How to assess the value of low-value care
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COMMENTARY
Open Access
How to assess the value of low-value care José Antonio Sacristán
Abstract Background: Many of the strategies designed to reduce “low-value care” have been implemented without a consensus on the definition of the term “value”. Most “low value care” lists are based on the comparative effectiveness of the interventions. Main text: Defining the value of an intervention based on its effectiveness may generate an inefficient use of resources, as a very effective intervention is not necessarily an efficient intervention, and a low effective intervention is not always an inefficient intervention. The cost-effectiveness plane may help to differentiate between high and low value care interventions. Reducing low value care should include three complementary strategies: eliminating ineffective interventions that entail a cost; eliminating interventions whose cost is higher and whose effectiveness is lower than that of other options (quadrant IV); and eliminating interventions whose incremental or decremental cost-effectiveness is unacceptable in quadrants I and III, respectively. Defining low-value care according to the efficiency of the interventions, ideally at the level of subgroups and individuals, will contribute to develop true value-based health care systems. Conclusion: Cost-effectiveness rather than effectiveness should be the main criterion to assess the value of health care services and interventions. Payment-for-value strategies should be based on the definition of high and low value provided by the cost-effectiveness plane. Keywords: Value, Cost-effectiveness, Efficiency, Comparative effectiveness
Background Most Western health systems are trying to identify and reduce wasteful health care use. Apart from avoiding potentially harmful treatments, the estimated cost of waste in countries like the US ranges from $760 billion to $935 billion, accounting for approximately 25% of total health care spending [1]. Surprisingly, many of the strategies designed to reduce low-value care have been implemented without a consensus on the definition of the term “value”. For example, the list of low-value services published by the Choosing Wisely campaign, an initiative led by the American Board of Internal Medicine (ABIM) Foundation, which coordinated more than 50 medical specialty societies, includes “services that
provide little or no health benefit to patients” [2]. This means that the list has been drawn up applying the criteria of effectiveness and not that of efficiency. For example, out of the 435 health services included in Choosing Wisely, only 2% cite cost-effectiveness to justify the recommendations, and only 29% of criteria for services contain the word “cost” (or related terms) vs 68% of criteria for services containing the words “clinical”, “outcome”, or “harm” [3]. In the same way, the American Society of Clinical Oncology (ASCO) has recently established effectiveness (without considering costs) as a key prioritization criterion. For example, a survival gain lower than 2.5 to 3 months wou
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