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Original Investigation
Less Is More
February 25, 2019

Measuring Hospital-Acquired Complications Associated With Low-Value Care

Author Affiliations
  • 1The University of Sydney, Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy, Charles Perkins Centre, Sydney Australia
  • 2Capital Markets Cooperative Research Centre, Health Market Quality Program, Sydney, Australia
  • 3Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
  • 4Activity Based Management, New South Wales Ministry of Health, Sydney, Australia
JAMA Intern Med. 2019;179(4):499-505. doi:10.1001/jamainternmed.2018.7464
Key Points

Question  Do patients who are admitted to the hospital for a low-value procedure (ie, those that would not be expected to require admission) develop hospital-acquired complications?

Findings  In this cohort study and descriptive analysis of 9330 episodes of low-value use of 7 procedures (ranging from 56 low-value spinal fusions to 3963 low-value knee arthroscopies), depending on the procedure, between 0.2% and 15.0% of patients receiving these low-value procedures developed at least 1 of 16 hospital-acquired complications, the most common being health care–associated infection.

Meaning  Use of these 7 low-value procedures is harming patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate.


Importance  Studies of low-value care have focused on the prevalence of low-value care interventions but have rarely quantified downstream consequences of these interventions for patients or the health care system.

Objective  To measure immediate in-hospital harm associated with 7 low-value procedures.

Design, Setting, and Participants  A cohort study with a descriptive analysis using hospital admission data from 225 public hospitals in New South Wales, Australia, was conducted from July 1, 2014, to June 30, 2017. All 9330 episodes involving 1 of 7 low-value procedures were evaluated, including endoscopy for dyspepsia in people younger than 55 years (3689 episodes); knee arthroscopy for osteoarthritis or meniscal tears (3963 episodes); colonoscopy for constipation in people younger than 50 years (665 episodes); endovascular repair of abdominal aortic aneurysm in asymptomatic, high-risk patients (508 episodes); carotid endarterectomy in asymptomatic, high-risk patients (273 episodes); renal artery angioplasty (176 episodes); and spinal fusion for uncomplicated low back pain (56 episodes). Sixteen hospital-acquired complications (HACs) were used as a measure of harm associated with low-value care.

Main Outcomes and Measures  For each low-value procedure, the percentage associated with any HAC and the difference in mean length of stay for patients receiving low-value care with and without HACs were calculated.

Results  Across the 225 hospitals and 9330 episodes of low-value care, rates of HACs were low for low-value endoscopy (4 [0.1%] episodes; 95% CI, 0.02%-0.2%), knee arthroscopy (18 [0.5%] episodes; 95% CI, 0.2%-0.7%), and colonoscopy (2 [0.3%] episodes; 95% CI, 0.0%-0.9%) but higher for low-value spinal fusion (4 [7.1%] episodes; 95% CI, 2.2%-11.5%), endovascular repair of abdominal aortic aneurysm (76 [15.0%] episodes; 95% CI, 11.1%-19.7%), carotid endarterectomy (21 [7.7%] episodes; 95% CI, 5.2%-10.1%), and renal artery angioplasty (15 [8.5%] episodes; 95% CI, 5.8%-11.5%). For most procedures, the most common HAC was health care–associated infection, which accounted for 83 (26.3%) (95% CI, 21.8%-31.5%) of all HACs observed. The highest rate of health care–associated infection was 8.4% (95% CI, 5.2%-11.4%) for renal artery angioplasty. For all 7 low-value procedures, median length of stay for patients with an HAC was 2 times or more the median length of stay for patients without a complication. For example, median length of stay was 1 (interquartile range [IQR], 1-1) day for knee arthroscopy with no HACs but increased to 10.5 (IQR, 1.0-21.3) days for patients with an HAC.

Conclusions and Relevance  These findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate. Although only some immediate consequences of just 7 low-value services were examined, harm related to all low-value procedures was noted, including high rates of harm for certain higher-risk procedures. The full burden of low-value care for patients and the health system is yet to be quantified.

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