The Issue
There is a major effort under way to curb rising health care costs by reducing the use of clinical interventions that offer little or no benefit or that may be harmful in some cases. Few of these interventions, however, have been formally assessed for safety, effectiveness, and cost. In this study, Commonwealth Fund Visiting Fellow Adam Elshaug and colleagues set out to establish a systematic, evidence-based, transparent strategy for identifying potential "low-value" clinical services that require closer review. The project took part against the backdrop of Australia's Medicare Benefits Schedule (MBS). The MBS includes cost information for, and descriptions of, all private medical services provided on a fee-for-service.
What the Study Found
Using a range of methods and information sources, including peer-reviewed literature and database searches, some 156 items were flagged as potentially ineffective or unsafe. Of these, 13 were identified as questionable by more than one search method. They are:
- testing of patients for factor V Leiden gene mutation
- arthroscopic surgery for knee osteoarthritis
- testing for C-reactive protein
- use of chest x-ray for acute coronary syndrome, preoperatively, or in diagnosing respiratory infections
- chlamydia screening
- exercise electrocardiogram for angina
- imaging in cases of lower back pain
- liver function tests
- blood, urine, or plasma testing in end-stage renal disease
- radical prostatectomy
- radiotherapy for patients with metastatic spinal cord disease
- routine dilatation and curettage
- surgery for obstructive sleep apnea
Conclusions
The authors stress that this project should be viewed as a starting point in a quality improvement project, not as a final product. Although the strategy for identifying "low value" clinical services was created for Australia's MBS, the researchers stress that the same evaluation tools can be used in any health care system. One important finding is that few services are ineffective or unsafe for all patients; instead, further research must concentrate on identifying the populations most likely to benefit from services and creating policies that minimize their use outside these indications. "This would allow funding to be reallocated to more beneficial or cost-effective services, thus maximizing health gain," the researchers conclude.