Abstract
Metrics that detect low-value care in common forms of health care data, such as administrative claims or electronic health records, primarily focus on tests and procedures but not on medications, representing a major gap in the ability to systematically measure low-value prescribing. To develop a scalable and broadly applicable metric that contains a set of quality indicators (EVOLV-Rx) for use in health care data to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders' perspectives. This qualitative study used an online modified-Delphi method to convene an expert panel of 15 physicians and pharmacists. This panel, comprising clinicians, health system leaders, and researchers, was tasked with rating and discussing candidate low-value prescribing practices that were derived from medication safety criteria; peer-reviewed literature; and qualitative studies of patient, caregiver, and physician perspectives. The RAND ExpertLens online platform was used to conduct the activities of the panel. The panelists were engaged for 3 rounds between January 1 and March 31, 2021. Panelists used a 9-point Likert scale to rate and then discuss the scientific validity and clinical usefulness of the criteria to detect low-value prescribing practices. Candidate low-value prescribing practices were rated as follows: 1 to 3, indicating low validity or usefulness; 3.5 to 6, uncertain validity or usefulness; and 6.5 to 9, high validity or usefulness. Agreement among panelists and the degree of scientific validity and clinical usefulness were assessed using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method. Of the 527 low-value prescribing recommendations identified, 27 discrete candidate low-value prescribing practices were considered for inclusion in EVOLV-Rx. After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥6.5). After round 2 panel deliberations, the criteria to detect 19 candidate practices were revised. After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for both scientific validity and clinical usefulness. Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥6.5) but uncertain clinical usefulness (scores <6.5) ratings, whereas 6 received uncertain scientific validity rating (scores <6.5). This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults. Applying EVOLV-Rx may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care across the full spectrum of health services.
Highlights
Low-value care, which is defined as the use of health services whose harms or costs exceed their benefits, is a major factor in wasteful health care spending and has been associated with physical, psychological, and financial harms.[1,2] In the US, more than $100 billion per year has been spent on the delivery of low-value care, affecting up to 43% of Medicare beneficiaries.[1,3] low-value care metrics primarily consist of tests and procedures and exclude the low-value prescribing of medications
This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults
We aimed to develop a scalable and broadly applicable metric that contains a set of quality indicators to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders’ perspectives
Summary
Low-value care, which is defined as the use of health services whose harms or costs exceed their benefits, is a major factor in wasteful health care spending and has been associated with physical, psychological, and financial harms.[1,2] In the US, more than $100 billion per year has been spent on the delivery of low-value care, affecting up to 43% of Medicare beneficiaries.[1,3] low-value care metrics primarily consist of tests and procedures and exclude the low-value prescribing of medications. Low-value care, which is defined as the use of health services whose harms or costs exceed their benefits, is a major factor in wasteful health care spending and has been associated with physical, psychological, and financial harms.[1,2]. In the US, more than $100 billion per year has been spent on the delivery of low-value care, affecting up to 43% of Medicare beneficiaries.[1,3]. Low-value care metrics primarily consist of tests and procedures and exclude the low-value prescribing of medications. This exclusion represents a major gap in the ability to systematically detect low-value prescribing and low-value care across the full spectrum of health services.[3,4]. Characterizing and reducing low-value prescribing are especially important for individuals who are 65 years or older. More than 40% of older adults have been subjected to polypharmacy (prescribed Ն5 medications), and 30% to 50% have been prescribed a potentially inappropriate medication, increasing their risk for adverse drug events and hospitalizations.[5,6] In addition, 35% of Medicare Part D beneficiaries have experienced hardship in paying for their medications.[6,7]
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