U.S. hospitals performed eight common, low-value procedures throughout the pandemic, continuing a trend of providing "unnecessary" care at rates similar to 2019 levels, according to an analysis published Tuesday by the Lown Institute. But the American Hospital Association (AHA) pushed back, taking issue with the report's methodology.

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Study details and key findings

For the study, researchers at the Lown Institute conducted an analysis of Medicare claims data from 2018 to 2020. During the first year of the pandemic, hospitals continued scheduling eight common, low-value procedures at a rate similar to pre-pandemic levels in 2019.

From March 2020 to December 2020, U.S. hospitals performed over 100,000 overused procedures on older patients. According to Modern Healthcare, these services, which are commonly believed to provide little to no clinical benefit to patients while presenting additional risks, include hysterectomies for benign disease, coronary stents for stable heart disease, and spinal fusions to treat lower-back pain.

In 2020, U.S. hospitals placed 45,176 coronary stents—the most overused procedure of those deemed unnecessary—and performed 30,094 back surgeries that fell into the overuse category. According to the study, roughly one in five coronary stents performed each year are unnecessary.

According to the report, the average rate of coronary stent overuse in the United States is 21%. However, some leading facilities, including the Cleveland Clinic, Houston Methodist Hospital, and Mt. Sinai Hospital, reported unnecessary stenting rates that were at least two times higher than the national average.

Notably, stenting procedures pose a variety of risks, including blood clots that can cause a stroke, heart attacks, heart artery injuries, catheter site infections, and allergic reactions or kidney damage from the dye and contrast used during the procedure.

Ultimately, Vikas Saini, president of the Lown Institute, argued that these types of procedures do not provide enough value to justify potential risks, especially among older patients who face the risk of getting infected with the coronavirus in hospitals.

Overall, the report found that hospitals in Oregon, Maine, and Vermont had the lowest rates of low-value procedures from 2018 to 2020, while Florida, Mississippi, and Alabama had the highest rates. Of the hospitals included in the report, Highland Hospital in Rochester, New York, had the lowest rate and Richardson Medical Center in Rayville, Louisiana, had the highest.

Commentary

According to Saini, volume declined for both necessary and unnecessary procedures in April and May 2020 because of pandemic-related shutdowns. However, as Covid-19 restrictions eased and coronavirus infections increased, the volume of low-value care also rose, almost reaching pre-pandemic rates.

The fact that hospitals cut unnecessary procedures at the start of the pandemic suggests they are able to differentiate between necessary and unnecessary care, Saini noted. "We have to understand how and why decisions were made during that period, and then begin to understand how to get rid of low-value care," he added.

Earlier this year, a Johns Hopkins University study published in JAMA found that health systems that own more physician groups are often associated with higher rates of unnecessary care. In addition, the study found that academic medical centers, facilities that employ larger numbers of primary care doctors, and those that use integrated delivery models typically performed fewer unnecessary services.

In a statement, AHA disputed Lown's rankings. Aaron Wesolowski, AHA's VP of policy research, analytics, and strategy, called the rankings "misleading" and specifically took issue with Lown's methodology, including its narrow focus on Medicare patients and the fact it only used claims data.

Wesolowski added that health care organizations and providers have been working on the front lines of unprecedented challenges during the pandemic.

"Throughout the pandemic, but especially in the early months, many nonessential services and procedures were put off due to government restrictions or voluntary actions from hospitals to make room for massive surges of COVID-19 patients," he said. "Studies have shown that these delays or sometimes even cancelations in nonemergent care have had some negative outcomes on the health and well-being of patients, who continue to show up at the hospital sicker and with more advanced illnesses. Many of these services may alleviate patients' pain or provide other help to patients. Lown may define these services as 'low value,' but they can be of tremendous value to the patients who receive them." (Devereaux, Modern Healthcare, 5/17; Gooch, Becker's Hospital Review, 5/17)