How Do We Reduce Low-Value Care in Urology?
By: Kassandra Dindinger-Hill, BS; Brock O'Neil, MD | Posted on: 01 Oct 2022
Low-value care (LVC) is widespread in health care, and urology is not immune. LVC is often thought of as highly expensive care that offers little benefit. However, evidence supports that the largest contributors to LVC are inexpensive services that are performed at high volumes. In one important study, 93% of LVC could be attributed to low- and very low-cost services.1 PSA-based prostate cancer screening can be a low-cost, low-value service when performed in patients who are unlikely to benefit. Unfortunately, this is a common occurrence. Estimates show that up to half of all PSA testing is done when it is unlikely to provide a benefit.2 With growing efforts aimed at reducing LVC in health care, it is important for urologists to be a part of the conversation. Services such as PSA screening are targeted by health systems and payers to reduce unnecessary spending, and if urologists remain indifferent there is potential for changes to negatively impact patients.
Clinicians, health care facilities, and patients have all been shown to contribute to LVC. One example of a clinician-level factor is decision fatigue, in which the quality of PSA testing decisions declines as the clinic day or week progresses.3 Substantial variation of LVC between facilities and health systems is well-documented and likely represents differences in facility type, volume, culture, organizational patterns, and reimbursement rates.4 Academic institutions tend to have lower rates of LVC compared to community hospitals, and different VA facilities have shown wide variations in low-value prostate cancer care.4
Our group is currently examining a previously overlooked aspect of LVC—the social context in which clinicians practice. In this work, we are studying how the level of LVC in various markets relates to the likelihood that an individual clinician will provide that service.5 Initial results show that there is a significant relationship between the market level of low-value PSA testing and individual clinician behavior. Primary care clinicians working in markets at the 80th percentile for providing low-value PSA testing are substantially more likely to perform low-value testing compared to clinicians working in markets at the 20th percentile (see Table).5 This ongoing analysis will explore what happens when clinicians change markets, and will encompass low-value prostate cancer staging imaging, breast cancer screening, and end of life cancer care in addition to PSA testing.
The American Urology Association, along with other specialty societies, has participated in the Choosing Wisely® campaign. This was developed to help identify and reduce LVC. Unfortunately, this simple process of identifying and promoting reductions in LVC has largely had little impact.6 So, what can be done about LVC? Combining the known contributors to LVC reveals that this is a complex issue that will require complex solutions.
Strategies that actively implement utilization of guidelines show promise.7,8 Health systems that implemented guidelines through multicomponent, clinician-oriented approaches have demonstrated significant effect at reducing LVC compared to systems that used nonclinician oriented or single component approaches.7 Some of these successful strategies include leveraging order sets, organizational or documentation changes, behavioral nudges, clinical decision support, and creation of new clinical pathways.7
Table. Likelihood of providing low-value PSA testing
|PSA Testing||2.17 (2.13, 2.20)||<0.001|
|OR80/20 refers to a market that is at the 80th percentile for performing low-value care relative to a market that is at the 20th percentile for performing low-value care.|
After identifying an effective strategy to reduce LVC, rolling that approach out on a larger scale has proved challenging. One example is in the use of remote patient monitoring to reduce acute care use, in which it was found to be successful in some institutions and patient populations but failed in others.9 Institutions that personalized care for patients, accurately targeted patients at highest risk, enhanced self-management, and encouraged strong collaborations between clinicians had the most success.9 Institutions where implementation failed essentially had the opposite. While this study is not urology specific, these findings could easily apply to urological services—good collaboration between clinicians, personalized care, and accurate identification of high-risk patients are intuitive goals for urologists to strive for.
Our work in evaluating social context provides another clue as to why prior de-implementation strategies may have failed: they tend to be generalized and do not account for the local context of the clinician. We propose that the best solutions will need to be flexible and tailored to the specific market or institution in which clinicians practice. Our group continues work on developing a decision support strategy that employs behavioral nudges and incorporates principles of clinician engagement, patient personalization, and targeting of highest risk encounters, and offers intervention flexibility. We are hopeful that this will contribute to important reductions in the provision of low-value PSA testing while preserving this important screening tool for those likely to benefit.
- Mafi JN, Russell K, Bortz BA, Dachary M, Hazel WA Jr, Fendrick AM. Low-cost, high-volume health services contribute the most to unnecessary health spending. Health Aff (Millwood). 2017;36(10):1701-1704.
- O’Neil B, Martin C, Kapron A, Flynn M, Kawamoto K, Cooney KA. Defining low-value PSA testing in a large retrospective cohort: finding common ground between discordant guidelines. Cancer Epidemiol. 2018;56:112-117.
- Hunt TC, Ambrose JP, Haaland B, et al. Decision fatigue in low-value prostate cancer screening. Cancer. 2021;127(18):3343-3353.
- Krimphove MJ, Cole AP, Friedlander DF, et al. The current landscape of low-value care in men diagnosed with prostate cancer: what is the role of individual hospitals? Urol Oncol. 2019;37(9):575.e9-575.e18.
- Dindinger-Hill K, Vehawn J, Choudry M, et al. The effect of social context on individual provider practices of low-value cancer care. 2022. Unpublished data.
- Lange S, Choudry M. Impact of Choosing Wisely on imaging in men with newly diagnosed prostate cancer. Unpublished data.
- Cliff BQ, Avanceña AL, Hirth RA. The impact of Choosing Wisely interventions on low-value medical services: a systematic review. Milbank Q. 2021;99(4):1024-1058.
- Welk B, Winick-Ng J, McClure JA, Lorenzo AJ, Kulkarni G, Ordon M. The impact of the Choosing Wisely campaign in urology. Urology. 2018;116:81-86.
- Thomas EE, Taylor ML, Banbury A, Lee SD. Factors influencing the effectiveness of remote patient monitoring interventions: a realist review. BMJ Open. 2021;11(8) e051844.