February 11, 2020 -- Payment policy changes are more effective for reducing unnecessary lab test utilization than optional clinical practice recommendations, researchers reported online on February 10 in JAMA Internal Medicine.
The cross-sectional study of claims data evaluated the effects of the American Board of Internal Medicine's Choosing Wisely recommendations, which have been adapted in more than 20 countries, and payment policy for two lab tests that have long been associated with overutilization and low value for broad, population-based screening: vitamin D and thyroid hormone triiodothyronine (T3) levels.
The researchers reviewed records for three health systems: Ontario, Canada; the U.S. Veterans Health Administration; and the U.S. employer-sponsored insurance market. Choosing Wisely recommendations advised against both tests for population-wide use, and a payment policy against broad vitamin D testing was implemented in Ontario at the end of 2010.
Records for a total of approximately 54 million people were reviewed across the health systems. After the 2010 payment policy was changed in Ontario to eliminate coverage for broad vitamin D testing, there was a 92.7% reduction in screening, James Henderson, PhD, from Consulting for Statistics, Computing & Analytics Research (CSCAR) at the University of Michigan, and colleagues wrote. In contrast, the publication of Choosing Wisely recommendations on vitamin D resulted in a decrease in testing of 4.5% in Ontario, 13.8% for the U.S. Veterans Health Administration, and 14% for U.S. employer-sponsored insurance.
Following the release of Choosing Wisely recommendations against the use of low-value triiodothyronine testing, rates increased overall by small levels: 0.3% in Ontario, 0.7% in the Veterans Health Administration, and 3% for U.S. employer-sponsored insurance.
"These findings suggest that recommendations alone may be insufficient to significantly reduce use of low-value services and that pairing recommendations with policy changes may be more effective," Henderson and colleagues concluded.
Do Choosing Wisely tools work?
Low-value tests are prevalent and costly in the U.S. and internationally, but research has been lacking on how and why low-value services change over time, including through best practice recommendations, the authors wrote. For the study, the researchers reviewed vitamin D testing records for approximately 50.8 million individuals and T3 testing for approximately 3.4 million people.
Screening for vitamin D deficiency has low value in people without high-risk conditions, notably renal disease. Meanwhile, T3 testing for patients with established hypothyroidism is not recommended -- rather, thyroid-stimulating hormone (TSH) tests should suffice, the authors noted.
"Given that Choosing Wisely is now an international campaign, there is need and opportunity to better understand how to improve the broad uptake of Choosing Wisely recommendations and to assess whether some countries and healthcare systems are more successful in this objective," Henderson and colleagues wrote.
Changes in payment policies affect utilization, but recommendations rely on an understanding of clinical status, and "payment policy change may be too prohibitive to ensure needed services can still be performed," the authors acknowledged. Diverse interventions, including payment incentives, may be appropriate to avoid the underuse of tests, they suggested.
Payment policy an 'underused lever'
"Payment policy is an underused lever to reducing low-value care," University of California, San Francisco (UCSF) cardiologists Dr. Sanket Dhruva and Dr. Rita Redberg wrote in an editorial about the study, also published February 10 in JAMA Internal Medicine.
But while payment policy has a lot of potential to reduce the use of tests with low value, it will take coverage to implement reimbursement changes, due to fears about lack of access to care, they suggested.
"However, noncoverage of low-value care is necessary to ensure thoughtful stewardship of limited healthcare resources and to ensure that patients do not receive nonevidence-based care for which the harms likely outweigh the benefits," Dhruva and Redberg wrote.