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For Value-Based Care, "Exnovation" is a Good Thing


To increase value, doctors need to de-adopt procedures that provide little of it. A new study found that they have ample room for improvement.

As premiums rise and new reimbursement policies loom, value-based care has become an imperative focus for doctors in the American healthcare system. One key to improving value is cutting out procedures that don’t provide enough of it, and a new study found that healthcare professionals have ample room for improvement on that front.

"As we try to reduce the use of low-value care…it's important that we get a much better understanding of the factors that affect a physician's decision to scale back on procedures that might no longer be the most effective," lead author and Dartmouth Institute assistant professor Kimon Bekelis, MD, said in a statement.

To make room for newer, better procedures, the researchers expressed the importance of “exnovation,” or the scaling-back of procedures that provide little benefit to patients. They contrast that with “de-adoption,” or the total abandonment of use.

In their study, the team chose one intervention that has come to be seen as low-value for some patients. Carotid revascularization, a procedure used to reverse narrowing of the carotid artery in hopes of reducing stroke risk, has seen declining implementation in recent years. The researchers used Medicare claims data linked to the Doximity physician database to study the frequency of such procedures between 2006 and 2013.

At the beginning of the observed period, 9,158 physicians performed carotid revascularization surgeries. The number of overall procedures fell 37.7% by 2013. The researchers attributed the drop primarily to exnovation, finding that most doctors continued to order the procedure but were more careful about who it was ordered for. The study found that physicians who specialized in vascular or thoracic surgeries, as well as those who had been in practice the longest, actually reduced implementation by the largest margin.

For patients, the story was different. Although the interventions are considered to be of the least benefit to patients aged 80 or older or without symptoms of carotid narrowing, those populations did not see a disproportionate decline in the number of surgeries performed.

“In the US, we're not doing a good job of cleaning out the closet of those moth-eaten sweaters, so to speak,” Dartmouth Institute health economist and study co-author Jonathan Skinner, PhD, said of the findings. “We need to do a better job to ensure that there's plenty of fiscal space for the new and valuable innovations appearing in the coming years."

The new study, “De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study,” was published recently in BMJ.

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