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The Language of Stewardship: Is the “Low-Value” Label Overused?

Published:November 11, 2016DOI:https://doi.org/10.1016/j.mayocp.2016.09.011
      Value, a construct for describing the economic efficiency of specific health care services or entire delivery systems, has become a major focus in US health care. The United States spends more on health care than any other nation and ranks poorly on numerous health measures, so increasing the value of care delivered has appropriately been the foundation of recent health care reforms.
      • Berwick D.M.
      • Nolan T.W.
      • Whittington J.
      The triple aim: care, health, and cost.
      One approach to increasing the value of US health care is to limit the use of interventions that do little to improve health, which may account for more than one-third of all health care spending.
      Institute of Medicine
      Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
      To that end, physicians have recently been leading a stewardship movement, arguing that the ability to continue delivering high-quality care requires recognizing that resources are limited and ensuring that those resources are used efficiently.
      • Reuben D.B.
      • Cassel C.K.
      Physician stewardship of health care in an era of finite resources.
      • Ubel P.A.
      • Jagsi R.
      Promoting population health through financial stewardship.
      A notable example is the Choosing Wisely campaign, which has enlisted professional societies to develop lists of tests and treatments that may be unnecessary.
      • Cassel C.K.
      • Guest J.A.
      Choosing Wisely: helping physicians and patients make smart decisions about their care.
      Not surprisingly, the services targeted by the stewardship movement generally and Choosing Wisely specifically are often labeled as “low-value.”
      • Elshaug A.G.
      • McWilliams J.M.
      • Landon B.E.
      The value of low-value lists.
      • Morden N.E.
      • Colla C.H.
      • Sequist T.D.
      • Rosenthal M.B.
      Choosing Wisely—the politics and economics of labeling low-value services.
      • Roman B.R.
      • Asch D.A.
      Faded promises: the challenge of deadopting low-value care.
      Despite the needed attention on value, the application of the low-value label to specific services may be overused. The label is not necessarily warranted for all services with small and uncertain benefit, may convey that cost containment is the primary rationale for discouraging services when there are potentially more compelling reasons, and may constrain the scope of the entire stewardship movement.

      Not All Health Care Services With Small and Uncertain Benefit Are Necessarily of Low Value

      The term value has numerous meanings in the English language, including “usefulness or importance.”

      Value. Merriam-Webster website. http://www.merriam-webster.com/dictionary/value. Accessed March 10, 2016.

      The famed investor Warren Buffett is credited with saying, “Price is what you pay. Value is what you get.”

      The Quotations Page website. www.quotationspage.com/quote/39122.html. Accessed October 6, 2016.

      It may seem natural to apply the low-value label to tests and treatments with small and uncertain benefit. However, value has recently acquired a more specific meaning in health care: the health outcomes achieved per dollar spent.
      • Porter M.E.
      What is value in health care?.
      In this context, value is a similar construct to cost-effectiveness, comparing alternative treatment strategies on the basis of the ratio of the incremental net health benefit (including harms) to the incremental cost.
      • Owens D.K.
      • Qaseem A.
      • Chou R.
      • Shekelle P.
      Clinical Guidelines Committee of the American College of Physicians
      High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions.
      The term may be attractive, in part, because it incorporates a consideration of costs while avoiding the negative implications that explicit cost considerations have acquired.
      The adoption of a common term to describe a specific construct potentially creates challenges in communication. For example, to say “patients value a compassionate doctor” should not be misinterpreted as a claim about the economic efficiency of compassionate doctors. As used in the literature today, however, high value and low value seem to almost universally apply to the economic efficiency construct,
      • Elshaug A.G.
      • McWilliams J.M.
      • Landon B.E.
      The value of low-value lists.
      • Morden N.E.
      • Colla C.H.
      • Sequist T.D.
      • Rosenthal M.B.
      Choosing Wisely—the politics and economics of labeling low-value services.
      • Roman B.R.
      • Asch D.A.
      Faded promises: the challenge of deadopting low-value care.
      which suggests a general acceptance of the meaning in this context and makes it a useful construct.
      In the economic efficiency context, value is directly proportional to health benefit but is a less intuitive measure because interventions with a small benefit can be of high value (eg, flu vaccinations for most patients), and interventions with a large benefit can be of low value (eg, chemotherapy for some patients).
      • Owens D.K.
      • Qaseem A.
      • Chou R.
      • Shekelle P.
      Clinical Guidelines Committee of the American College of Physicians
      High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions.
      Value can be calculated through cost-effectiveness analyses,
      • Owens D.K.
      • Qaseem A.
      • Chou R.
      • Shekelle P.
      Clinical Guidelines Committee of the American College of Physicians
      High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions.
      which are not conducted for most health care services.
      • Neumann P.J.
      Why don't Americans use cost-effectiveness analysis?.
      However, without actually comparing the benefits of a service to its cost, any claim about the value of that service is speculative and may not be accurate.
      As an example of the challenge in determining value, consider screening healthy adults with complete blood cell counts (CBCs). Even though there is no strong evidence that screening CBCs are beneficial, they are frequently performed as part of general medical examinations.
      • Kale M.S.
      • Bishop T.F.
      • Federman A.D.
      • Keyhani S.
      “Top 5” lists top $5 billion.
      Despite the lack of evidence, screening CBCs do have potential benefits: an elevated white blood cell count could uncover a malignant condition, or a low hemoglobin level could lead to the diagnosis of a treatable cause of anemia. Screening CBCs also have potential harms: a falsely abnormal result could lead to unnecessary invasive testing. Although definitive studies weighing the benefits and harms of screening CBCs are lacking, it would be reasonable to say that they have small and uncertain benefit (although the confidence intervals would be wide, and it is possible that the harms actually outweigh the benefits). Cost-effectiveness analyses of screening CBCs have not been performed, however, and because CBC screenings are inexpensive, it is uncertain whether they are actually of low value in this context; their value hinges on downstream costs and the precise size of the potential benefit, however small. In other words, screening CBCs could plausibly provide minimal benefit and still be an acceptable value.

      Better Reasons Than Low Value to Discourage Services

      Beyond the challenge of determining whether tests and treatments are of low value, patients and physicians have been hesitant to consider societal costs in clinical decision making,
      • Sommers R.
      • Goold S.D.
      • McGlynn E.A.
      • Pearson S.D.
      • Danis M.
      Focus groups highlight that many patients object to clinicians' focusing on costs.
      • Tilburt J.C.
      • Wynia M.K.
      • Sheeler R.D.
      • et al.
      Views of US physicians about controlling health care costs.
      so from the perspective of individual patients and physicians making decisions about health care, simply being of low value may not seem like sufficient reason to voluntarily forgo potentially beneficial care. A common argument about low-value care is that finite societal resources make it impossible to provide all potentially beneficial interventions, so doing without some low-value care is an unfortunate reality. This argument implies that low-value care is still desirable, and if only resources were less constrained or delivery was more efficient, more low-value interventions could be provided. The message that low-value care still has value is a major challenge for the stewardship movement, which has been characterized by appeals for physicians and patients to forgo low-value interventions voluntarily.

      Minimal Benefit

      There can be good reasons for people to forgo health care that offers only minimal health benefit. Health is not the only thing people consider valuable in their lives. Potential health benefit can conflict with non–health-related considerations, such as personal finances, time, convenience, or other personal preferences. In many cases, seeking the maximum health benefit will not make people better off, all things considered. For example, consider the benefit of close monitoring of blood pressure in patients with hypertension. These patients might derive some marginal benefit from seeing their physician for follow-up every week instead of every 6 months, but any incremental benefit would likely be so small that it would not outweigh the hassle of more frequent visits.
      Although every medical intervention has potential adverse effects and not every incremental health benefit is worth the risks or opportunity cost, this bit of common sense often seems to be forgotten, on both the individual and societal levels. Sociologists have been writing about the downsides of “medicalization” for decades.
      • Zola I.K.
      Medicine as an institution of social control.
      • Conrad P.
      The Medicalization of Society: On the Transformation of Human Conditions Into Treatable Disorders.
      Medicalization is the process by which health care offers increasing ways to intervene in people's lives—often providing solutions to problems that were not previously even considered medical. Medicalization invariably means more health care—screening, diagnostics, monitoring, procedures, and medications—much of which has small benefit. Medicalization has been blamed in part for the “paradox of health”—the observation that even as objective health measures in society improve, people can become less satisfied with their health and more concerned about minor symptoms.
      • Barsky A.J.
      The paradox of health.
      This is not to say that health care with low benefit is never worth pursuing. Arguably, very few health interventions have a large net benefit. Those that are convenient and have high probability of benefit and low risk of iatrogenic harm are often worth pursuing even if the net benefit is small. Conversely, when the extra procedure, visit to the clinic, or additional daily pill imposes a burden on patients and their caregivers, those interventions should be questioned regardless of their cost, not blindly pursued in the name of better health.
      • May C.
      • Montori V.M.
      • Mair F.S.
      We need minimally disruptive medicine.

      Uncertain Benefit

      Many common medical practices have very little evidence to support their use, and a substantial number of Choosing Wisely recommendations are justified on these grounds.
      • Gliwa C.
      • Pearson S.D.
      Evidentiary rationales for the Choosing Wisely Top 5 lists.
      Medical research frequently finds that established practices are nonbeneficial or harmful.
      • Prasad V.
      • Gall V.
      • Cifu A.
      The frequency of medical reversal.
      Clearly, physicians do not help current patients when they use interventions with uncertain benefit that are later found to be nonbeneficial or harmful. Arguably, they also harm future patients by prematurely adopting practices of uncertain benefit. Once practices become widespread, it can be challenging to “de-adopt” them in the future, even in the face of new and convincing evidence.
      • Roman B.R.
      • Asch D.A.
      Faded promises: the challenge of deadopting low-value care.
      • Ubel P.A.
      • Asch D.A.
      Creating value in health by understanding and overcoming resistance to de-innovation.
      Widespread use of interventions can also make it more difficult to generate the definitive evidence for or against their use.
      As an example of the harm of prematurely adopting new medical practices, consider the prostate-specific antigen (PSA) test for prostate cancer screening. The PSA test became available in the 1980s, initially intended as a tumor marker to monitor patients with known prostate cancer.
      • Kramer B.S.
      • Brown M.L.
      • Prorok P.C.
      • Potosky A.L.
      • Gohagan J.K.
      Prostate cancer screening: what we know and what we need to know.
      • Barry M.J.
      Screening for prostate cancer—the controversy that refuses to die.
      It was soon realized that the PSA test could also identify localized prostate cancer that had not yet become clinically evident, so physicians started using it for screening purposes. By the time the first large screening trial funded by the National Institutes of Health started enrolling patients in 1993, PSA screening was already widespread.
      • Kramer B.S.
      • Brown M.L.
      • Prorok P.C.
      • Potosky A.L.
      • Gohagan J.K.
      Prostate cancer screening: what we know and what we need to know.
      When the initial results were published in 2009, high “contamination” (PSA screening done outside the trial by the control group) complicated the interpretation of the null results.
      • Andriole G.L.
      • Crawford E.D.
      • Grubb III, R.L.
      • et al.
      PLCO Project Team
      Mortality results from a randomized prostate-cancer screening trial.
      Now, prostate cancer screening with the PSA test is controversial, at least in part because of the persistent uncertainty regarding the true harms and benefits. Society has an important obligation to evaluate the effectiveness of new medical practices, but physicians should be aware that aggressively adopting unproven practices can hamper the ability to do so in some cases.

      A More Expansive View of Stewardship

      In some respects, labeling is a matter of semantics. Labels such as “minimally beneficial,” “unnecessary,” and “low-value” may be applicable for certain tests and treatments highlighted by those in the stewardship movement. However, caution should be taken in applying labels because of the messages that labels can send. There are numerous reasons to consider forgoing interventions with small, unproven, and likely insignificant benefit; labeling them as low value risks sending the message that, primarily, they are not worth it for financial reasons.
      Stewardship was inspired by cost containment, but that does not mean that low-value services are the only appropriate targets of stewardship or that cost containment needs to be the primary objective. The stewardship movement can be an opportunity to examine the role health care plays in people's lives. By understanding the impact that health care has on their patients, physicians can encourage less medicalization if they remind themselves and their patients that when medicine cannot provide meaningful benefit, it may be better to do nothing at all. Physicians can show restraint in adopting unproven interventions, which may have positive implications for current and future patients. Taking a more expansive view of stewardship can result in a less intrusive form of medicine that respects patients and improves their well-being. Saving money would almost certainly follow as a result, but it need not be the primary aim.

      Conclusion

      The low-value label is being applied to many health care services with small and uncertain benefits, but this label may not always be warranted. More importantly, the label risks conveying that cost containment is the primary reason for reducing their use when there may be more compelling reasons. Avoiding the low-value label and instead highlighting that many common health care services offer patients minimal and uncertain health benefits would be a better approach for the stewardship movement.

      Acknowledgments

      The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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