Low-value procedures associated with hospital-acquired complications

Last Updated: 2019-02-26

By Will Boggs MD

NEW YORK (Reuters Health) - Several low-value procedures are associated with significant hospital-acquired complications and prolonged length of stay, researchers from Australia report.

"Low-value care is often presented as a costs issue. Reducing low-value care saves money," said Tim Badgery-Parker, a biostatistician at the Menzies Centre for Health Policy at the University of Sydney.

"But this report highlights that it is also a patient safety issue, with harmful cascade effects that go beyond the initial low-value procedure," he told Reuters Health by email. "The evidence is that these procedures are not likely to benefit these particular patients, and yet the procedures are performed, and the patients suffer measurable physical harm."

A recent study found that as many as 20% of procedures in public hospitals in New South Wales were low-value, that is, interventions that are not expected to provide a net benefit to patients or may even cause net harm.

Badgery-Parker's team examined immediate in-hospital complications associated with seven low-value procedures for which patients receiving appropriate care would not usually be hospitalized.

These procedures included endoscopy for dyspepsia in people younger than 55 years; knee arthroscopy for osteoarthritis or meniscal tears; colonoscopy for constipation in people younger than 50 years; endovascular repair of abdominal aortic aneurysm (EVAR) in asymptomatic, high-risk patients; carotid endarterectomy in asymptomatic, high-risk patients; renal-artery angioplasty; and spinal fusion for uncomplicated low back pain.

The percentage of low-value episodes with any hospital-acquired complication (HAC) ranged from 0.1% for endoscopy to 15.0% for EVAR, the researchers report in JAMA Internal Medicine, online February 25.

Other low-value procedures associated with high HAC rates included spinal fusion (7.1%), carotid endarterectomy (7.7%) and renal-artery angioplasty (8.5%).

HAC rates for endoscopy, knee arthroscopy and colonoscopy were 0.5% or lower.

For all seven low-value procedures, the median length of stay for patients with an HAC was at least twice that for patients without an HAC.

For example, patients undergoing low-value endoscopy with an HAC spent a mean 7.9 additional days in the hospital (compared with those without an HAC), and patients who had a low-value knee arthroscopy with an HAC spent a mean 13.8 additional days in the hospital (compared with those without an HAC).

The most common HAC for most procedures was healthcare-associated infection, which accounted for 26.3% of all HACs.

"We have only looked at a handful of procedures and a limited number of complications within the same episode," Badgery-Parker said. "Physical harm to patients from these procedures is likely to be higher if we measure more complications and look at later readmissions after the procedure."

"In addition," he said, "there are many other possible adverse 'cascading' consequences of low-value care for patients. These can include a financial burden from out-of-pocket costs and time off work for treatment and a psychological burden of stress and anxiety about the condition and treatment."

"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," the researchers conclude. "These procedures probably should not have been provided."

SOURCE: https://bit.ly/2U4zbLL

JAMA Intern Med 2019.