Measuring low-value care: learning from the US experience measuring quality

There is wide recognition that promoting healthcare value involves decreasing ‘low-value’ services—care without clinical benefit, little benefit compared with cost or disproportionate potential harm.1 While low-value care has been presumed to be a problem predominantly in the USA in the context of an expensive, fragmented, multipayer, fee-for-service system, recent evidence suggests low-value services are pervasive even in government-funded healthcare systems with universal coverage and interoperability.2 Accordingly, low-value care is garnering attention across the globe.3 In response, policymakers, insurers and individual healthcare systems must work together to create and track measures of low-value care. In the USA, a number of states have begun to use such measures to characterise low-value care delivered by healthcare provider organisations.4–6 Many of the existing measures have been derived from the national Choosing Wisely campaign7 with examples such as cervical cancer screening in women >65 years, preoperative testing in asymptomatic patients undergoing low-risk surgical procedures and diagnostic imaging for uncomplicated headache.8 More measures are likely to emerge amid the proliferation of value-based payment and care delivery reforms. While measuring low-value care is laudable and necessary, it is also challenging. Widely available data sources, such as claims, imperfectly capture clinical appropriateness of specific services. Measures should be valid and clearly define which facet(s) of value are being captured, and for which stakeholders. Engagement and collaboration between insurers and clinicians are needed to meaningfully implement these measures. Measures could create unintended consequences by prompting clinicians to focus disproportionately on measured services to the detriment of other aspects of care or select diagnostic coding aligned with a desired outcome. For example, a low-value care measure dissuading antibiotic prescribing in patients with acute bronchitis could drive clinicians to code more diagnoses as ‘upper respiratory tract infection’ …