Reducing Low-Value Care Through the Smarter Care Virginia Initiative

Importance Low-value care costs more than $100 billion annually and remains pervasive despite decades of evidence documenting its clinical and financial harms. While several US states have begun discouraging its use, the feasibility of such statewide interventions in partnership with large health systems remains unknown. Objective To investigate the effectiveness of a clinician-led, multistakeholder, statewide initiative to reduce low-value care in the Commonwealth of Virginia. Design, Setting, and Participants This quality improvement study used a difference-in-differences analyses comparing low-value service changes among patients attributed to 6 health systems vs 12 control systems in the Commonwealth of Virginia preintervention (January 1 to December 31, 2019) vs postintervention (January 1 to December 31, 2022). Any patient eligible to receive 1 or more of the 9 measured low-value services in the 18 health systems evaluated were included. Data were analyzed between December 1, 2023, and September 1, 2026. Exposure The intervention, Smarter Care Virginia, included health system financial support, clinician education, and quarterly peer-comparison performance scorecards. Main Outcomes and Measures The primary outcome was the percentage of patients receiving any of 9 selected low-value services: (1-3) preoperative laboratory, imaging, and cardiac testing; (4-5) electrocardiogram/cardiac screening and cardiac stress testing; (6-7) diagnostic imaging and opioids for acute back pain; (8) advanced diagnostic eye imaging; and (9) peripherally inserted central catheter lines for patients with chronic kidney disease. Secondary outcomes included adverse events (eg, myocardial infarction–related hospitalization) and per-capita spending on the 9 low-value services. Results A total of 17 223 clinicians (7222 in the intervention group and 10 001 in the control group) and 4.5 million patients (approximately 68% of Virginia’s adult population) were identified. In 2019, 10.5% of patients in the intervention group and 10.7% of patients in the control group received 1 or more low-value services; in 2021 to 2022, rates declined to 8.5% and 9.1%, respectively. The intervention was associated with 10.4% fewer patients receiving 1 or more low-value services (absolute reduction, −1.1 percentage points; 95% CI, −2.1 to −0.1 percentage points; P = .04). There was no statistically significant change in adverse events (0.03%; 95% CI, −0.02% to 0.03%; P = .84) or spending on the 9 low-value services ($0.33; 95% CI, −$3.43 to $4.11). Conclusions and Relevance In this quality improvement study, a statewide, clinician-led initiative was associated with a small but statistically significant reduction in low-value care delivery without evidence of harm. Achieving larger reductions may require combining such health system–driven efforts with additional strategies, such as payment reform and physician and hospital accountability, that discourage the use of low-value care.