Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration

JAMA Netw Open. 2020 Sep 1;3(9):e2016445. doi: 10.1001/jamanetworkopen.2020.16445.


Importance: Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration.

Objectives: To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition.

Design, setting, and participants: This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020.

Exposures: Continuous enrollment in Veterans Health Administration during fiscal year 2015.

Main outcomes and measures: Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level.

Results: Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001).

Conclusions and relevance: In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Acute Disease
  • Adult
  • Aged
  • Carotid Arteries / diagnostic imaging
  • Cohort Studies
  • Diagnostic Imaging / statistics & numerical data*
  • Electroencephalography / statistics & numerical data*
  • Female
  • Headache / diagnosis*
  • Humans
  • Low Back Pain / diagnostic imaging*
  • Male
  • Middle Aged
  • Paranasal Sinuses / diagnostic imaging
  • Retrospective Studies
  • Sinusitis / diagnostic imaging*
  • Syncope / diagnostic imaging*
  • Time Factors
  • Tomography, X-Ray Computed / statistics & numerical data
  • Ultrasonography / statistics & numerical data
  • United States
  • United States Department of Veterans Affairs*
  • Unnecessary Procedures / statistics & numerical data*