Harm and a Foul for Low-Value Care

No harm, no foul.

It’s an expression I’ve used countless times to shrug off a mistake by me or by someone else that didn’t result in any real damage. Like dropping a Christmas ornament that didn’t break when it hit the ground.

I also think that the healthcare industry uses it quietly to itself to shrug off unnecessary diagnostic tests or medical interventions that may not have helped a patient but certainly didn’t hurt them either. Let’s do a chest X-ray just to be sure. Let’s prescribe you this antibiotic just in case.  No harm, no foul. 

But a new study in JAMA Internal Medicine suggests that healthcare providers who adopt that attitude toward low-value care actually risk harming patients. Harm, foul.  You can download the study here. 

Researchers from the Harvard Medical School, Brigham and Women’s Hospital, the Harvard School of Public Health, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College conducted an exhaustive  review of all the low-value care dos and don’ts now available through the Choosing Wisely campaign in the U.S. The campaign, which started in 2012, educates and encourages providers to avoid care that offers little or no diagnostic or therapeutic value to patients.

Education and encouragement come in the form of clinical recommendations from medical specialty societies. The number of clinical recommendations from the medical specialty societies has grown to 626 this year compared with 45 when the campaign first started nine years ago. 

The researchers then sliced and diced the recommendations by a number of different categories and domains. For example:

• Imaging tests were No. 1 in the service category, which represented about 27 percent of the recommendations
• Treatment was No. 1 in the clinical indication category, which represented about 39 percent of the recommendations
• Chronic conditions were No. 1 in the clinical context category, which represented about 27 percent of the recommendations

But the most interesting thing to me was the “direct harm potential” category. About 45 percent of the Choosing Wisely recommendations, according to the researchers, addressed low-value care that has a “high” potential to directly harm patients. The researchers said about 55 percent of the low-value care targeted by the recommendations represented a “low” potential to directly harm patients.

“Low-value services can harm patients and the health care system through direct effects on physical, psychological, and social health,” the researchers said.    

In-other-words, nearly half of the Choosing Wisely guidelines tell providers to do something or not do something because doing it or not doing it has a pretty good chance of injuring or killing a patient. 

Here’s one example of something not to do because it carries a high potential to cause patient harm, according to a supplemental spreadsheet that the researchers published along with their study:   

• “Don’t treat uncomplicated, nonmelanoma skin cancer less than 1 centimeter in size on the trunk and extremities with Mohs micrographic surgery.”

I don’t know exactly what that is, but there are 279 more recommendations like it on the spreadsheet.

Now, if it’s on a spreadsheet in a publicly available study in a peer-reviewed medical journal, shouldn’t it also be embedded in clinical decision support software that’s integrated with an EHR system? Or at least hanging on the wall of the physicians’ lounge or quality department at a hospital or outpatient-care site?  

We know what to do—or not do.  We just need to start—or stop—doing it.

To learn more on this topic and which hospitals aren’t following the recommendations, please read “Transparency Comes to Low-Value Care Providers” on 4sighthealth.com.

Thanks for reading.