In this retrospective analysis with a sample size of over 30 thousand, compared to public hospitals, private hospitals, regardless of whether not-for-profit or for-profit in nature were more likely to provide low-value hysterectomies. By eliminating the excess risks associated with private hospitals, we can anticipate a noteworthy reduction of 9.73% in the amount of low-value hysterectomy episodes, corresponding to 48,375 fewer low-value episodes and a total social burden of 1.82 billion USD costs nationwide annually.
Among the above attributable low-value episodes, there is a potential for 1,793 more cases to face the risk of major surgical complications compared to using the alternative procedure (eTable 5). Apart from the clinical burden, we have further computed the economic burden (1.82 billion USD) associated with these attributed cases. Compared to the alternative procedure (laparoscopic hysterectomy), low-value hysterectomy (abdominal hysterectomy for benign gynecological disease) incurs higher social costs and exhibits poorer clinical performance, resulting in poor cost-effectiveness, consistent with the conclusions of the majority of previous literature.23,24 In both international low-value care catalogs and the existing domestic method for identifying low-value care, the definition and identification of low-value hysterectomy procedures primarily rely on their suboptimal clinical outcomes. Our research undoubtedly expands the economic evidence for its definition, aligning with the mainstream research on adding cost-effectiveness to define low-value care.25
Public hospitals were more inclined to provide high-value hysterectomies (laparoscopic hysterectomies), which is consistent with previous research.26 Underlying factors that explain why private hospitals were more likely to provide low-value hysterectomies (abdominal hysterectomies) are not clear. However, we speculate that the unevenly distributed healthcare professionals, the different patient demands, and the profit motives between the two types of hospitals could partly explain the disparities in the provision of low-value hysterectomies. First, despite the swift proliferation of private hospitals in the past decade, the progress of these newly established medical facilities is still at an embryonic stage of development. This phase is characterized by inadequate human resource management systems that struggle to ensure the availability of sufficient experienced and skilled medical professionals. Meanwhile, limited training, technical difficulty, and lack of personal surgical experience as substantial barriers to performing minimally invasive hysterectomy (high-value hysterectomy).27 Therefore, in China, private hospitals might not be able to offer higher-value minimally invasive hysterectomy like public hospitals do. Instead, they might have to resort to offering lower-value abdominal hysterectomy. Second, private hospitals, to retain patients in a fiercely competitive market, may tend to offer services that have lower short-term economic costs for patients.28 Public hospitals, in contrast, emphasize patient safety and long-term affordability, and prefer to provide laparoscopic hysterectomy that offer comprehensive long-term benefits.28,29 Third, hysterectomy might serve as a way for hospitals to generate profits30 and private for-profit hospitals may have more motivations to provide low-value hysterectomy with lower consumable costs to maximize their profits. Additionally, public hospitals are required to consider the public welfare, adhere to stricter policy regulations, and comply with more rigorous oversight. Furthermore, in China, private non-profit hospitals that fall between these two categories are still on their way towards profit-oriented goals,31 but they also bear certain social responsibilities like public hospitals. Consequently, their performance in providing low-value hysterectomies falls somewhere between the above two types (eTable 14).
We found that private hospitals may be more inclined to provide low-value care, suggested hypotheses about possible mechanisms, and further calculated the attributable burdens, which can inform low-value care reduction efforts more broadly. Initially, the establishment of a robust human resource management system is imperative to ensure an ample and well-qualified workforce of healthcare professionals. This necessitates increased investment in healthcare personnel, accompanied by efforts to elevate the overall technical proficiency of physicians through a hybrid approach of online and offline training methods. Secondly, there is a critical need to bolster the cultivation of medical ethics and professionalism to elevate the moral and ethical standards of healthcare practitioners. Furthermore, ensuring seamless information exchange, particularly between public and private hospitals, is essential and requires the strengthening of technological collaboration. Last but not least, the utilization of low-value care hinges on the collaborative efforts of both physicians and patients.32 Therefore, it is imperative to strive for transparency in the diagnostic and treatment processes and to facilitate enhanced communication between these two pivotal stakeholders. Any action derived from these findings should be subject to meticulous deliberation to prevent the erosion of hospital and clinician goodwill.
Our study has three strengths. First, we have made advancements in the method by incorporating causal inference techniques that mimic randomized controlled trials based on observational data.33,34 Comparison with a majority of the retrospective studies35,36 exploring differences in low-value provision based on correlation analysis, which is straightforward but suffers from bias by the impact of residual confounders,37 our measure could yield more accurate effect adjustment. Second, we apply a means of evaluating the risk factor and quantifying the impact of preventive health strategies for the first time and validate the feasibility of utilizing indirect indicators to determine the harmful effects of risk factors on the provision of low-value care for assessing and comparing burden levels associated with different risk factors for the population. Third, the study provides a way to estimate the maximum effectiveness of potential interventions for low-value care, i.e., the avoidable cost waste (5.81 million USD).
Our study had six limitations. First, the major threat to the external validity of our findings is our IV. The IV analysis results of this study apply specifically to statistically marginal patients38 who were admitted (or not admitted) based on their proximity to a given hospital and such patients represent those with a borderline or uncertain need for a public or private hospital. The IV analysis failed to identify individual patients who are “marginal”, but we were able to identify certain characteristics associated with these patients (eTable 3 in the Supplementary Materials). This suggests that the population of patients in this study with those characteristics was likely to be the primary population for proximity to medical care. Therefore, our findings, focused on inpatients, might not be generalizable to populations who benefit from public (private) hospitals, younger populations undergoing non-hospitalization, or populations outside China. Nevertheless, our study demonstrates the feasibility of using instrumental variables to study disparities in low-value care at the institutional level, in the absence of large-scale and long-term RCTs. Second, it is imperative to highlight the pivotal role of physicians as the primary arbiters of medical decision-making, which significantly influences the utilization of low-value care.39 While our study presumes that the majority of physicians can render judicious decisions based on their patient's medical conditions, it is important to acknowledge the challenge unable to adjust in quantifying certain attributes, such as physician practice type and compensation structures. These intricacies may introduce certain limitations to our research. Third, it is crucial to recognize that the overall equipment and facilities available within a hospital can exert a considerable influence on whether the institution is compelled to provide low-value care. To mitigate this influence, we have incorporated hospital grade as a variable within our models. Fourth, we calculated IV based on the Euclidean distance, where the coordinates were obtained by querying Amap, similar to Google Maps in the United States. Since the annual road network data between 2016–2020 is not available, there is a discrepancy between our calculation and the actual situation, which is the limitation of most similar IV empirical research methods.40 Fifth, our measures of low-value care may still be susceptible to measurement error due to the limited clinical information available in inpatient discharge records and the lack of gold standards of clinical appropriateness. Although the aforementioned limitations can lead to disparities between our study results and the empirical reality, these variances pose no significant implications for the credibility and validity of the findings. Sixth, due to the differences in the structure of medical insurance and the provision of low-value care in different regions, there are some biases in our estimated national excess costs, and data from other provinces need to be further included.
In consequent studies, it is crucial to investigate other risk factors related to the provision of low-value care to identify appropriate targets for interventions. Furthermore, it is important to delve deeper into the drivers behind the provision of low-value care in private hospitals and to enable the implementation of timely, appropriate, individualized, and multi-component interventions and treatment measures.41,42 These measures will help to alleviate the mounting pressures of low-value care on patients and healthcare institutions, enhance the efficacy of healthcare resource allocation, exert control over healthcare expenditure, elevate the caliber of healthcare services, and ultimately advance the implementation of value-based care.