CHOOSING EVEN MORE WISELY: HEALTH SERVICES THAT IMPROVE HEALTH BUT WOULD STILL BE CONSIDERED LOW-VALUE PER COST-EFFECTIVENESS ANALYSIS

Purpose: Most actors in U.S. health policy would agree that low-value care should be avoided, but value is not consistently defined. Physician groups, such as those included in the Choosing Wisely Campaign, and other researchers have created lists of services that should be avoided in value-based frameworks, but these lists have typically focused on services that both increase costs and do not show significant clinical benefit. We sought to identify low-value services that improve health but are not worth their additional costs based on cost-effectiveness evidence.

Methods: We search the Tufts Cost-Effectiveness Analysis Registry (CEAR) online database for published cost-effectiveness studies with incremental cost-effectiveness ratios (ICERs) >$100,000/quality-adjusted life year (QALY). Our search terms included highly prevalent disease areas and widely-used and/or expensive procedures (Footnote). We included cost-utility studies for the U.S. setting published between 2000-2014 and recorded the ICER, prevention stage, intervention type, disease classification, and quality score (ranging from 1 [worst] to 7 [best]) from the CEAR.

Results: We found 102 published cost-effectiveness studies for healthcare services the U.S. with ICERs >$100,000/QALY, of which 67 had ICERs greater than $150,000/QALY and 39 greater than $250,000/QALY. ICERs ranged from $110,000-$5,400,000/QALY (median of $210,000/QALY). Study quality scores ranged from 3-6 (median of 5.0). About half of the ICERs were for preventive services (19% primary prevention, 34% secondary prevention). The most common intervention types among these services were screening (30%), pharmaceutical (25%), and diagnostic (24%); the most common disease classifications were cancers (30%), cardiovascular diseases (18%), and infectious diseases (9%). Among the 45 low-value services on the initial Choosing Wisely Campaign list, only 5 were also on our list. 

Conclusions: Reducing low-value care will require not only moving away from healthcare services that harm health (or have no significant impact on health) but also those that improve health but at a cost that is unfavorable per conventional cost-effectiveness standards. Our list aids this process by using ICERs as a systematic metric for defining value, leveraging publicly available and comprehensive cost-utility data from CEAR, and focusing on a previously unaddressed set of services (health-improving but cost-ineffective). Even with our limited search and not having access to the complete CEAR database, we found 97 potentially low-value services per cost-effectiveness standards not included in the initial Choosing Wisely Campaign list.