I would say that 4.5 V is a rather unusual reference voltage, but this has nothing to do whether it is efficient or inefficient.
This ADC is particularly designed for biomedical applications and I assume that in these fields the traditional signal level suits a 4.5 V reference voltage. This is possibly the range of the output signals which used to be fed into multi-track chart recorders..
It could be inefficient because if the reference is 4.5v, the input voltage range could only be 0.5v above the reference before getting saturated. However, if the reference voltage is 2.5v, the input voltage is much wider: 2.5v above reference before getting saturated.
I just don't understand why the reference is so high. Is there a standard for these kind of devices? Hmm...
EDIT:
I just checked out the data sheet for ADS1298 (ADC specifically for EKG) and found out TI used 4v reference for a 5v power supply. Looks like these medical devices use very high references...