Hospitals criticized for ‘low-value’ procedures

THE LOWN INSTITUTE of Needham has long argued that hospitals perform way too many procedures it has identified as being low-value, meaning they offer little to no clinical benefit to patients and, in many cases, are more likely to harm them than help them.

Earlier this year, the institute looked at Medicare claims data and concluded that the COVID-19 pandemic failed to put a major dent in the use of low-value procedures. From June to December 2020, according to the institute, hospitals nationwide continued to deliver low-value services to Medicare patients at a pace comparable to the same time period in 2019 even though COVID vaccines were still on the horizon.

At the request of CommonWealth, the Lown Institute drilled down into its hospital database for Massachusetts.  The Massachusetts data indicate there were 1,721 low-value medical procedures performed in Massachusetts hospitals during the COVID time period June to December 2020 — 9 percent less than during the pre-COVID time period June to December 2019.   

Vikas Saini, the president of the Lown Institute and a physician, said the 9 percent drop means that for many hospitals it was business as usual.  “You couldn’t go into your local coffee shop [during the pandemic], but hospitals brought people in for all kinds of unnecessary procedures,” he said.  “The fact that a pandemic barely slowed things down shows just how deeply entrenched overuse is in America.”

Hospitals are critical of the Lown analysis, pointing out that it is nearly impossible to assess the validity of a diagnosis and treatment using only billing information. They say the key factor is a physician’s judgment based on the circumstances of each individual case.

The Lown Institute determines what constitutes low-value services based on an in-depth review of medical literature. For CommonWealth, it extracted overuse data for Massachusetts hospitals for coronary stenting, hysterectomy, and spinal fusion/laminectomy.  (The institute was required by the Centers for Medicare & Medicaid Services not to release data for patient counts fewer than 11.)

Coronary stenting involves cleaning out an artery clogged with plaque and then using a catheterto insert a tiny tube called a stent to prop the artery open so that oxygen-rich blood can flow to the heart. The stent is left in place.  With few exceptions, this procedure is unnecessary in the presence of stable heart disease (the absence of chest pain and shortness of breath, for example), according to the Lown Institute.  One study found that patients with moderate to severe, but stable, heart disease who were prescribed medication instead were no more at risk of a heart attack than those who had been stented.

The risks of coronary stenting include blood clots that can lead to a stroke or a heart attack, injury to the arteries of the heart, infection at the catheter site, allergic reaction to the dye or contrast used, and kidney damage from the dye or contrast.

Moreover, every 1,000 low-value coronary stenting procedures performed in hospitals is associated with nine hospital-acquired conditions or patient safety events.

At Massachusetts General Hospital in Boston, there was an increase in the number of low-value coronary stenting procedures performed between the pre-COVID (June 2019 to December 2019) and COVID (June 2020 to December 2020) time periods, going from 80 to 92, with 36 percent of the stents inserted during the COVID period being of low value.

UMass Memorial Medical Center went in the opposite direction, going from carrying out 43 low-value coronary stenting procedures during the pre-COVID time period to doing 22 during the COVID time period, with 13 percent of the stents put in during the COVID period being of low value.  Cape Cod Healthcare experienced a similar scenario.

A number of other Massachusetts hospitals stayed more or less at the same level.  These include Beth Israel Medical Center (61 pre-COVID/59 COVID), where 32 percent of the coronary stents inserted during the COVID time period were of low value; Brigham and Women’s Hospital (61/56), where 26 percent of the stents put in during the COVID period were of low value; and Baystate Medical Center (46/43), where 16 percent of the stents inserted during the COVID period were of low value.

“We’ve known for over a decade that we shouldn’t be putting so many stents into patients with stable heart disease, but we do it anyway,” said Saini of the Lown Institute.  “As a cardiologist, it’s frustrating to see this behavior continue at such high levels especially during the pandemic.”

A hysterectomy involves the surgical removal of the uterus.  This procedure is unnecessary in the presence of malignancy and carcinoma in situ (localized). It is improperly used, for example, when ovarian cancer is suspected even though there are far less invasive procedures that could be done instead, according to the Lown Institute.

Newton-Wellesley Hospital had a big increase in the number of low-value hysterectomies it performed between the pre-COVID and COVID time periods, going from 17 to 33, with 80 percent of the hysterectomies being carried out during the COVID period being of low value.

Massachusetts General Hospital went from performing 30 low-value hysterectomies during the pre-COVID time period to carrying out 43 during the COVID time period, with 38 percent of the hysterectomies done during the COVID period being of low value.

Going in the opposite direction, Brigham and Women’s Hospital went from performing 36 low-value hysterectomies during the pre-COVID time period to carrying out 30 during the COVID time period, with 30 percent of the hysterectomies done during the COVID period being of low-value.

Spinal fusion/laminectomy is a surgery to treat back pain.  With spinal fusion, two or more vertebrae are fused together using metal plates, rods, or screws to eliminate the motion between the vertebrae that causes the pain.  With laminectomy, a part of a spinal vertebra is removed.  Both procedures are unnecessary in the presence of low-back pain, with some exceptions, according to the Lown Institute.

Baystate Medical Center had a big increase in the number of low-value back surgeries performed between the pre-COVID and COVID time periods, going from 39 to 55, with 45 percent of the back surgeries being carried outduring the COVID period being of low value.

Mass General also had an increase, going from performing 43 low-value back surgeries during the pre-COVID time period to 53 during the COVID time period, with 21 percent of the back surgeries being carried out during the COVID period being of low value.

The American Hospital Association was critical of Lown’s national study.  “The need for a clinical procedure is based on many factors, chief among them a physician’s judgment, informed by her or his evaluation of the totality of a patient’s medical needs, history and circumstances,” the association said in a press release. “Patient preferences regarding the risks and benefits of a procedure are also important factors when making decisions about care.  Billing data alone simply do not fully reflect all of those complex factors.”

Mass General and Brigham and Women’s issued a joint statement critical of Lown’s analysis. “A comparison of care between these two time periods is always difficult due to the variable circumstances presented to hospitals across the country,” the statement said. “Additionally, the methodology of the data neither reflects the complexities of the procedures nor the difficult details of the patient cases involved.”

A spokeswoman for Baystate was also critical of the analysis.  “After review from our neuroscience medical experts, it is our belief that the information you provided us is not a legitimate analysis of overuse of medical procedures,” she said.

A spokeswoman for Beth Israel said the hospital was often dealing with emergency situations — something the “methodology does not quite capture.”

A spokeswoman for Newton-Wellesley declined comment on the Lown analysis.

Asked why physicians overuse low-value procedures, Saini of the Lown Institute said the answer is complex.  “I don’t think most physicians consciously or deliberately decide, ‘Today I’m going to put in a bunch of unnecessary stents or do some unnecessary surgeries,’ ” he said. “That’s not really how it works.  They’ve convinced themselves they’re going to help somebody.  Maybe they’ve trained where this is done. There are a lot of expectations from patients on doctors that everything is fixable and death is optional.”

Judith Garber, a senior policy analyst at the Lown Institute, said the use of low-value medical procedures is driven by cultural and financial factors.

“We need not only payment reform and movement toward value-based payments, but also a shift in our ‘more is better’ mindset, which is arguably the harder task,” she said.