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Comment & Response
Less Is More
August 2019

In Low-Value Care, Less Is (Not Always) More—Reply

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
JAMA Intern Med. 2019;179(8):1148. doi:10.1001/jamainternmed.2019.1659

In Reply We welcome the comments by Forbes about our article1 in measuring low-value endovascular repair of abdominal aortic aneurysms (EVAR), but we disagree with his conclusions.

First, he objects to our use of the American Society of Anesthesiologists (ASA) classification to define “high-risk” patients. Identifying “high-risk patients with limited life expectancy” in our data is challenging. Given the available variables, our clinical advisers agreed that using the ASA classification is reasonable. Although the interrater reliability for the ASA score is moderate, the score is a valid indicator of perioperative risk.2 It needs to be emphasized that the ASA III and IV definitions are predicated on “severe systemic disease,” implying vulnerability to death or poor outcomes owing to major organ insufficiency, which may be exacerbated by invasive intervention. This is separate to having an aneurysm in isolation. Although there may be some inconsistencies in how these definitions are interpreted or recorded, we believe it is better to produce the best measurements that we can with current data, recognize their limitations, and improve them as better data become available, rather than to abandon measurement as too hard.

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