VIDEO: Our May 17, 2022 launch event featured Lown overuse experts Vikas Saini, MD, president; Shannon Brownlee, MSc, special advisor to the president; and Kelsey Chalmers, PhD.
The Lown Institute is the first to measure rates of hospital overuse during the COVID-19 pandemic. Overuse, or low-value care, refers to medical services that offer little to no clinical benefit or are more likely to harm patients than help them.
Eight low-value procedures were examined, including hysterectomy for benign disease, coronary stents for stable heart disease, and spinal fusion for low-back pain. The eight procedures were chosen based on validation in previous overuse studies. (press release | methodology)
The Lown Hospitals Index for Social Responsibility is also releasing 2022 rankings of the top and bottom 50 hospitals on Avoiding Overuse. For these rankings, eight procedures and four imaging services are considered, and Medicare claims data from 2018-2020 is used.
Hospitals delivered more than 100,000 low-value procedures in the first ten months of Covid-19. Below is the breakdown of low-value services by procedure.
Hospitals performed more than 45,000 coronary stents from March-December 2020 that met criteria for overuse. Coronary stenting, in which a wire mesh stent is used to open a blocked artery, has shown to be no more beneficial than medication therapy alone for patients with stable coronary disease.
What’s at stake?
Risks of stenting include blood clots that can lead to stroke or heart attack, injury to the heart arteries, infection at the catheter site, allergic reaction to the dye or contrast used, and kidney damage from the dye or contrast. Additionally, every 1000 low-value coronary stents performed in hospitals is associated with 9 hospital-acquired conditions or patient safety events (not counting the risk of contracting COVID-19). Our health system would also save an estimated $500 million if we didn’t put coronary stents into people without symptoms.
Which hospitals placed the most low-value stents in 2020?
Among general hospitals (not specialty hospitals) the worst offenders for unnecessary stenting were NYU Langone Medical Center, St Francis Hospital, and Mt. Sinai Hospital in the New York City area, and Scripps Memorial Hospital and Cedars-Sinai Medical Center in Southern California. For each of these hospitals, low-value stents made up at least one third of all of the stents placed in 2020.
Table: These 19 hospitals performed at least 200 low-value coronary stents in 2020. All of these hospitals had a rate of overuse over 30%.
All 20 hospitals on the U.S. News Honor Roll had rates of coronary stent overuse above the national average in 2020. Four hospitals (Cleveland Clinic, Houston Methodist Hospital, Mount Sinai Hospital, and Barnes Jewish Hospital) had overuse rates at least double the national average.
These are the top 50 hospitals for avoiding overuse on the 2022 Lown Hospitals Index for Social Responsibility. This ranking includes overuse of eight common low-value procedures and four low-value tests. Data for these rankings comes from 2018-2020 Medicare claims.
These are the 50 lowest ranked hospitals for Avoiding Overuse on the 2022 Lown Hospitals Index for Social Responsibility. This ranking includes overuse of eight common low-value procedures and four low-value tests. Data for these rankings comes from 2018-2020 Medicare claims.
U.S. states ranked by average performance on Avoiding Overuse on the 2022 Lown Hospitals Index for Social Responsibility. This ranking includes overuse of eight common low-value procedures and four low-value tests. Data for these rankings comes from 2018-2020 Medicare claims.
The Lown Institute used data from the 100% Medicare claims database from January – December 2020 to evaluate overuse of eight common low-value services. Procedures and overuse criteria were based on our previously published research into measurement of low-value care at hospitals. Procedures included were:
Arthroscopic knee surgery – Surgery to remove damaged cartilage or bone in the knee using an arthroscope (tiny camera). Defined as overuse for patients with osteoarthritis or “runner’s knee” (damaged cartilage). Excluding patients with meniscal tear.
Carotid endarterectomy – Procedure to remove plaque buildup from a carotid (neck) artery in a patient to prevent stroke. Considered overuse when performed on female patients without stroke symptoms or history of stroke.
Coronary artery stenting – Procedure to place a stent or balloon in a coronary artery. Defined as overuse when performed on patients with stable heart disease (not having a heart attack or unstable angina). Excluding patients with past diagnosis of unstable angina or heart attack within the past two weeks, or any procedures performed in the emergency department.
Hysterectomy – Procedure to remove the uterus. Considered overuse for patients without a diagnosis of cancer or carcinoma in situ.
Inferior Vena Cava (IVC) filter – Procedure to place a filter (a medical device) in the large vein in the abdomen to prevent blood clots from moving to the lungs. Considered overuse for all patients except those with history of multiple pulmonary embolism.
Renal artery stenting – Procedure to place a stent or balloon in the renal (kidney) artery. Considered overuse for patients with high blood pressure or plaque buildup in the artery. Excluding patients that had diagnosis of fibromuscular dysplasia of the renal artery (abnormal twisting of the blood vessels).
Spinal fusion/laminectomy – Procedure to fuse vertebrae together (spinal fusion) or remove part of a vertebra (laminectomy). Defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discities, spondylosis, myelopathy, radiculopathy, radicular pain or scoliosis.
Vertebroplasty – Procedure to inject cement into the vertebrae to relieve pain from spinal fractures. Considered overuse for patients with spinal fractures caused by osteoporosis. Excluding patients with bone cancer, myeloma, or hemangioma.
In addition to the analysis of hospital overuse in Covid-19 above, the Lown Institute also ranked the top and bottom 50 hospitals on their avoidance of low-value tests and procedures. This ranking includes the eight procedures above, plus and four imaging services. These rankings use data from 2018-2020 Medicare claims.
Only hospitals with the capacity to do four or more services were ranked. Hospitals’ overuse score for each service is based on the rate of overuse as well as the volume of overuse. The overuse composite ranking is based on all services, with more weight placed on the services that make up the larger share of overuse.
Carotid artery imaging for fainting – A test to screen for carotid (neck) artery disease. Considered overuse for patients where syncope (fainting) is the primary diagnosis, and there is no history of syncope in the past two years. Excluding patients with stroke or mini-stroke, retinal vascular occlusion/ischemia, or nervous and musculoskeletal symptoms.
EEG for fainting – A test of the electrical activity of the brain. Considered overuse for patients where syncope (fainting) is the primary diagnosis, and there is no history of syncope in the past two years.
EEG for headache – A test of the electrical activity of the brain. Defined as overuse for patients with headache as the primary diagnosis on the claim and no history of headache in the past two years. Excluding patients with epilepsy and recurrent seizures, convulsions, and abnormal involuntary movements.
Head imaging for fainting – Considered overuse for patients where syncope (fainting) is the primary diagnosis, and there is no history of syncope in the past two years. Excluding patients with epilepsy or convulsions, cerebrovascular diseases, head or face trauma, altered mental status, nervous and musculoskeletal system symptoms, and history of stroke.
Media inquiries should be directed to Aaron Toleos, vice president of communications for the Lown Institute, at firstname.lastname@example.org.