Frequency of low-value care in Alberta, Canada: a retrospective cohort study

BMJ Qual Saf. 2018 May;27(5):340-346. doi: 10.1136/bmjqs-2017-006778. Epub 2017 Sep 14.


Objective: To determine how frequently 10 low-value services highlighted by Choosing Wisely are done and what factors influence their provision.

Methods: This is a retrospective cohort study using routinely collected health data from five linked data sets from 2012 to 2015 in the Canadian province of Alberta to determine the frequency with which 10 low-value services were provided.

Results: Between 2012 and 2015, 162 143 people (4% of all 3 814 536 adult Albertans and 5% of the 3 423 135 who saw a physician at least once in that time frame) received at least one of the 10 low-value services, including 29.8% of Albertans older than 75 years (57 811 of 194 068). The proportion of adults receiving low-value services ranged from carotid artery imaging in 0.1% of asymptomatic adults without cerebrovascular disease, to prostate-specific antigen (PSA) testing in 55.5% of men 75 years or older without a history of prostate cancer. Although age, Charlson scores and frequency of primary care visits were associated with low-value service provision, the directions of the association differed across services; however, higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians in the patient's region were associated with an increased risk of receiving all of the low-value services we examined. The low-value services which resulted in the greatest costs to the healthcare system were cervical cancer screening in women older than 65 without history of cervical dysplasia or genital cancer, PSA testing in men older than 75 without history of prostate cancer and preoperative stress testing/cardiac imaging before non-cardiac surgery.

Conclusions: Even within a universal coverage healthcare system, the proportion of patients receiving low-value services varied widely (from <0.1% to 56%). Increased use was associated with higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians.

Keywords: ambulatory care; health services research; healthcare quality improvement.

MeSH terms

  • Age Factors
  • Alberta
  • Guideline Adherence
  • Health Services Administration / economics*
  • Health Services Administration / statistics & numerical data*
  • Humans
  • Insurance Claim Review
  • Logistic Models
  • Medical Overuse / economics*
  • Medical Overuse / statistics & numerical data*
  • Patient Preference*
  • Practice Guidelines as Topic
  • Retrospective Studies
  • Socioeconomic Factors
  • Specialization / economics
  • State Medicine / economics
  • State Medicine / statistics & numerical data
  • Unnecessary Procedures / economics
  • Unnecessary Procedures / statistics & numerical data