Waste in U.S. healthcare spending amounts to about 25% of total healthcare expenditures each year (an estimated $760 billion to $935 billion) and about 25% of this figure (approximately $191 billion to $282 billion) could be saved by implementing interventions targeted at reducing waste (JAMA 2019; doi:10.1001/jama.2019.13978).

This analysis from 71 estimates in 54 peer-reviewed publications, government-produced reports, and other studies on cost, waste, and savings produced between 2012 and 2019 builds on two seminal studies that pegged the tab for waste at 30% to 35% of healthcare expenditures. The authors also used six domains of waste similar to those identified in the prior reports, including: failure of care delivery; failure of care coordination; overtreatment or low-value care; pricing failure; fraud and abuse; and administrative complexity.

The investigators found the most studies involving failure of care delivery (21). The domains failure of care delivery, failure of care coordination, and overtreatment or low-value care collectively account for an estimated $345 billion in waste associated with suboptimal care quality.

Diagnostic testing generally falls into the domains of overtreatment or low-value care and pricing failure, where the researchers estimated that $12.8-28.6 billion and $81.4-91.2 billion, respectively, might be saved through interventions such as accountable care organization efforts to curb overtreatment or low-value use and pricing transparency strategies for lab orders.

The authors found that the administrative complexity domain contributed the most to healthcare waste ($265.6 billion), but they found no studies that identified ways to wring savings from this figure.

Three editorials that accompanied the study suggested that this research should be part of a “national discussion” about the future of the healthcare system and explored why policy initiatives have not had much of an effect on waste reductions. One author concluded that change-paralyzing politics is the “most plausible” reason opportunities to curb waste haven’t taken off (JAMA 2019; doi:10.1001/jama.2019.14610). Others called for “a simpler more holistic approach to value-based payment” in which hospital care, when feasible, would be set up around disease management and procedure bundles with “clear quality measures around safety” (JAMA 2019; doi:10.1001/jama.2019.13977).

Auto Mode Poses Challenges for Continuous Glucose Monitoring System Users

A 1-year observational study of patients with type 1 diabetes who used the first commercial hybrid closed-loop continuous glucose monitoring (CGM) system found that using this system in auto mode, which automatically controls basal insulin delivery based on CGM data, was associated consistently with lower HbA1c levels and more time in range (Diabetes Care 2019; doi.org/10.2337/dc19-0855). However, this study also highlights “significant variables related to user experience that limit [such technology’s] potential benefits,” according to the authors.

The study involved 87 patients ages 9 to 79 at Stanford University Medical Center who started using the Medtronic 670G hybrid closed-loop system between May 2017 and May 2018. The study protocol called for patients to provide data for at least one visit at 1 week, and at 3, 6, 9, and/or 12 months, after the device’s auto mode had been started. Five individuals did not provide any data, and not all the remaining 79 provided data at each visit interval.

Overall, auto mode use declined over time, with 31% of participants discontinuing this function at 3 months and 46% doing so by the time of their 12-month visit. Use of auto mode more than 70% of the time also declined as the study went on, with 43% of participants doing so at 3 months, versus 32% at 12 months.

Participants who kept operating the device in auto mode cited as their reason for doing so the desire to stay in range. Most of those who stopped using auto mode reported experiencing sensor issues such as multiple requests for calibrations, alarms, and the system exiting auto mode, which required additional blood glucose checks.

The investigators noted that Medtronic issued a transmitter upgrade to remedy issues that prompted multiple blood glucose checks but that study participants had not implemented this upgrade during the study period. “Education and adequate preparation are crucial in setting realistic expectations for closed-loop systems,” they emphasized.

Universal Multigene Testing in Breast Cancer Would Be Cost-effective

Unselected multigene testing for three high-risk genes—BRCA1, BRCA2, and PALB2—in all patients with breast cancer would be an “extremely cost-effective” strategy for reducing future breast cancer and ovarian cancer cases and related deaths in both the U.S. and U.K., and “provides a basis for change in current guidelines and policy to implement this strategy” (JAMA Oncol 2019; doi:10.1001/jamaoncol.2019.3323).

An international team of researchers compared this strategy against the current standard of performing genetic testing only in women with breast cancer who meet family history or clinical criteria. They did so in a microsimulation model study using data from 11,836 women in four breast cancer studies in the U.K. The investigators used data on the incidence of breast cancer by age in the U.S. from the Centers for Disease Control and Prevention’s 2015 U.S. cancer statistics data.

Such a strategy in comparison with existing practice would cost payers in the U.S. $65,661 per quality adjusted life year (QALY) gained and $61,618 per QALY from a societal perspective, well below the U.S. incremental cost-effectiveness ratio threshold of $100,000 per QALY.

In addition, an unselected strategy implemented in the U.S. would prevent in 1 year 5,478 breast cancer cases and 4,255 ovarian cancer cases, which would correspond to averting 2,406 lifetime cancer deaths.