This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Low value surgery comes with risks and costs that outweigh benefits. Reducing or stopping this surgery could save the NHS time and money, and save people from undergoing surgical procedures that may not benefit them. NHS initiatives exist to identify low value procedures; researchers have developed an alternative method to shortlist potentially low value procedures quickly, easily, and regularly. Decision-makers can then review these procedures.
The team analysed hospital records to identify surgical procedures that varied from region to region, or had seen a rapid increase in the numbers carried out. They found that many did not have strong evidence of cost-effectiveness to support them.
The issue: low value care wastes NHS time and money
Low value procedures are not effective or cost-effective for some or all of those treated. The NHS Evidence Based Interventions programme draws on NICE guidelines, international recommendations, regional variation in care, and other resources to identify these procedures. This is a thorough process that takes time.
Researchers developed a simpler method. They predicted that high regional variation could indicate uncertainty about a procedure’s effectiveness. A rapid increase in the number of procedures carried out suggests that evidence of its effectiveness might need to be checked before the procedure becomes established.
In this study, the researchers tested their method of identifying potentially low value care. They also explored what research supported the value for money offered by those procedures.
What’s new?
The researchers examined hospital records in England from 2014 to 2019. They identified the 5% of surgical procedures that showed the greatest variation or growth over a 5-year period, adjusted for the local population’s age, sex, ethnicity and level of deprivation. They then reviewed evidence (including NICE guidance, systematic reviews, economic studies) of the procedures’ effectiveness and value for money.
They found 10 procedures with high regional variation or high growth. For 8 of them, there was little or no evidence of cost-effectiveness. They were:
- hip replacements (with cemented pelvic or femur component, but not both)
- shoulder replacements (without cement)
- joint surgery for traumatic dislocations and fractures
- removal of bone or tissue pressing on nerves in the neck
- nerve destruction with radio waves to alleviate pain in the spine
- deep brain electrical stimulation for involuntary muscle spasms
- prostate removal for prostate cancer.
Of these, hip replacements and prostate removal had evidence of effectiveness but no clear evidence of being cost-effective compared to alternative therapies.
Another 2 procedures, weight loss surgery and a type of total knee replacement (uncemented), varied across regions but were cost-effective compared to non-surgical approaches.
Why is this important?
Methods used in this study could provide a quick and relatively effective way of helping NHS commissioners to identify procedures that may have low value, the researchers say. These procedures may need to be investigated in further research, stopped, reduced or reserved for groups of the population most likely to benefit.
The cost-effectiveness of the 8 procedures identified needs to be investigated more thoroughly. The researchers note that clinical trials of some are ongoing, for example, the RADICAL trial of nerve destruction with radio waves to alleviate pain in the spine.
A reduction in low value care could save the NHS time and money, while protecting patients from undergoing procedures that are unlikely to help them. Regular reviews of procedures, using these and other methods, could help to identify those that may have low value and optimise services, the researchers say.
What’s next?
This research is part of a wider move within the NHS to ensure that treatment and care is based on sound evidence. It overlaps with NHS England’s Getting it Right First Time initiative, which uses in-depth reviews and benchmarking to encourage NHS Trusts to share best practice. Reducing unnecessary care is part of this.
Alongside the current study, these researchers are evaluating the success of the NHS’s Evidence Based Interventions programme in reducing procedures identified as low value. In future, they hope their methods will be widely taken up and accelerate the process of identifying and reducing low value care.
NHS England, the Academy of Royal Medical Colleges and local commissioners can use this methodology to identify procedures for which guidance on appropriate use is most needed, the team says. Research funders can use this methodology to identify topics for which better evidence is required to ensure fairer access to cost-effective care across the NHS.
You may be interested to read
This is a summary of: Jones T, and others. Identifying potentially low value surgical care: A national ecological study in England. Journal of Health Services Research & Policy 2024; 29: 223 – 229.
An NIHR article about the study.
An article about low value care: Mafi JN and Parchman M. Low-value care: an intractable global problem with no quick fix. BMJ Quality and Safety 2024; 27: 333 – 336.
First paper from the researchers' assessment of the Evidence Based Interventions programme: Glynn J, and others. Did the evidence-based intervention (EBI) programme reduce inappropriate procedures, lessen unwarranted variation or lead to spill-over effects in the National Health Service? PLoS ONE 2023; 18: e0290996.
Funding: NIHR Applied Research Collaboration (ARC) West.
Conflicts of Interest: None declared.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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