Professional Role · Topic 19 of 26
High-Value & Cost-Effective Care
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High-Value & Cost-Effective Care
High value means benefit justifies cost and harms. Order only to answer a question, and read cost-effectiveness as added cost per added QALY.
What high value means
Health benefits must justify costs and harms
Ordering tests
Order for a specific clinical question, not on a schedule
The stable-inpatient rule is one of the Society of Hospital Medicine's Choosing Wisely recommendations. Laboratory test overuse has been estimated at about 20%; a multifaceted hospital intervention in internal medicine departments was evaluated as a way to reduce unnecessary ordering.
Reading a cost-effectiveness analysis
ICER = difference in cost ÷ difference in health benefit
Still in review books: the 2014 ACC/AHA statement used under $50,000 per QALY as high value, $50,000 to $150,000 as intermediate and $150,000 or more as low value. Dollar thresholds get revised; the $120,000 figure is dated to the 2025 statement. A cost-effectiveness analysis should report two reference cases (health care sector and societal perspectives) plus an impact inventory of consequences included. The US Second Panel recommended in 2016 discounting future costs and health benefits at 3% a year, suggesting 3% be kept for at least 10 years; whether to revise it is now under debate, so check the perspective and assumptions before trusting the ratio.
Low-value care in the ICU
Critical Care Societies Collaborative recommendations
The AACN release prints the transfusion unit as mg/dL; the threshold is 7 g/dL. Comfort-focused care is offered to patients and families as the alternative before continuing life support.
Low-value care on the floor
SHM's 2022 update added items co-created with patient advocates, including avoiding opioids for mild acute pain and avoiding daily chest radiographs without a specific clinical indication. SHM also advises against transfusing red cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke.
Choosing Wisely
Societies named low-value care to prompt conversations
The campaign's lists are no longer maintained on its website; societies are encouraged to publish their own.
Drugs and the formulary
One generic competitor can lower prices by about 30%, and five competing generics are associated with price drops of nearly 85%.
Generic or biosimilar?
| Generic | Biosimilar | |
|---|---|---|
| Copy of | A brand-name drug | An original biologic |
| Sameness | Same active ingredient, strength, form and route | Highly similar, not identical |
| FDA standard | Bioequivalent; same clinical benefit | No clinically meaningful differences |
| Pharmacy substitution | Expected: can be effectively substituted | Only if interchangeable, subject to state law |
Multimorbidity: the AGS domains
Weigh competing priorities with the patient
If the result will not answer a clinical question, do not order the test.
Sources · Owens et al. High-value, cost-conscious health care: concepts for clinicians. Ann Intern Med 2011 · AACN: Critical Care Societies Collaborative Choosing Wisely list · Bulger et al. Choosing Wisely in adult hospital medicine (SHM). J Hosp Med 2013 · Cho et al. Choosing Wisely in adult hospital medicine: co-creation of new recommendations. J Gen Intern Med 2022 · ABIM Foundation: Choosing Wisely · 2025 AHA/ACC statement on cost/value methodology in clinical practice guidelines. Circulation 2025 · 2014 ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures. Circulation 2014 · Sanders et al. Second Panel on Cost-Effectiveness in Health and Medicine. JAMA 2016 · ICER: Cost-effectiveness, the QALY, and the evLY · FDA: Generic drug facts · FDA: Biosimilars basics for patients · ASHP guidelines on the P&T committee and the formulary system. Am J Health Syst Pharm 2021 · AGS guiding principles for the care of older adults with multimorbidity. J Am Geriatr Soc 2012 · Association of a multifaceted intervention with ordering of unnecessary laboratory tests among caregivers in internal medicine departments (2019) · ISPOR 2025 session: The three percent discount rate (US Second Panel recommendation) · Follow your institution's protocols.