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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Vandenplas Y, Simoens S, Turk F, Vulto AG, Huys I. Applications of Behavioral Economics to Pharmaceutical Policymaking: A Scoping Review with Implications for Best-Value Biological Medicines. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:803-817. [PMID: 35972683 PMCID: PMC9379236 DOI: 10.1007/s40258-022-00751-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Pharmaceutical policies are generally based on the assumption that involved stakeholders make rational decisions. However, behavioral economics has taught us that this is not always the case as people deviate from rational behavior in rather predictable patterns. This scoping review examined to what extent behavioral concepts have already been applied in the pharmaceutical domain and what evidence exists about their effectiveness, with the aim of formulating future applications and research hypotheses on policymaking for best-value biologicals. METHODS A scoping literature review was conducted on the evidence of behavioral applications to pharmaceuticals. Scientific databases (Embase, MEDLINE, APA PsycArticles, and Scopus) were searched up to 20 October, 2021. RESULTS Forty-four full-text scientific articles were identified and narratively described in this article. Pharmaceutical domains where behavioral concepts have been investigated relate to influencing prescribing behavior, improving medication adherence, and increasing vaccination uptake. Multiple behavioral concepts were examined in the identified studies, such as social norms, defaults, framing, loss aversion, availability, and present bias. The effectiveness of the applied interventions was generally positive, but depended on the context. Some of the examined interventions can easily be translated into effective policy interventions for best-value biological medicines. However, some applications require further investigation in a research context. CONCLUSIONS Applications of behavioral economics to pharmaceutical policymaking are promising. However, further research is required to investigate the effect of behavioral applications on policy interventions for a more sustainable market environment for best-value biological medicines.
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Affiliation(s)
- Yannick Vandenplas
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Arnold G Vulto
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Candon M, Xue L, Shen S, Cole ES, Donohue J, Rothbard A. The impact of opioid prescribing report cards in Medicaid. J Manag Care Spec Pharm 2022; 28:862-870. [PMID: 35876292 PMCID: PMC10373013 DOI: 10.18553/jmcp.2022.28.8.862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Performance feedback has been used for decades to improve health care quality and safety, with varying degrees of success. One example is the use of customized report cards that target inappropriate prescribing of high-risk medications, including opioids. Randomized controlled trials suggest that report cards are an effective tool to change opioid prescribing behavior, but their effectiveness in community settings is unclear. OBJECTIVE: To evaluate the impact of opioid prescribing report cards, which were mailed to Medicaid providers in Philadelphia, Pennsylvania. METHODS: Using a quasi-experimental approach, we compared trends in opioid prescribing by Medicaid providers in Philadelphia, who received a report card in late 2017, with Medicaid providers in surrounding counties, who did not receive report cards. First, we used propensity score matching to balance observed differences in the treatment and comparison groups; matching variables included provider specialty, sex, and selected characteristics of providers' Medicaid patient panels. We then estimated a difference-in-differences model to isolate the impact of report cards on opioid prescribing. RESULTS: The analytical sample included 1,598 providers in Philadelphia and 2,117 providers in surrounding counties, who prescribed opioids to 99,548 Medicaid patients during the study period. Although the number of Medicaid patients receiving opioids and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month. CONCLUSIONS: After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization. DISCLOSURES: Drs Candon and Rothbard and Ms Shen received funding from Community Behavioral Health in Philadelphia, Pennsylvania. Drs Xue, Cole, and Donohue received funding from Pennsylvania Department of Human Services. Neither Community Behavioral Health nor the Pennsylvania Department of Human Services was involved in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.
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Affiliation(s)
- Molly Candon
- Departments of Psychiatry and Health Care Management, Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia
| | - Lingshu Xue
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Siyuan Shen
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Evan S Cole
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Julie Donohue
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Aileen Rothbard
- Department of Psychiatry, Perelman School of Medicine and School of Social Policy & Practice, University of Pennsylvania, Philadelphia
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Navathe AS, Liao JM, Yan XS, Delgado MK, Isenberg WM, Landa HM, Bond BL, Small DS, Rareshide CAL, Shen Z, Pepe RS, Refai F, Lei VJ, Volpp KG, Patel MS. The Effect Of Clinician Feedback Interventions On Opioid Prescribing. Health Aff (Millwood) 2022; 41:424-433. [PMID: 35254932 DOI: 10.1377/hlthaff.2021.01407] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An initial opioid prescription with a greater number of pills is associated with a greater risk for future long-term opioid use, yet few interventions have reliably influenced individual clinicians' prescribing. Our objective was to evaluate the effect of feedback interventions for clinicians in reducing opioid prescribing. The interventions included feedback on a clinician's outlier prescribing (individual audit feedback), peer comparison, and both interventions combined. We conducted a four-arm factorial pragmatic cluster randomized trial at forty-eight emergency department (ED) and urgent care (UC) sites in the western US, including 263 ED and 175 UC clinicians with 294,962 patient encounters. Relative to usual care, there was a significant decrease in pills per prescription both for peer comparison feedback (-0.8) and for the combination of peer comparison and individual audit feedback (-1.2). This decrease was sustained during follow-up. There were no significant changes for individual audit feedback alone, and no interventions changed the proportion of encounters with an opioid prescription.
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Affiliation(s)
- Amol S Navathe
- Amol S. Navathe , Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Liao
- Joshua M. Liao, University of Washington, Seattle, Washington, and University of Pennsylvania
| | - Xiaowei S Yan
- Xiaowei S. Yan, Sutter Health, Walnut Creek, California
| | | | | | | | - Barbara L Bond
- Barbara L. Bond, Sutter Health, Castro Valley, California
| | | | | | - Zijun Shen
- Zijun Shen, Sutter Health, San Francisco
| | | | | | | | | | - Mitesh S Patel
- Mitesh S. Patel, Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania
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Oskvarek JJ, Aldeen A, Shawbell J, Venkat A, Zocchi MS, Pines JM. Opioid Prescription Reduction After Implementation of a Feedback Program in a National Emergency Department Group. Ann Emerg Med 2022; 79:420-432. [DOI: 10.1016/j.annemergmed.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
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Abstract
OBJECTIVE Nudges are interventions that alter the way options are presented, enabling individuals to more easily select the best option. Health systems and researchers have tested nudges to shape clinician decision-making with the aim of improving healthcare service delivery. We aimed to systematically study the use and effectiveness of nudges designed to improve clinicians' decisions in healthcare settings. DESIGN A systematic review was conducted to collect and consolidate results from studies testing nudges and to determine whether nudges directed at improving clinical decisions in healthcare settings across clinician types were effective. We systematically searched seven databases (EBSCO MegaFILE, EconLit, Embase, PsycINFO, PubMed, Scopus and Web of Science) and used a snowball sampling technique to identify peer-reviewed published studies available between 1 January 1984 and 22 April 2020. Eligible studies were critically appraised and narratively synthesised. We categorised nudges according to a taxonomy derived from the Nuffield Council on Bioethics. Included studies were appraised using the Cochrane Risk of Bias Assessment Tool. RESULTS We screened 3608 studies and 39 studies met our criteria. The majority of the studies (90%) were conducted in the USA and 36% were randomised controlled trials. The most commonly studied nudge intervention (46%) framed information for clinicians, often through peer comparison feedback. Nudges that guided clinical decisions through default options or by enabling choice were also frequently studied (31%). Information framing, default and enabling choice nudges showed promise, whereas the effectiveness of other nudge types was mixed. Given the inclusion of non-experimental designs, only a small portion of studies were at minimal risk of bias (33%) across all Cochrane criteria. CONCLUSIONS Nudges that frame information, change default options or enable choice are frequently studied and show promise in improving clinical decision-making. Future work should examine how nudges compare to non-nudge interventions (eg, policy interventions) in improving healthcare.
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Affiliation(s)
- Briana S Last
- Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alison M Buttenheim
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carter E Timon
- College of Liberal and Professional Studies, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rinad S Beidas
- Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Decreased Overall and Inappropriate Antibiotic Prescribing in a Veterans Affairs Hospital Emergency Department following a Peer Comparison-Based Stewardship Intervention. Antimicrob Agents Chemother 2020; 65:AAC.01660-20. [PMID: 33020159 DOI: 10.1128/aac.01660-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/01/2020] [Indexed: 12/19/2022] Open
Abstract
Antibiotic prescribing is very common in emergency departments (EDs). Optimal stewardship intervention strategies in EDs are not well defined. We conducted a prospective, observational cohort study in a Veterans Affairs ED in which clinician education and monthly e-mail-based peer comparisons were directed against all oral antibiotic prescribing for discharged patients. Oral antibiotic prescriptions were compared in baseline (June 2016 to December 2017) and intervention (January to June 2018) periods using an interrupted time series regression model. Prescribing appropriateness was compared during January to June 2017 and the intervention period. During the intervention period, antibiotic prescriptions decreased monthly by 10.4 prescriptions per 1,000 ED visits (P = 0.07 [95% confidence interval {CI}, -21.7 to 1.0]). The relative decrease in the trend of antibiotic prescriptions during the intervention period compared to baseline was 9.9 prescriptions per 1,000 ED visits per month (P = 0.07 [95% CI, -20.9 to 1.0]). The intervention was associated with a significant decrease and increase in amoxicillin-clavulanate and cephalexin prescriptions, respectively (P < 0.001, P = 0.004). Decreasing trends in ciprofloxacin prescriptions during the baseline period were maintained during the intervention. Unnecessary antibiotic prescribing (i.e., antibiotic not indicated) decreased from 55.6% to 38.7% during the intervention (30.4% decrease, P = 0.003). Optimal antibiotic prescribing (i.e., antibiotics were indicated, and a guideline-concordant agent was prescribed for guideline-concordant duration) increased by 36% (21.6% to 29.3%, P = 0.12). A peer comparison-based stewardship intervention directed at ED clinicians was associated with reductions in overall and unnecessary oral antibiotic prescribing. There is potential to further improve antibiotic use as suboptimal prescribing remained common.
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Winslow L, Holstine J, Samora JB. Reducing the Use of Opioids for Pediatric Patients with Supracondylar Humerus Fractures. Jt Comm J Qual Patient Saf 2020; 46:581-587. [DOI: 10.1016/j.jcjq.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 11/29/2022]
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