Low-value health care provides little benefit relative to its cost. Australian policy makers, health care payers and providers want to reduce its use due to unnecessary costs and harms. These decisions, however, need to be informed by the measurement of low-value care in the context of Australia’s mixed public-private health care system. This thesis investigated low-value procedures using routinely collected data and direct measures.
Direct measures use patient- or episode-level clinical information to distinguish low-value from appropriate care. Based on our review of the literature, we introduced a framework to classify direct measures as providing either a service-centric or a patient-centric result.
The Choosing Wisely campaign publishes clinician-endorsed ‘do-not-do’ recommendations, and provides a source of potential direct measures. We screened 824 recommendations, and found only a small proportion measurable in a hospital-claims data set. We used these and other recommendations to develop 21 measures applicable to private health insurance claims from 376,354 patients (approximately 7% of the Australian privately insured population). There were 14,662 patients with at least one of the 21 procedures in 2014 (the service-centric result, according to our framework). Of these patients, 20.8 to 32.0% had a low-value procedure according to a narrow (more specific) and broad (more sensitive) set of measures. We extended this investigation to all payer types using the New South Wales (NSW) Admitted Patient Data Collection, and generally found higher proportions and volumes of low-value procedures in the private sector. In 2014-15, 40.3% of all low-value procedures in NSW state were for privately insured patients in private hospitals (relative to 35.6% of all procedures).
Despite the limited scope of health care captured by these measures, the work in this thesis has already led to several policy-focussed projects informing governments and payers on low-value care.