Lan Tianjiao, Chen Lingwei, Hu Yifan, Wang Jianjian, Tan Kun, Pan Jay
HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China.
Lancet Reg Health West Pac. 2023 Aug 31;38:100887. doi: 10.1016/j.lanwpc.2023.100887. eCollection 2023 Sep.
Plenty of efforts have been made to reduce the use of low-value care (the care that is not expected to provide net benefits for patients) across the world, but measures of low-value care have not been developed in China. This study aims to develop hospital discharge records-based measures of low-value surgical procedures, evaluate their annual use and associated expenditure, and analyze the practice patterns by characterizing its temporal trends and correlations across rates of different low-value procedures within hospitals.
Informed by evidence-based lists including Choosing Wisely, we developed 11 measures of low-value surgical procedures. We evaluated the count and proportion of low-value episodes, as well as the proportion of expenditure and medical insurance payouts for these episodes, using hospital discharge records in Sichuan Province, China during a period of 2016-2022. We compared the count and expenditure detected by different versions of these measures, which varied in sensitivity and specificity. We characterized the temporal trends in the rate of low-value surgical procedures and estimated the annual percent change using joint-point regression. Additionally, we calculated the Spearman correlation coefficients between the risk-standardized rates of low-value procedures which were estimated by multilevel models adjusting for case mix across hospitals.
Low-value episodes detected by more specific versions of measures accounted for 3.25% (range, 0.11%-71.66%), and constituted 6.03% (range, 0.32%-84.63%) and 5.90% (range, 0.33%-82.86%) of overall expenditure and medical insurance payouts, respectively. The three figures accounted for 5.90%, 8.41%, and 8.38% in terms of more sensitive versions of measures. Almost half of the low-value procedures (five out of eleven) experienced an increase in rates during the period of 2016-2022, with four of them increasing over 20% per year. There was no significant correlation across risk-standardized rates of different low-value procedures within hospitals (mean for pairwise, 0.03; CI, -0.02, 0.07).
Despite overall low-value practices detected by the 11 developed measures was modest, certain clinical specialties were plagued by widespread low-value practices which imposed heavy economic burdens for the healthcare system. Given the pervasive and significant upward trends in rates of low-value practices, it has become increasingly urgent to reduce such practices. Interventions in reducing low-value practices in China would be procedure-specific as practice patterns of low-value care varied by procedures and common drivers of low-value practices may not exist.
The National Science Foundation of China (72074163), Taikang Yicai Public Health and Epidemic Control Fund, Sichuan Science and Technology Program (2022YFS0052 and 2021YFQ0060), and Sichuan University (2018hhf-27 and SKSYL201811).
全球已做出诸多努力以减少低价值医疗服务（即预计不会为患者带来净收益的医疗服务）的使用，但中国尚未制定低价值医疗服务的衡量标准。本研究旨在制定基于医院出院记录的低价值外科手术衡量标准，评估其年度使用情况及相关支出，并通过描述其时间趋势以及医院内不同低价值手术发生率之间的相关性来分析实践模式。
参考包括“明智选择”在内的循证清单，我们制定了11项低价值外科手术衡量标准。我们利用中国四川省2016 - 2022年期间的医院出院记录，评估了低价值医疗事件的数量和比例，以及这些事件的支出和医疗保险赔付比例。我们比较了不同版本衡量标准所检测到的数量和支出，这些版本在敏感性和特异性方面存在差异。我们描述了低价值外科手术发生率的时间趋势，并使用联合点回归估计年度百分比变化。此外，我们计算了通过调整医院病例组合的多水平模型估计的低价值手术风险标准化发生率之间的斯皮尔曼相关系数。
更具特异性版本衡量标准检测到的低价值医疗事件占3.25%（范围为0.11% - 71.66%），分别占总支出的6.03%（范围为0.32% - 84.63%）和医疗保险赔付的5.90%（范围为0.33% - 82.86%）。就更具敏感性版本的衡量标准而言，这三个数字分别为5.90%、8.41%和8.38%。在2016 - 2022年期间，几乎一半的低价值手术（11项中的5项）发生率有所上升，其中4项每年增长超过20%。医院内不同低价值手术的风险标准化发生率之间无显著相关性（成对均值为0.03；置信区间为 - 0.02，0.07）。
尽管所制定的11项衡量标准检测到的总体低价值医疗实践程度适中，但某些临床专科仍受广泛存在的低价值医疗实践困扰，这给医疗系统带来了沉重的经济负担。鉴于低价值医疗实践发生率普遍且显著上升，减少此类实践变得愈发紧迫。鉴于低价值医疗服务的实践模式因手术而异且可能不存在低价值医疗实践的共同驱动因素，中国减少低价值医疗实践的干预措施应针对具体手术。
中国国家自然科学基金（72074163）、泰康医财公共卫生与疫情防控基金、四川省科技计划（2022YFS0052和2021YFQ0060）以及四川大学（2018hhf - 27和SKSYL201811）。
