The costs and harms associated with systemic overdiagnosis and overtreatment are receiving international attention. Clinicians and their professional organisations are obliged to assume resource stewardship as an ethical responsibility as embodied in the 2002 millennium professional charter.

Low-value care is use of an intervention where evidence suggests it confers no or very little benefit on patients, or risk of harm exceeds likely benefit, or, more broadly, the added costs of the intervention do not provide proportional added benefits. The lattermost concept involves considering benefit and cost relative to those of alternative care options, as embodied in cost-effectiveness analysis.1 Examples of high-value and low-value care occupy a matrix which emphasises this relativity of benefit over cost (Appendix 1). Care may be high (or low) value if, despite higher (or lower) costs, it confers proportionately greater (or lower) benefit. Choosing low-value care consumes resources that could have been expended on alternative forms of care conferring greater levels of benefit, either to the patient in question or to other patients.

Efforts to reduce low-value care run counter to the dominant financial incentives in our fee-for-service (private sector) and activity-based funding (public sector) systems that reward volume over value, challenge the cultural assumption that more is better, and raise concerns about stinting on necessary care. Historically, most research and effort in quality improvement has focused on underuse of high-value care2 — a legitimate concern — rather than overuse of low-value care.

How much low-value care exists?

It has been claimed that at least 20% of health care expenditure in the United States is wasted on activities that add no value.3 Studies using US Medicare claims data suggest that almost half of beneficiaries receive some form of low-value care.4 While comparable statistics for Australian health care are not available, reviews of Medicare Benefits Schedule (MBS) items have suggested that at least 150 commonly used tests and procedures are associated with little high-quality evidence of benefit, and that for some there is evidence of harm for their assigned indications.5 To date, fewer than 5% of MBS items have been closely scrutinised for their evidence-based worth. Operations such as arthroscopic debridement for uncomplicated knee osteoarthritis are frequently performed despite randomised trials showing no benefit.6 Investigation requests — such as those for vitamin B₁₂, folate7 and vitamin D8 assays, and for computed tomography scans for back pain and chest diseases9 — have surged in recent years despite considerable doubt as to their usefulness to patient care. Screening and diagnostic tests and procedures predominate over therapeutic agents in most studies of overuse.4 Some are of high value in high-risk populations (such as screening colonoscopy in patients younger than 60 years of age with premalignant colon conditions or family history of bowel cancer) but assume much lower value when extended to low-risk populations (patients older than 75 years of age with no risk factors).5 Overuse may also partly explain the marked geographical variation in age- and sex-standardised rates of cardiac catheterisation (7.4-fold variation) and hysterectomies (4.0-fold variation).10 In 2006, the Productivity Commission estimated that the efficiency of Australian health care could be improved by up to 20% by aligning performance with best practice across a range of service areas.11

The science of measuring overuse is in its infancy — a recent review noted that only 37 fully specified measures exist for overuse, compared with hundreds for underuse.12 Measures may take several forms (see Box) but all are constrained by the lack of systematic collection of granular clinical data at the level of individual patient care that captures the indications for the intervention (why was it given?) and the views and preferences of patients (in cases of marginal benefit, was there a strong patient preference to receive it?). Such nuanced data are necessary in deciding when the same service is high value in one patient but low value in another. Electronic health records which mandate insertion of indications, linked to utilisation databases (pathology, radiology, MBS, Pharmaceutical Benefits Scheme), may enable development of data repositories that are capable of interrogation at the individual level using unique identifiers. Although routine data can suggest that a low-value treatment has been provided, they cannot reveal why it occurred.

Attention must also be given to potential unintended adverse consequences of overuse measurement such as underuse of indicated care, biased patient selection, harm to doctor–patient relationships, and shifts to alternative tests and treatments in clinical settings not subject to measurement.13

What strategies can be deployed to reduce low-value care?

Currently, there is considerable government interest in Australia in using policy levers to minimise overservicing and contain health care costs. Strategies focus on decision making involving consumers (demand side) or providers (supply side). It should be noted at the outset that the impact of these strategies appear unaffected by whatever system of health care financing (fee-for-service, capitation, or managed care) predominates in particular clinical settings.14

Demand-side levers targeting patients principally include financial incentives and education. Increasing patient cost-sharing by way of copayments for services is a blunt instrument and can lead to reduced use of both low-value and high-value care, as most patients cannot differentiate between the two. Indeed, patients overestimate benefit or underestimate harm in about two-thirds of clinical decisions amenable to benefit–risk analysis.15 Furthermore, most research on consumer education campaigns, including public reporting on provider performance, suggest that such campaigns are weak instruments for changing patient behaviour.16 Patient information and decision-aid approaches in the context of shared decision making show promise,17 but are currently confined to relatively few clinical scenarios.

Supply-side levers, aimed at health care providers, depend heavily on financial incentives which may be service specific (eg, pay-for-performance and prior authorisation) or population based (eg, risk-sharing, in which providers accept financial responsibility for total costs of care under bundled or blended care payment schemes). However, evidence of effectiveness of such incentives remains limited,18 and Australian trials of prepaid coordinated care (a blended payment scheme) for managing patients with diabetes have not been finalised. Removing or lowering Medicare rebates or diagnosis-related group payments for low-value interventions is another option. However, past efforts to substantially revise the MBS have failed and very few items have been removed from the schedule in the past decade. However, a major review process is currently underway. One innovative option is indication-specific pricing whereby remuneration for an intervention depends on the amount of benefit it confers for a specific indication, with the base price anchored to the indication for which it provides the most value, or linked to a preset value.19

As for information-based supply-side interventions, clinical practice guidelines, clinical audits and feedback, academic detailing, decision support and other professional educational interventions exert limited impact in curtailing inappropriate care. Embedding of decision support, quality measurement and instant feedback into electronic health records and handheld-device applications may help to reduce low-value care at the point of care. Examples include lung cancer guidelines in the US20 and various guidelines from Cancer Council Australia.

While waiting for digital solutions, analysing claims-based data and identifying providers (as groups or as individuals) with inordinately higher rates of use compared with peer averages may be useful in terms of stimulating practice reviews for evidence of overuse. While such datasets are inexpensive, widely available, and population-based, they lack detailed clinical information. Population-based outcome monitoring linked to professional incentives is another option; this approach is finding favour in the US in accountable care contracts which encourage decreased use of low-value care through partial capitation or shared savings.

What is the role of clinicians in recognising and minimising low-value care?

What constitutes low-value care lies in the eye of the beholder. Most clinicians regard very few interventions as conferring no benefit in all clinical circumstances. They are reticent in labelling a practice low value if, in their personal experience at least, the practice has stood the test of time and conferred benefit on some patients with no safety concerns.

Altering such perceptions is not easy. First, evidence of treatments that are of little or no benefit is viewed sceptically if it: is perceived as lacking objectivity, consistency or clinical plausibility; is not equally applicable to all individuals (different magnitude of effects or different patient valuations of benefit among different patient groups); or challenges strongly held professional beliefs based on personal experience and peer opinion. Information about what constitutes ineffective treatment is diffuse, sometimes low quality and hard to use.

Second, various cognitive factors distort perceptions of low-value care,21 reflecting clinician desire to avoid potential injustice to individuals, and their own sense of regret or medicolegal liability, from withholding interventions that may possibly bestow some benefit. In many such cases, the absence of any other viable treatment option pushes the clinician to offer the only available, but still low-value, treatment.

Third, external factors such as quality-of-care metrics, competitiveness in the medical marketplace, and organisational aspirations to be “centres of excellence” all encourage “thoroughness”, pro-intervention bias and desire to meet expectations of patients, referring clinicians and corporate stakeholders at the risk of overservicing.

However, professional organisations in the US have begun the task of defining instances where the use of a particular intervention is likely to constitute low-value care. The American Board of Internal Medicine Foundation’s Choosing Wisely campaign involves more than 60 specialty societies, each identifying at least five commonly encountered scenarios in their specialty where specific interventions should be avoided.22 Examples of how these can be applied in clinical practice are described in Appendix 2.

Critics worry that US specialty groups have found it easier to recommend reduction in use of services by other specialties compared with those within their own specialty, or focus solely on low-cost diagnostic tests, rather than address high-cost interventions specific to their own craft group.23 Nevertheless, it represents a beginning and the Royal Australasian College of Physicians24 and the National Prescribing Service (http://www.choosingwisely.org.au) are mounting similar campaigns. The US Preventive Services Task Force, the National Quality Forum and the American College of Physicians’ High Value Care platform all seek to educate front-line clinicians on methods for identifying unnecessary and wasteful services.1

In the United Kingdom, the Academy of Medical Royal Colleges has released a report outlining the rationale and principles behind reducing low-value care, illustrated by numerous case studies.25 Specialty societies and researchers are employing expert panels equipped with the best available research syntheses to rank the level of appropriateness of different interventions using consensus methods and Delphi rounds.26 These activities recognise that most interventions are neither low value nor high value in all cases, and seek instead to identify their nuanced low-value and high-value applications according to clinical context.

Should clinicians be allowed to be the final arbiters of low-value care? In making complex and highly individualised clinical decisions, nuanced clinical judgements of experienced, well informed clinicians will arguably outperform any service-level measurement and incentive program aimed at recognising and reducing low-value care. Attempts to distil and apply evidence-informed “do not do” rules at the population level are bedevilled by the rule of legitimate exceptions when care is directed at specific individuals.

Moreover, in a recent national US survey, 92% of physicians said they felt responsible for ensuring patients avoid unnecessary tests and procedures, and 58% believed that physicians were best positioned to do so.27 Arguably, deciding how and when to use limited health care resources are clinical questions that are best addressed by those with sufficient training and experience. Clinicians are more likely to respond to evaluations of quality by their peers than to adverse comments from non-clinical reviewers or managers, or to threats of financial sanctions and penalties for seemingly low-value care based solely on macro level analysis.

At the micro level, some physicians are establishing programs in their areas of practice that identify and remove low-value care using evidence of effectiveness, cost awareness, and regular audits and feedback.28 Training and education programs can enhance and assess the ability of aspiring clinicians to recognise and practice high-value care.29,30 Such bottom-up approaches are a good place to start and public policy interventions should support clinician-led efforts to seek professional consensus on what constitutes low-value care and the best means for reducing it.

It’s time for all of us to accept responsibility

“The standard you walk past is the standard you are prepared to accept.” With this wake-up call in June 2013, Lieutenant General David Morrison challenged all those serving in the Australian Army to take responsibility for the culture and reputation of the army and the environment in which they work.1 He made this call in response to an emerging scandal of sexual abuse and harassment in the army. At the 2015 Australian Medical Association national conference in May, James Lawler, President of the Australian Medical Students’ Association, named bullying, harassment, sexual harassment and their mental health as the biggest problems affecting medical students.2 He explained that he could not tell his peers to take a stand against the perpetrators because “the hierarchy is too high and too strong”. Quoting David Morrison, he called on those present to help change the culture of medicine.

Discrimination, bullying and sexual harassment are illegal and breach both published and implicit codes of ethics and professional standards in medicine.3 Yet they are prevalent in medicine and health care, not only in Australia, but in many other countries and cultures and in other professions, notably law.4 Both men and women perpetrate this behaviour, but the most common pattern is a male perpetrator and female victim. The behaviour affects the individuals involved and the organisations they work in, reducing individual and team morale and performance and, in health care, ultimately diminishing patient safety.5

Most incidents are not reported. Reasons for this include lack of confidence in complaint processes, fear of adverse consequences, reluctance to be viewed as a victim and cultural minimisation of the problem.6

Hierarchies lend themselves to misuse of power. Our profession remains hierarchical, and the further one advances up the hierarchy in many parts of the profession, the greater the imbalance between the sexes. This is particularly so in surgery, where only 10% of fellows are female, and few women hold office.7

In this issue of the Journal, Walton points to the profound power imbalance that exists for junior medical staff8 and Mathews draws attention to the system of patronage where trainees depend on powerful senior colleagues for advancement.3 These articles go some way towards explaining why victims cannot be expected to solve the problem or even to take primary responsibility for identifying and naming it.

What can the rest of us, the bystanders, do?

How can peers and colleagues not notice inappropriate behaviour going on around us? Or do we notice but feel disinclined to become involved or reluctant to act? And how do we respond if a student or trainee comes to us for help and support? Or if we are part of a formal complaints mechanism?

Those who are perpetrators, whether their behaviour is deliberate or unconscious, need to know that their peers do not accept and will not tolerate it. The behaviour needs to be recognised and condemned as and where it occurs.

The lack of confidence in complaint processes and fear of reprisals is a sad reflection of the hidden curriculum in medicine, the cultural norms and expectations that run counter to the explicit curriculum of professionalism.

The way forward

“Good medical practice”, the code of conduct issued by the Medical Board of Australia outlines the professional values on which all doctors are expected to base their practice.9 These values include integrity, truthfulness, dependability, compassion and self-awareness. Bullying, discrimination and sexual harassment are incompatible with these qualities.

Problems of discrimination, bullying and harassment are not new, but they are increasingly at odds with the standards expected in the 21st Century. Other institutions are facing up to the darker aspects of their history and culture, bringing them into the light of day and committing to eliminating abuse and exploitation. It is time for all of us to accept responsibility for the culture and reputation of our profession and work to create environments in which respect is the dominant quality of relationships with our colleagues, trainees and patients.

Personalised care does not justify use of therapies that have been shown to lack benefit

Will you be disbelieving, dismissive, disheartened or alert to the dangers after reading the study in this issue of the MJA that identified potentially inappropriate care in Australian hospitals?1 Using routine hospital admissions data, Duckett and colleagues found that five procedures not supported by clinical evidence happen more than 100 times a week and there is great variation in hospital-specific rates of procedures that should not be done routinely.

Disbelieving

Confirmation that inappropriate care continues to occur challenges to the core the optimal, ethical and patient-centred medical care that medical professionals strive to provide.2 To disbelieve the findings would be human,3 as “evidence contrary to our personal beliefs tends to be dismissed as unreliable, erroneous or unrepresentative”.4

To counter the discomfort these findings provoke, we may rationalise, arguing that the appropriateness of care is quintessentially where the art and science of medicine merge, where balancing the logic of evidence with the personal values of each individual patient leads to variation in care. However, personalised care does not justify inappropriate care.

Or we may argue that this is to be expected when there is a vacuum of evidence about what is appropriate (eg, the established and widespread practice of off-label use of medications5), or that today’s radical ideas may become standard practice in another era.6,7 However, neither of these are valid counterarguments to Duckett et al’s findings.1

Instead of disbelieving, we should consider how we respond to consumers who will react to the results of the study with incredulity — and perhaps even outrage — that a contemporary health care system continues to deliver therapies with clinical research evidence showing they are of no benefit to patients. Patients should be receiving care that is appropriate and, ideally, based on evidence of benefit. Robust research evidence from testing the merits of a therapy and demonstrating a lack of benefit identifies inappropriate care. This is different to a lack of research evidence of benefit.

Dismissive

Those who would be dismissive will point to the inherent limitations in the study; for example, reaching conclusions about health care interventions with the use of a secondary analysis of hospital discharge data instead of clinical registries.8 The use of cross-sectional data, describing clinical practice from 5 years ago, provides no insight into temporal trends and whether these inappropriate procedures have tapered and are now eradicated. Further, a very small number of interventions were examined; and the highest volume of inappropriate care, also referred to as “do not do” treatments, involved hyperbaric oxygen therapy. This highly specialised therapy is only available in a small proportion of health services in Australia and accounted for 79% (4659/5888) of all procedures included. The remaining do-not-do interventions affected a very small but important number of patients.

Disheartened

The true believers who sought a revolution to improve patient safety and quality of health care will be disheartened. Unexplained variation in care was first reported over 5 decades ago9,10 and there was a flurry of activity throughout the world11 to improve the quality of health care, which generated considerable momentum from the evidence of patient harm.12

Duckett and colleagues’ study reminds us that we still do not have answers about how to ensure a high quality of care, that the impacts of most interventions to improve care remain incompletely understood, and the potential for inadvertent adverse consequences is ever present.

Alert to the dangers ahead

Inappropriate care is a “wicked problem”13 — difficult to resolve and requiring a fundamental change across the health care system. The danger ahead is we become mired in negative emotions. Now is the time to be interested, somewhat trusting and encouraged. Be interested in understanding and contributing to solving a complex problem, and put to use the natural inquisitiveness and skills of inquiry required in any consultation to make a diagnosis. Be somewhat trusting of the data, given there is substantial other robust empirical evidence showing inappropriate use of common procedures (coronary angiography, carotid endarterectomy, caesarean section) in health care.14 Be encouraged that this important aspect of quality health care continues to receive attention.

These findings call for action and we should all be interested in the outcome. However, we need to be only somewhat trusting of the recommendations for addressing inappropriate care through pay for performance, the use of rewards or sanctions as these may be premature, are conventional and provide at best a partial solution.

What should happen next?

Instead of dismissing, we should consider that for any inappropriate care to occur, complicit action on a large scale is required. To deliver a do-not-do procedure a medical practitioner must first be credentialled, have a defined scope of practice and operate within their clinical team alongside support services and the governance structures of an organisation. Start counting how many people are involved. Therefore, the question we should be asking is: how is it possible for inappropriate care to occur? And what systems-level agreements perpetuate this situation?

Instead of feeling disheartened we should embrace this opportunity to address appropriateness of care, which is integral to all six domains of quality.15 Our approach to this situation will be far more sophisticated because of the collective experiences and lessons on how to improve practice from the past 25 years.

Instead of merely feeling alert to the dangers ahead, we must be engaged and encouraging in our efforts to seek out the underlying factors and new solutions. This requires a change in thinking16 and incorporating the science of performance measurement with the science of human factors (a branch of applied science that draws on psychology, engineering, computing science, education, ergonomics and anthropology to improve patient care).

Prudent policy makers, medical practitioners and patients expect community resources to focus on efficacious and effective provision of health care. The ideas and concepts presented by Duckett et al1 are worthy of heated debate and concerted action to explore what we must do to eradicate inappropriate care.