diagnosis, to be rational and preferably accompanied by evidence of efficacy. Unfortunately, it has become acceptable to label people with, “non-specific low back pain” (NSLBP). This is pain for which no one has found an explanation and yet treatments are advocated. We have previously expressed our concerns that this approach is fundamentally flawed, inevitably leading to low value care as well as being a potential barrier to high value care (1, 2).

    Treating people without a clear diagnosis is common across the breadth of medicine. What exactly is irritable bowel syndrome or fibromyalgia? Is it rational to staple a normal stomach to treat obesity? How many causes of anorexia are there? The practice has become embedded within the healthcare establishment (e.g. national guidelines on the management of NSLBP) and there are many vested interests in maintaining the status quo. I suggest that understanding and addressing this behaviour is the best way to address the problem of low value care.

    REFERENCES

    1. Germon TJ, Hobart JC. Definitions, diagnosis, and decompression in spinal surgery: problems and solution. The Spine Journal. 2015 Mar 2;15(3):S5-8.
    2. Germon TJ et al. Low Back Pain.
    https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32220-7/fulltext
    CONFLICT OF INTEREST: None Reported
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