Measuring Hospital-Acquired Complications Associated With Low-Value Care

Abstract

Importance: Studies of low-value care have focused on the prevalence of low-value care interventions but have rarely quantified downstream consequences of these interventions for patients or the health care system.

Objective: To measure immediate in-hospital harm associated with 7 low-value procedures.

Design, setting, and participants: A cohort study with a descriptive analysis using hospital admission data from 225 public hospitals in New South Wales, Australia, was conducted from July 1, 2014, to June 30, 2017. All 9330 episodes involving 1 of 7 low-value procedures were evaluated, including endoscopy for dyspepsia in people younger than 55 years (3689 episodes); knee arthroscopy for osteoarthritis or meniscal tears (3963 episodes); colonoscopy for constipation in people younger than 50 years (665 episodes); endovascular repair of abdominal aortic aneurysm in asymptomatic, high-risk patients (508 episodes); carotid endarterectomy in asymptomatic, high-risk patients (273 episodes); renal artery angioplasty (176 episodes); and spinal fusion for uncomplicated low back pain (56 episodes). Sixteen hospital-acquired complications (HACs) were used as a measure of harm associated with low-value care.

Main outcomes and measures: For each low-value procedure, the percentage associated with any HAC and the difference in mean length of stay for patients receiving low-value care with and without HACs were calculated.

Results: Across the 225 hospitals and 9330 episodes of low-value care, rates of HACs were low for low-value endoscopy (4 [0.1%] episodes; 95% CI, 0.02%-0.2%), knee arthroscopy (18 [0.5%] episodes; 95% CI, 0.2%-0.7%), and colonoscopy (2 [0.3%] episodes; 95% CI, 0.0%-0.9%) but higher for low-value spinal fusion (4 [7.1%] episodes; 95% CI, 2.2%-11.5%), endovascular repair of abdominal aortic aneurysm (76 [15.0%] episodes; 95% CI, 11.1%-19.7%), carotid endarterectomy (21 [7.7%] episodes; 95% CI, 5.2%-10.1%), and renal artery angioplasty (15 [8.5%] episodes; 95% CI, 5.8%-11.5%). For most procedures, the most common HAC was health care-associated infection, which accounted for 83 (26.3%) (95% CI, 21.8%-31.5%) of all HACs observed. The highest rate of health care-associated infection was 8.4% (95% CI, 5.2%-11.4%) for renal artery angioplasty. For all 7 low-value procedures, median length of stay for patients with an HAC was 2 times or more the median length of stay for patients without a complication. For example, median length of stay was 1 (interquartile range [IQR], 1-1) day for knee arthroscopy with no HACs but increased to 10.5 (IQR, 1.0-21.3) days for patients with an HAC.

Conclusions and relevance: These findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate. Although only some immediate consequences of just 7 low-value services were examined, harm related to all low-value procedures was noted, including high rates of harm for certain higher-risk procedures. The full burden of low-value care for patients and the health system is yet to be quantified.

Figure.. Hospital-Acquired Complications (HACs) Associated With 7 Low-Value Procedures in New South Wales Public Hospitals

Counts per 100 low-value episodes are shown for 13 of the 16 individual HACs for each procedure: carotid endarterectomy (A), colonoscopy (B), endoscopy (C), endovascular repair of abdominal aortic aneurysm (EVAR) (D), knee arthroscopy (E), renal artery angioplasty (F), and spinal fusion (G). Two HACs (perineal laceration; neonatal birth trauma) are not relevant to any of these procedures, and 1 HAC (unplanned admission to intensive care unit) is not measurable in our data. Note that the horizontal scale varies between panels. Error bars indicate 95% percentile bootstrap CIs accounting for clustering of episodes by hospital. GI indicates gastrointestinal.