Developing and applying measures of low-value care in New South Wales public hospitals

1. Developing and applying measures of low-value care in New South Wales public hospitals Presented by Tim Badgery-Parker Menzies Centre for Health Policy

2. Acknowledgements • Capital Markets CRC • Activity Based Management, NSW Health • The University of Sydney • Kelsey Chalmers, Menzies Centre for Health Policy • Adam Elshaug, Supervisor • Sallie-Anne Pearson, Co-supervisor • Jonathan Brett, Clinical Advisor • Ian A Scott, Clinical Advisor • Susan Dunn, Manager, Stakeholder Engagement, Activity Based Management, NSW Health • Neville Onley, Executive Director, Activity Based Management, NSW Health

3. Atlases present indirect measures of low-value care

4. Aim to develop direct measures • Identify low-value care at individual patient level • Can estimate actual rates of low-value care • Can aggregate at any relevant level • Allow examining factors associated with low-value care

5. Defining low-value care • Low-value care • Care for which the expected benefit does not outweigh the potential harm • For this study • Use of a test or procedure when there is a published recommendation against using the test or procedure • NICE ‘do not do’ • Choosing Wisely (US, Canada, Australia, UK) • RACP EVOLVE • Other clinical guidance

6. Developing indicators of low-value care

7. Identify measurable recommendations EXAMPLE RECOMMENDATIONS EXCLUDED FROM MEASUREMENT EXAMPLE RECOMMENDATION INCLUDED IN MEASUREMENT 1. Observable in setting. Recommendations on in-patient services Don't routinely do a pelvic examination with a Pap smear . 2. Record of service. Recommendations where service can be coded in the claim Avoid prescribing antibiotics for upper respiratory tract infection. 3. Indication. Recommendations where inappropriate service use can be distinguished Don't perform repair of minimally symptomatic or asymptomatic inguinal hernias without careful consideration, particularly in patients who have significant co-morbidities. 4. Consistent documentation. Recommendations where service is routinely recorded in the claim Don't perform epidural steroid injections to treat patients with low back pain who do not have radicular symptoms in the legs originating from the nerve roots Don't order chest x-rays in patients with uncomplicated acute bronchitis .

8. Identify low-value care

9. Account for heterogeneity and uncertainty Harm health benefit : harm trade-off Broader definition Narrower definition Adapted from Skinner and Chandra typology of medical technologies with heterogeneous benefits. 25% 50% 75% 100% Representative sample of actual/potential recipients of care (intervention quantity)

10. Example: Carotid endarterectomy Don’t routinely recommend surgery for a narrowed carotid artery (> 50% stenosis) that has not caused symptoms. — Choosing Wisely Australia and EVOLVE. Australian and New Zealand Association of Neurologists (2016) Don’t perform carotid endarterectomies or stenting in most asymptomatic high risk patients with limited life expectancy. — Choosing Wisely Canada. Canadian Society for Vascular Surgery (2015) Don’t recommend CEA for asymptomatic carotid stenosis unless the complication rate is low (< 3%). — Choosing Wisely. American Academy of Neurology (2013)

11. Example: Carotid endarterectomy Limited life expectancy High-risk patient Asymptomatic Narrower • Carotid endarterectomy with no stroke or focal neurological symptoms recorded in the episode, and ASA code 4–5 or (age ≥ 75 and ASA 3). Minimum age: 18. Sex: both. Exclude emergency admissions and admissions from the emergency department. Broader • Carotid endarterectomy with no stroke or focal neurological symptoms recorded in the episode, and ASA code 4–5 or age ≥ 75. Minimum age: 18. Sex: both.

12. Applying indicators in New South Wales Rates, trends, and variation in low-value care

13. 27 measures of low-value care

14. 13 procedures have negligible low-value care

15. 14 procedures have higher volume of low-value care

16. Counts per year, 2010-11 to 2016-17 Note vertical scale varies between panels

17. 7 decreasing and 3 increasing

18. Prevalence varies between hospitals

19. Prevalence varies between hospitals

20. Trends vary: knee arthroscopy example NSW

21. Trends vary: knee arthroscopy example NSW LHDs

22. Trends vary: knee arthroscopy example NSW hospitals

23. Limitations of the indicators

24. Measures might incorrectly label episodes • Hospital claims data does not include all the clinical information available to the treating doctor • Possible that treatment is justified but information is not available to us • Need comparison with chart review to determine accuracy • Other studies of inpatient care found indicators underestimate low-value care • One study of primary care found indicators overestimate low-value care • Modelling suggests my indicators more likely underestimate than overestimate • Not an independent validation

25. Limitations: case study • Sentinel lymph node biopsy not recommended for melanoma in situ, but we found 39 episodes • Plausible explanation: • Lesion excised in general practice • Pathology shows malignancy • Patient admitted for wider excision and lymph node biopsy • Wider excision pathology shows no malignancy (already removed) • Appears in data as biopsy for melanoma in situ as we do not have the general practice information Not visible in our data Morton, Thompson. BMJ Quality & Safety. doi: 10.1136/bmjqs-2018-009138

26. Measure specific recommendations only • Low-value care defined according to specific recommendations • Example: hysterectomy • Abdominal approach is low value compared with vaginal/laparoscopic • We did not look at whether the hysterectomy was justified at all • Example: colonoscopy • Colonoscopy for constipation in people < 50 is low value • Colonoscopy is also low value if performed too frequently in older people • We did not look at this scenario

27. Uses of these indicators • Identify where further investigation should be targeted • Which procedures have high rates? Why? • Which hospitals have high or low rates? Why? • Monitor rates and trends • Evaluate initiatives to reduce low-value care • Be wary of applying penalties without better understanding factors that may explain the results • Sentinel lymph node biopsy shows there may be plausible explanations

28. Applying indicators in New South Wales Downstream consequences of low-value care

29. Low-value care is associated with patient harm

30. Low-value care is associated with patient harm

31. Substantial additional burden to patients • Any HAC associated with low-value procedure at least doubled median length of stay • Knee arthroscopy • no HAC: median 1 day in hospital • HAC: median 10.5 days in hospital

32. Infection is most common complication

33. HACs underestimate harm • Only 16 complications in the HACs list • Chosen because clinical risk mitigation strategies may reduce (but not necessarily eliminate) the risk of that complication occurring, and they have substantial impact on patient and hospital resources • Many more possible complications in hospital • We only looked in the same episode • Need to examine full ‘cascade’ of admissions and treatments

34. References • Badgery-Parker, et al. BMJ QualSaf. 2019; 28: 3 • Badgery-Parker, et al. JAMA Intern Med. 2019. doi:10.1001/jamainternmed.2018.7464 • Chalmers, Badgery-Parker, et al. BMC Res Notes. 2018; 11: 163 • Morton, Thompson. BMJ Qual Saf. 2019; 28: 253 • Schwartz, et al. JAMA Intern Med. 2014; 174: 1067