Over 150 potentially low-value health care practices: an Australian study

In reply: I thank Bece and colleagues and Pitson for engaging constructively with this quality improvement agenda. Bece et al challenge the inclusion of radiotherapy for spinal cord disease in our list of 150 candidate treatments potentially warranting further review under a quality improvement program.1 Pitson calls attention to “loose terminology” in the same example. This latter point, I concede. Precision of language in relation to treatment type and patient indications is essential in this debate.

However, I respectfully disagree with the assertion from Bece et al that listing radiotherapy for spinal cord disease represents an “erroneous conclusion”. In our article we state: “The list includes examples where practice optimisation (ie, assessing relative value of a service against comparators) might be required.”1 Later, I further qualify this point2 and extend the debate.3 The study we cited investigated the relative value of surgery with adjuvant radiotherapy compared with radiotherapy alone.4 The authors of that study concluded: “Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.”4 Hence, rather than listing radiotherapy for spinal cord disease being an “erroneous conclusion”, it seems the relative value of radiotherapy alone is open for legitimate debate, and, therefore, for inclusion in our list based on a-priori inclusion criteria.

As Pitson goes on to highlight, appropriate selection of patients for what might become high-value as opposed to low-value applications of these procedures (or combinations thereof) is key. Surely these complexities and treatment choices support calls for further practice (as well as funding) optimisation in this area. I am hopeful that with a tightening of the language, any disagreement might be diminished.