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Frequency of low-value care in Alberta, Canada: a retrospective cohort study
  1. Finlay A McAlister1,
  2. Meng Lin2,
  3. Jeff Bakal2,
  4. Stafford Dean3
  1. 1Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
  2. 2Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
  3. 3Alberta Health Services, Calgary, Alberta, Canada
  1. Correspondence to Dr Finlay A McAlister, University of Alberta, Edmonton,Alberta T6G2R7, Canada; finlay.mcalister{at}


Objective To determine how frequently 10 low-value services highlighted by Choosing Wisely are done and what factors influence their provision.

Methods This is a retrospective cohort study using routinely collected health data from five linked data sets from 2012 to 2015 in the Canadian province of Alberta to determine the frequency with which 10 low-value services were provided.

Results Between 2012 and 2015, 162 143 people (4% of all 3 814 536 adult Albertans and 5% of the 3 423 135 who saw a physician at least once in that time frame) received at least one of the 10 low-value services, including 29.8% of Albertans older than 75 years (57 811 of 194 068). The proportion of adults receiving low-value services ranged from carotid artery imaging in 0.1% of asymptomatic adults without cerebrovascular disease, to prostate-specific antigen (PSA) testing in 55.5% of men 75 years or older without a history of prostate cancer. Although age, Charlson scores and frequency of primary care visits were associated with low-value service provision, the directions of the association differed across services; however, higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians in the patient’s region were associated with an increased risk of receiving all of the low-value services we examined. The low-value services which resulted in the greatest costs to the healthcare system were cervical cancer screening in women older than 65 without history of cervical dysplasia or genital cancer, PSA testing in men older than 75 without history of prostate cancer and preoperative stress testing/cardiac imaging before non-cardiac surgery.

Conclusions Even within a universal coverage healthcare system, the proportion of patients receiving low-value services varied widely (from <0.1% to 56%). Increased use was associated with higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians.

  • ambulatory care
  • healthcare quality improvement
  • health services research

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  • Contributors FMA is the guarantor of this manuscript and has the right to grant, on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd to permit this article (if accepted) to be published in BMJ editions and any other BMJPGL products and sublicences such use and exploit all subsidiary rights, as set out in our licence. FMA conceived and designed the study and wrote the first draft, JB and ML obtained the data and conducted analyses, and all authors edited the manuscript and gave final approval.

  • Funding no project specific funding

  • Competing interests None declared.

  • Ethics approval University of Alberta Health Research Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Due to the restrictions of the Alberta Health Information Act, we are not allowed to release ministry data to external repositories.

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