Public hospitals already Choosing Wisely on low value procedures

Public Health

By Michael Woodhead

10 Aug 2018

While it’s said that 30% of healthcare activity is ‘waste’ that’s not borne out by the minimal rates of low-value care procedures in public hospitals, an Australian study shows.

A review of 27 procedures included in Choosing Wisely lists or the RACP’s EVOLVE initiatives has found that half of them (13) accounted for negligible levels of low value care and most of the remainder showed declines in use over time.

Only three procedures  – colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopsy for melanoma in situ – showed increasing trends in NSW hospitals, according to an analysis, carried out by the University of Sydney’s Menzies Centre for Health Policy.

The researchers found that while some widely used procedures such as knee arthroscopy had high proportions of low value episodes (26%), the trend was for an 8% annual decline.

Other procedures such as endovascular repair of  abdominal aortic aneurysm had high rates of low value episodes (43%) but the absolute number of episodes per year (175) was low.

“Low-value care in this Australian public hospital setting is not common for most of the measured procedures,” they said.

Nevertheless this did not mean that low value care was not a problem in some settings, they argued, as it still accounted for substantial resources in terms of dollars and bed days in some hospitals.

They also noted  that the analysis was limited to procedures on Choosing Wisely lists, which have been criticised by some for including many low impact items.

“The 27 procedures are those we could measure, not necessarily the most important for health system efficiency or patient outcomes, and clinicians in Australia may not have recognised these services as requiring action,” they commented.

For the three procedures identified with significant levels of low value episodes there should be further investigation of the drivers to determine what can be done to reduce the use, they suggested.

Feedback of the results and the use of possible restrictions such as requiring  ‘permissions’ for procedures could help reduce low value procedures, they suggest.

However, “any action based on these results needs to be carefully considered, to avoid undermining the clinician goodwill associated with Choosing Wisely,” they warn.


Significant Low Value Care, Increasing Trend 

  • Endoscopy in adults <55
  • Colonoscopy in adults <50
  • Sentinel lymph node biopsy

Significant Low Value Care, Decreasing Trend 

  • Knee arthroscopy
  • Hysterectomy
  • Endovascular repair of abdominal aortic aneurysm
  • Percutaneous coronary intervention
  • Carotid endarterectomy
  • Renal artery angioplasty
  • Vena cava filters
  • Surgery for vesicoureteric reflux
  • ERCP
  • Spinal fusion
  • Epidural steroid injection

Negligible Number of Low Value Care Episodes

  • Vertebroplasty
  • Bariatric surgery
  • Nasolacrimal probe in infants
  • Vertebral biopsy
  • Retinal laser or cryotherapy
  • Hyperbaric oxygen
  • Laparoscopic uterine nerve ablation
  • Gall bladder removal during bariatric surgery
  • Electrotherapy
  • Pelvic lymphadenectomy
  • Endometrial biopsy
  • Radiotherapy after radical prostatectomy
  • Electroconvulsive therapy in children

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