Hospitals in South Fare Worst in Avoiding Low-Value Tests, Analysis Finds

More than 1 million tests and procedures that Medicare patients received in hospitals over a three-year period were likely not needed, according to an analysis released today.

The Lown Institute, named for Bernard Lown, MD, a Nobel Laureate who died earlier this year at age 99, released its annual ranking of hospitals that measures how well they do in avoiding low-value care, based on established criteria for overuse.

Most of the top performing hospitals in the Lown Institute Hospital Index are not from large, well-known health systems that appear on the annual rankings of U.S. News and World Report—in fact, only Cleveland Clinic, which ranked 58th on the Lown list, is on the U.S. News honor roll, according to the a statement on findings.

But there were some patterns: of the 50 top performers, nine are in the Northeast and 10 were in the Pacific Northwest. By contrast, the South is home to highest number of poor performers—41 out of 50—and five of the 10 worst performers are found in Florida. The Lown Institute noted that 47% of Florida’s hospitals are for-profit enterprises.

The 2021 Lown Institute Hospital Index measured overuse at 3,100 hospitals from 2016-2018, using data from 100% of Medicare claims between January 1, 2016, and December 31, 2018. The analysis focuses on 12 low-value services, including four tests and eight procedures, with the index giving added weight to services that account for higher shares of overuse.

According to the Center for Value-based Insurance Design at the University of Michigan, low-value care includes services “that provide little or no benefit to patients, have potential to cause harm, incur necessary costs to patients, and waste limited healthcare resources.” The Center estimates that low-value care costs the country more than $345 billion a year, and notes that there have been several initiatives to squeeze low-value care from the system.

“Overuse in American hospitals is a pervasive problem that needs to be addressed,” said Vikas Saini, MD, president of the Lown Institute. “Hospitals want to do better and these objective measures of performance can help them move forward.”

Services measured in the Lown Index are: arthroscopic knee surgery when patients have not had a meniscal tear; carotid artery imaging for fainting; carotid endarterectomy, which maps plaque buildup, if done on female patients who have no stroke symptoms or history; coronary artery stenting, when performed on patients with stable heart disease; electroencephalography (EEG) for fainting; EEG for headache if patients have not had epilepsy or seizures; head imaging for fainting if other symptoms are not present; hysterectomy, if no cancer is present; and inferior vena cava filter if patients have not had pulmonary embolism; renal artery stenting for patients without a diagnosis of fibromuscular dysplasia of the renal artery; spinal fusion/laminectomy if done only for lower back pain; and vertebroplasty, absent the presence of cancer.

The top 10 high-performing hospitals are as follows:

1. Scott County Hospital in Scott City, Kansas
2. Beth Israel Deaconess Medical Center in Boston, Massachusetts
3. West River Regional Medical Center in Hettinger, North Dakota
4. Highland Hospital in Rochester, New York
5. Mayo Clinic Health System in Lake City, Minnesota
6. Maine Medical Center in Portland, Maine
7. Sidney Regional Medical Center in Sidney, Nebraska
8. Mary Hitchcock Memorial Hospital in Lebanon, New Hampshire
9. Healdsburg District Hospital in Healdsburg, California
10. Contra Costa Regional Medical Center in Martinez, California

CMS has tried to target low-value care in recent years through the use of alternative payment models (APMs), and efforts to eliminate wasteful hip- and knee replacements have been deemed largely successful. Other hospital safety organizations have zeroed in on unnecessary hysterectomies, which the 2021 Lown analysis found were unnecessary in 64% of the cases. In North Dakota and Wyoming, hysterectomy overuse was 90% and 94%, respectively.

The analysis also ranked states based on the overall record of its hospitals and found that Vermont did the best job of avoiding unnecessary procedures, while Alabama fared the worst.