Abstract
Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration. To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition. This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020. Continuous enrollment in Veterans Health Administration during fiscal year 2015. Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level. Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001). In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.
Highlights
At the Veterans Affairs Medical Center (VAMC) level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001)
The delivery of multiple specific low-value health services has been described among Medicare and private insurance beneficiaries, the use of such services in the Veterans Health Administration (VHA) has not been well characterized.[5,7,8,9,10,11,12]
The VHA electronic medical record contains information on veterans’ care across all Veterans Affairs Medical Centers (VAMCs) and decision support tools for ordering appropriate health services, which may be associated with a decreased likelihood of VA clinicians delivering low-value care.[14,15]
Summary
Wasteful health care spending accounts for up to $935 billion, or 25% of total health care expenditures in the US.[1,2] Over $100 billion has been spent on low-value care, defined as the use of health services for which immediate or downstream harms or costs exceed the potential benefits.[1,2] Examples include cancer screening for patients with a limited life span or performing preoperative electrocardiography for patients undergoing low-risk cataract surgery.[3,4] Up to 43% of Medicare beneficiaries have received low-value care, which may be associated with physical and psychological harm and an erosion of their trust in the health care system.[5,6] the delivery of multiple specific low-value health services has been described among Medicare and private insurance beneficiaries, the use of such services in the Veterans Health Administration (VHA) has not been well characterized.[5,7,8,9,10,11,12] As the largest integrated and federally operated health care system in the US, the practice environment at the VHA differs considerably from other systems, potentially impacting the provision of low-value care.[13]. Wasteful health care spending accounts for up to $935 billion, or 25% of total health care expenditures in the US.[1,2] Over $100 billion has been spent on low-value care, defined as the use of health services for which immediate or downstream harms or costs exceed the potential benefits.[1,2] Examples include cancer screening for patients with a limited life span or performing preoperative electrocardiography for patients undergoing low-risk cataract surgery.[3,4] Up to 43% of Medicare beneficiaries have received low-value care, which may be associated with physical and psychological harm and an erosion of their trust in the health care system.[5,6]. The VHA electronic medical record contains information on veterans’ care across all Veterans Affairs Medical Centers (VAMCs) and decision support tools for ordering appropriate health services, which may be associated with a decreased likelihood of VA clinicians delivering low-value care.[14,15] several studies focused on the use of individual low-value health services (eg, prostate cancer screening and colonoscopy) have demonstrated that the delivery of low-value care still occurs at VAMCs.[3,16,17,18,19,20,21,22]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
