Defining, Measuring, and Reducing Use of Low-Value Health Care Services

How do we define socially and personally optimal decisions about health service use? How can policy help physicians and patients make high-quality decisions about low-value care? At The Dartmouth Institute, our research team of clinicians and health economists focuses on developing an understanding of what services are of low-value, how to measure them, and what influences their use.

Choosing Wisely

Choosing Wisely Nancy Morden (left) and Carrie Colla (right) are part of The Dartmouth Institute research team helping to measure and reduce the use of low-value health care an initiative of the ABIM (American Board of Internal Medicine) Foundation to identify low-value medical procedures and tests whose necessity should be questioned and discussed. Launched in 2012, Choosing Wisely seeks to encourage physician societies to develop lists titled,"Five Things Physicians and Patients Should Question." These lists are intended to "spark discussion about the need – or lack thereof – for many frequently ordered tests and treatments. Today, many participating physician societies are working to identify these unnecessary interventions, thereby achieving efficiency of care through quality improvement, risk reduction and lower spending.

Our research in this area focuses on:

  • Identification of low-value services in medical charts, electronic health records, and commercial and Medicare administrative claims
  • Determining and mapping the prevalence of use of low-value services
  • Determining potential health system and physician-level factors that contribute to use of low-value care
  • Evaluating the effectiveness of interventions to reduce low-value care

We outlined a framework categorizing the types of interventions that might work to reduce use of low-value care. These include patient education along with financial interventions such as pay for performance and prior authorization. We are working on a complete literature review of evidence on effective interventions to reduce low-value care.


Fig. 1. Variation in the composite measure of Choosing Wisely test and treatment use (N=306 hospital referral regions)


This work has been supported by grants from The Robert Wood Johnson Foundation’s Health Care Financing and Organization initiative, The Commonwealth Fund, The Petersen Foundation, the Agency for Healthcare Research and Quality, and Academy Health.

Our Team

Our research team consists of clinicians and health economists collaborating closely, including:

Carrie Colla, PhD
Dr. Colla is Associate Professor at The Dartmouth Institute for Health Policy and Clinical Practice. She is a health economist specializing in health insurance markets, insurance benefit design, provider payment, and the care and needs of the elderly.

Nancy Morden, MD, MPH
Dr. Morden is an Associate Professor at The Dartmouth Institute for Health Policy and Clinical Practice. As a physician and pharmacoepidemiologist, Dr. Morden’s work focuses on prescription drug use patterns and their associated health benefits and health risks. Her ongoing work assesses individual and system factors predictive of guideline concordant medication use and associated outcomes in disease-specific cohorts.

Thomas Sequist, MD, MPH
Dr. Sequist is the Chief Quality and Safety Officer at Partners HealthCare and an Associate Professor of Medicine and Health Care Policy at Harvard Medical School. Dr. Sequist’s research interests include ambulatory quality measurement and improvement, with a focus on patient and provider education, and the innovative use of health information technology. 

Meredith Rosenthal, PhD
Dr. Rosenthal is Professor of Health Economics and Policy and Associate Dean for Diversity at the Harvard T.H. Chan School of Public Health. Dr. Rosenthal’s research focuses primarily on policies that will help slow the growth in healthcare spending. These efforts include changes in payment incentives, benefit design, and the provision of information and behavioral “nudges” to both patients and providers.


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