Treating, Fast and Slow: Americans' Understanding of and Responses to Low-Value Care

Randomized Experiments to Reduce Overuse of Health Care: A Scoping Review

OBJECTIVE

Health care overuse is pervasive in countries with advanced health care delivery systems. We hypothesize that effective interventions to reduce low-value care that targets patients or clinicians are mediated by psychological and cognitive processes that change behaviors and that interventions targeting these processes are varied. Thus, we performed a scoping review of experimental studies of interventions, including the interventions' objectives and characteristics, to reduce low-value care that targeted psychological and cognitive processes.

METHODS

We systematically searched databases for experimental studies of interventions to change cognitive orientations and affective states in the setting of health care overuse. Outcomes included observed overuse or a stated intention to use services. We used existing frameworks for behavior change and mechanisms of change to categorize the interventions and the mediating processes.

RESULTS

Twenty-seven articles met the inclusion criteria. Sixteen studied the provision of information to patients or clinicians, with most providing cost information. Six studies used educational interventions, including the provision of feedback about individual practice. Studies rarely used counseling, behavioral nudges, persuasion, and rewards. Mechanisms for behavior change included gain in knowledge or confidence and motivation by social norms.

CONCLUSIONS

In this scoping review, we found few experiments testing interventions that directly target the psychological and cognitive processes of patients or clinicians to reduce low-value care. Most studies provided information to patients or clinicians without measuring or considering mediating factors toward behavior change. These findings highlight the need for process-driven experimental designs, including trials of behavioral nudges and persuasive language involving a trusting patient-clinician relationship, to identify effective interventions to reduce low-value care.

Enhancing Impact: A Call to Action for Equitable Implementation Science

Despite investments in evidence-based interventions and Implementation Science, most evidence-based interventions are not widely or routinely adopted, delivered, or sustained in many real-world community and healthcare settings. This gap is even greater in settings and populations experiencing numerous social and structural barriers to health, with important implications for persistent patterns in health inequities. In this Viewpoint, as part of a Special Issue on Advancing the Adaptability of Chronic Disease Prevention and Management through Implementation Science, we outline seven calls to action for the field of Implementation Science, with the goal of encouraging researchers, practitioners, and funders to be more intentional and accountable in applying Implementation Science to have greater impact on promoting health equity. Calls to action include (1) enhance public health, community, and multi-sectoral partnerships to promote health equity and equitable implementation; (2) revisit and build the evidence base needed to promote health equity and impact at multiple levels; (3) prioritize focus on policy development, dissemination, and implementation; (4) be agile and responsive in application of Implementation Science frameworks, processes, and methods; (5) identify and redefine meaningful metrics for equity and impact; (6) disseminate scientific evidence and research to a diverse range of partners and potential beneficiaries; and (7) extend focus on de-implementation, mis-implementation, and sustainability which are central to enhancing health equity. Additionally, we outline why a focus on prevention and public health is essential to making progress towards health equity in Implementation Science, summarize important advancements that the field has made towards making equity more foundational, and pose important research questions to enhance equitable impact of work in this area.

Effects of exposure to media messages about limiting breast cancer screening: A qualitative experimental study

OBJECTIVE

Examine how women aged 35-50 respond to messages about limiting cancer screening.

METHODS

A national sample of women aged 35-50 (n = 983) were randomly assigned to read one of four media vignettes: three provided information about potential harms of mammograms using evidence, norms, or an anecdote strategy, and one provided no such information. Participants listed thoughts they had about the message, and after coding these themes, we tested for associations between the themes evoked, message exposure, and mammogram history.

RESULTS

Thematic categories included emotions (8 %); behavioral intentions (14 %); and cognitions, attitudes, and beliefs (67 %). Pro-screening attitudes, questioning, and cues to get screened were most prevalent. The anecdote message often elicited pro-screening attitudes, while the evidence message often elicited negative emotions and anger, as well as questioning or skeptical responses. Those with a history of mammograms expressed more pro-screening attitudes and disagreed with the message more often.

CONCLUSIONS

Media messaging about guideline-supported care, especially when it involves reducing a clinical service that is routine and valued by patients, may evoke counterarguing, skepticism, and other negative responses.

PRACTICE IMPLICATIONS

Clinicians should recognize the role of the media in potentially shaping women's attitudes, beliefs, and intentions when it comes to breast cancer screening.

Can we nudge to reduce the perioperative low value care? Decision making factors influencing safe practice implementation

PURPOSE OF THE REVIEW

Highlight sources of low-value care (LVC) during the perioperative period help understanding the decision making behind its persistence, the barriers for change, and the potential implementation strategies to reduce it.

RECENT FINDINGS

The behavioural economics science spread of use through aligned strategies or nudge units offer an opportunity to improve success in the LVC reduction.

SUMMARY

LVC, such as unneeded surgeries, or preanaesthesia tests for low-risk surgeries in low-risk patients, is a relevant source of waste and preventable harm, most especially in the perioperative period. Despite the international focus on it, initial efforts to reduce it in the last decade have not clearly shown a sustainable improvement. Understanding the shared decision-making process and the barriers to be expected when tackling LVC is the first step to build the change. Applying a structured strategy based on the behavioural science principles may be the path to increasing high value care in an effective an efficient way. It is time to foster nudge units at different healthcare system levels.

Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands

BACKGROUND

Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries.

METHODS

We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis.

RESULTS

The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy.

CONCLUSION

Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

Effects of politicized media coverage: Experimental evidence from the HPV vaccine and COVID-19

Although concerns about politicization of health and science are not new, the COVID-19 pandemic has amplified attention to how political disagreement over scientific guidelines and recommendations might influence attitudes and behaviors about the health topics in question and might even spill or carry over to affect other attitudes important to public health. The literature employs differing definitions of politicization-at times referring to controversy in the public sphere, at others referring to the exploitation of the uncertainty inherent in science, and at still others referring to whether the issue enters political discourse-all of which are viewed as distinct dimensions by the public. What is not known is how these different aspects of politicization influence public attitudes about the health topics and or broader attitudes about scientific guidelines, and-assuming adverse effects-what strategies might be effective at mitigating the consequences. This paper draws on a survey experiment of 3012U.S. respondents fielded in summer 2020 that was designed as a pilot study to assess the effects of different dimensions of politicization. Findings do not suggest that one type of politicization is necessarily more pernicious than the others. In fact, all types of politicization increased negative emotional responses and confusion, both with respect to the health topic in question (HPV vaccine and COVID-19) but also on other domains, although opinions about policy were unaffected. The findings also suggest that inoculation may have potential as a messaging strategy for blunting the adverse effects of exposure to politicization.

Views of healthcare consumer representatives on defensive practice: 'We are your biggest advocate and supporter… not the enemy'

Background

The patient–clinician interaction is a site at which defensive practice could occur, when clinicians provide tests, procedures and treatments mainly to reduce perceived legal risks, rather than to advance patient care. Defensive practice is a driver of low‐value care and exposes patients to the risks of unnecessary interventions. To date, patient perspectives on defensive practice and its impacts on them are largely missing from the literature. This exploratory study conducted in Australia aimed to examine the views and experiences of healthcare consumer representatives in this under‐examined area.

Methods

Semi‐structured interviews were conducted with healthcare consumer representatives involved in healthcare consumer advocacy organisations in Australia. Data were transcribed and analysed thematically.

Results

Nine healthcare consumer representatives participated. Most had over 20 years of involvement and advocacy in healthcare, including personal experiences as a patient or carer and/or formal service roles on committees or complaint bodies for healthcare organisations. Participants uniformly viewed defensive practice as having a negative impact on the clinician–patient relationship. Themes identified the importance of fostering patient–clinician partnership, effective communication and informed decision‐making. The themes support a shift from the concept of defensive practice to preventive practice in partnership, which focuses on the shared interests of patients and clinicians in achieving safe and high‐value care.

Conclusion

This Australian study offers healthcare consumers' perspectives on the impacts of defensive practice on patients. The findings highlight the features of clinician–patient partnership that will help to improve communication and decision‐making, and prevent the defensive provision of low‐value care.

Patient or Public Contribution

Healthcare consumer representatives were involved as participants in this study.

Engaging consumers and health professionals in collaborative decision-making to optimize care

Shared communication and collaborative decision-making between consumers and health professionals is essential in optimizing the quality of consumer care. However, the consumers' ability to ask questions and seek answers, as well as health professionals' communication skills to engage with the consumer, are necessary considerations for the collaborative decision-making process. This quality improvement initiative sought to understand the context of collaborative decision making from the perspective of consumers and health professionals adapted from the international Choosing Wisely program. Findings indicated health professionals acknowledged a problem with unnecessary and overuse of tests, treatments, and procedures. Consumers suggested they were confident asking questions about their health and care. The findings of this study highlight collaborative decision-making as a worthwhile and beneficial undertaking.

How do people understand overtesting and overdiagnosis? Systematic review and meta-synthesis of qualitative research

RATIONALE

The public should be informed about overtesting and overdiagnosis. Diverse qualitative studies have examined public understandings of this information. A synthesis was needed to systematise the body of evidence and yield new, generalisable insights.

AIM

Synthesise data from qualitative studies exploring patient and public understanding of overtesting and overdiagnosis.

METHODS

We searched Scopus, CINAHL, Ovid MEDLINE and PsycINFO databases from inception to March 18, 2020. We included published English-language primary studies exploring the perspectives of patients/the public about overtesting/overdiagnosis from any setting, year and relating to any condition. Only qualitative parts of mixed-methods studies were synthesised. We excluded studies that only examined overtreatment or sampled people with specialised medical knowledge. Two authors independently selected studies, extracted data, assessed the methodological quality of included studies using the CASP tool, and assessed confidence in the synthesis findings using the GRADE-CERQual approach. Data was analysed using thematic meta-synthesis, utilising descriptive and interpretive methods.

RESULTS

We synthesised data from 21 studies, comprising 1638 participants, from 2754 unique records identified. We identified six descriptive themes, all graded as moderate confidence (indicating they are likely to reasonably represent the available evidence): i) high confidence in screening and testing; ii) difficulty in understanding overuse; iii) acceptance that overuse can be harmful; iv) rejection or problematisation of overuse; v) limited impacts of overuse information on intended test and screening uptake; vi) desire for information and shared decision-making regarding overuse. The descriptive themes were underpinned by two analytic themes: i) perceived intrinsic value of information and information gathering, and; ii) differences in comprehension and acceptance of overuse concepts.

CONCLUSIONS

This study identified novel and important insights about how lay people interpret overuse concepts. It will guide the development of more effective public messages about overuse, highlighting the importance of interpretative frameworks in these communications.

Association of Low-Value Care Exposure With Health Care Experience Ratings Among Patient Panels

IMPORTANCE

Patient reviews of health care experiences are increasingly used for public reporting and alternative payment models. Critics have argued that this incentivizes physicians to provide more care, including low-value care, undermining efforts to reduce wasteful practices.

OBJECTIVE

To assess associations between rates of low-value service provision to a primary care professional (PCP) patient panel and patients' ratings of their health care experiences.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used Medicare fee-for-service claims from January 1, 2007, to December 31, 2014, for a random 20% sample of beneficiaries to identify beneficiaries for whom each of 8 low-value services could be ordered but would be considered unnecessary. The study also used health care experience reports from independently sampled beneficiaries who responded to the 2010-2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare fee-for-service survey. Statistical analysis was performed from January 1, 2019, to December 9, 2020.

MAIN OUTCOMES AND MEASURES

The main outcomes were health care experience ratings from Medicare beneficiaries who responded to the CAHPS survey from 2 domains, namely "Your Health Care in the Last 6 Months" (overall health care, office wait time, timely access to nonurgent care, and timely access to urgent care) and "Your Personal Doctor" (overall personal physician and a composite score for interactions with personal physician). Beneficiaries in both samples were attributed to the PCP with whom they had the most spending. For each PCP, a composite score of low-value service exposure was constructed using the 20% sample; this score represented the adjusted relative propensity of the PCP patient panel to receive low-value care. The association between low-value service exposure and health care experience ratings reported by the CAHPS respondents in the PCP patient panel was estimated using regression analysis.

RESULTS

The final sample had 100 743 PCPs, with a mean of approximately 258 patients per PCP. Only 1 notable association was found; more low-value care exposure was associated with more frequent reports of having to wait more than 15 minutes after the scheduled time of an appointment (a mean of 0.448 points lower CAHPS score on a 10-point scale for PCP patient panels who received the most low-value care vs the least low-value care). Although some other associations were statistically significant, their magnitudes were substantially smaller than those typically considered meaningful in other CAHPS literature and were inconsistent in direction across levels of low-value service exposure.

CONCLUSIONS AND RELEVANCE

This quality improvement study found that more low-value care exposure for a PCP patient panel was not associated with more favorable patient ratings of their health care experiences.

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration

IMPORTANCE

The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.

OBJECTIVE

To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.

EXPOSURES

A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.

MAIN OUTCOMES AND MEASURES

Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).

RESULTS

A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.

CONCLUSIONS AND RELEVANCE

Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018

Importance

Low-value care, defined as care offering no net benefit in specific clinical scenarios, is associated with harmful outcomes in patients and wasteful spending. Despite a national education campaign and increasing attention on reducing health care waste, recent trends in low-value care delivery remain unknown.

Objective

To assess national trends in low-value care use and spending.

Design, Setting, and Participants

In this cross-sectional study, analyses of low-value care use and spending from 2014 to 2018 were conducted using 100% Medicare fee-for-service enrollment and claims data. Included individuals were aged 65 years or older and continuously enrolled in Medicare parts A, B, and D during each measurement year and the previous year. Data were analyzed from September 2019 through December 2020.

Exposure

Being enrolled in fee-for-service Medicare for a period of time, in years.

Main Outcomes and Measures

The Milliman MedInsight Health Waste Calculator was used to assess 32 claims-based measures of low-value care associated with Choosing Wisely recommendations and other professional guidelines. The calculator designates services as wasteful, likely wasteful, or not wasteful based on an absence of indication of appropriate use in the claims history; calculator-designated wasteful services were defined as low-value care. Spending was calculated as claim-line level (ie, spending on the low-value service) and claim level (ie, spending on the low-value service plus associated services), adjusting for inflation.

Results

Among 21 045 759 individuals with fee-for-service Medicare (mean [SD] age, 77.4 [7.9] years; 12 515 915 [59.5%] women), the percentage receiving any of 32 low-value services decreased from 36.3% (95% CI, 36.3%-36.4%) to 33.6% (95% CI, 33.6%-33.6%) from 2014 to 2018. Uses of low-value services per 1000 individuals decreased from 677.8 (95% CI, 676.2-679.5) to 632.7 (95% CI, 632.6-632.8) from 2014 to 2018. Three services comprised approximately two-thirds of uses among 32 low-value services per 1000 individuals: preoperative laboratory testing decreased from 213.8 (95% CI, 213.4-214.2) to 166.2 (95% CI, 166.2-166.2), while opioids for back pain increased from 154.4 (95% CI, 153.6-155.2) to 182.1 (95% CI, 182.1-182.1) and antibiotics for upper respiratory infections increased from 75.0 (95% CI, 75.0-75.1) to 82 (95% CI, 82.0-82.0). Spending per 1000 individuals on low-value care also decreased, from $52 765.5 (95% CI, $51 952.3-$53 578.6) to $46 921.7 (95% CI, $46 593.7-$47 249.7) at the claim-line level and from $160 070.4 (95% CI, $158 999.8-$161 141.0) to $144 741.1 (95% CI, $144 287.5-$145 194.7) at the claim level.

Conclusions and Relevance

This cross-sectional study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign in collaboration with clinician specialty societies and increased attention on low-value care. While most use of low-value care came from 3 services, 1 of these was opioid prescriptions, which increased over time despite the harms associated with their use. These findings may represent several opportunities to prevent patient harm and lower spending.

Patient Perspectives on Treatment Options for Older Women With Hormone Receptor-Positive Breast Cancer: A Qualitative Study

Importance

Women aged 70 years or older with hormone receptor-positive breast cancer have an excellent prognosis, but because of their age and comorbidities, they are at higher risk for treatment-related adverse events. Despite studies demonstrating the safety of omitting previously routine therapies, including sentinel lymph node biopsy (SLNB) and postlumpectomy radiotherapy, these treatments continue to be used at high rates. Physicians cite patient preference as one factor associated with overuse. However, little is known about how women view potential de-escalation of therapies.

Objective

To evaluate older women's preferences for SLNB and radiotherapy in the setting of guidelines recommending them or allowing for their omission.

Design, Setting, and Participants

This qualitative study was performed from October 2019 to January 2020. Midwestern women aged 70 years and older who had never received a diagnosis of breast cancer were recruited online and interviewed. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from January to March 2020.

Exposures

Participants were presented with hypothetical scenarios in which they received a diagnosis of low-risk, hormone receptor-positive breast cancer and were given treatment options in accordance with current guidelines.

Main Outcomes and Measures

The interviews elicited perspectives on breast cancer treatment, including surgery, SLNB, chemotherapy, and postlumpectomy radiotherapy.

Results

The median (interquartile range) age of the 30 participants was 72.0 (71.0-76.5) years. Most of the women were White (26 participants [87%]), lived in metropolitan areas (29 participants [97%]), and were college educated (20 participants [67%] had a 4-year degree or higher). Overall, women expressed the belief that age-based guidelines were appropriate on the basis of decreased recurrence risk and increased frailty in older patients. However, many participants stated that these guidelines should not apply to healthy older women with a long life expectancy. Some participants struggled to understand that the basis for treatment de-escalation in older patients is a favorable, not poor, prognosis. Women who said they would undergo SLNB (12 participants [40%]) perceived the procedure as low risk and providing peace of mind. Most participants (22 participants [73%]) expressed a preference for omitting postlumpectomy radiotherapy because of the perceived risks, lack of benefit, and inconvenience.

Conclusions and Relevance

Positive reframing of the excellent prognosis driving national recommendations for de-escalation may reduce breast cancer overtreatment in older women. Strategies for reducing SLNB use will likely require education on the risks vs benefits and addressing patient preferences for peace of mind. In contrast, efforts to reduce radiotherapy use may need to address clinician or organizational factors.

How do patients and the public understand overtesting and overdiagnosis? A protocol for a thematic meta-synthesis of qualitative research

INTRODUCTION

Examining patient and public understanding of overtesting and overdiagnosis (OverTD) is vital for reducing the burden of OverTD. Studies from disparate contexts, disciplines and focusing on disparate healthcare issues have examined patient and public understanding of OverTD. A synthesis is needed to bring this literature together, examine common themes, strengthen conclusions and identify gaps. This will help steer further research, policy and practice to improve patient and public understanding of OverTD. The objective of this study is to synthesise qualitative research data about patient and public understanding of OverTD.

METHODS AND ANALYSIS

A thematic meta-synthesis will be used to synthesise primary qualitative research and qualitative components of primary mixed-methods research about patient and public understanding of OverTD. Studies published in English will be included. These will be identified using systematic searches from inception to March 2020 in the Scopus, CINAHL, PsycINFO and MEDLINE databases. Studies that satisfy eligibility criteria will be assessed for methodological quality using the Critical Appraisal Skills Programme (CASP) checklist. Thematic meta-synthesis will comprise three stages: (1) line-by-line coding; (2) generation of descriptive themes and (3) generation of analytic themes. Confidence in the synthesis findings will be assessed using the Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence (GRADE CERQual) approach. A summary of GRADE CERQual results will be presented alongside the key themes. Study eligibility screening, data extraction, analysis and the CASP and GRADE CERQual assessments will be undertaken independently by two review authors.

ETHICS AND DISSEMINATION

Ethics approval is not required for this secondary analysis of published data. The results will be disseminated in peer-reviewed journals and may be presented in conference papers and elsewhere.

PROSPERO REGISTRATION NUMBER

CRD42020156838.

Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review

CONTEXT

There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care.

OBJECTIVE

The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice.

METHODS

We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored.

RESULTS

We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs.

CONCLUSION

Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.

Patient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review

BACKGROUND OR CONTEXT

Routine imaging for non-specific low back pain is advised against in guidelines yet imaging continues to occur. Patient and public beliefs regarding imaging may be a driving factor contributing to this.

OBJECTIVES

To review the current evidence in relation to patient and public beliefs regarding imaging for low back pain.

DATA SOURCES

A systematic scoping review was conducted in databases Medline, Embase, Cinahl, Psyc info (inception - Jan 2018).

STUDY SELECTION

Any method of study including beliefs of adults about imaging for non-specific low back pain.

DATA EXTRACTION AND DATA SYNTHESIS

Descriptive data was extracted and patient and public beliefs about imaging for low back pain was analysed using conventional qualitative content analysis.

RESULTS

12 studies from an initial search finding of 1135 were analysed. 3 main themes emerged; (1) The Desire for imaging; (2) Influences on patient desire for imaging including (a) clinical presentation, (b) past experience and (c)relationships with care professionals and (3) Negative consequences of imaging.

LIMITATIONS

Few qualitative studies were found, all studies were in English language, the majority of studies were older than 2003.

CONCLUSION AND IMPLICATIONS OF KEY FINDINGS

There is little available evidence on patient and public beliefs about imaging but what evidence there is suggests that imaging is seen as positive in the management of low back pain and patient desire for a diagnosis is a big driver of this. There is also a suggestion that these beliefs may still be being influenced by health care professionals.

Semistructured interviews regarding patients' perceptions of Choosing Wisely and shared decision-making: an Australian study

OBJECTIVES

This study aimed to examine how patients perceive shared decision-making regarding CT scan referral and use of the five Choosing Wisely questions with their general practitioner (GP).

DESIGN

This is a qualitative exploratory study using semistructured interviews.

SETTING

This study was conducted in a large metropolitan public healthcare organisation in urban Australia.

PARTICIPANTS

Following purposive sampling, 20 patients and 2 carers participated. Patient participants aged 18 years or older were eligible if they were attending the healthcare organisation for a CT scan and referred by their GP. Carers/family were eligible to participate when they were in the role of an unpaid carer and were aged 18 years or older. Participants were required to speak English sufficiently to provide informed consent. Participants with cognitive impairment were excluded.

FINDINGS

Eighteen interviews were conducted with the patient only. Two interviews were conducted with the patient and the patient's carer. Fourteen participants were female. Five themes resulted from the thematic analysis: (1) needing to know, (2) questioning doctors is not necessary, (3) discussing scans is not required, (4) uncertainty about questioning and (5) valuing the Choosing Wisely questions. Participants reported that they presented to their GP with a health problem that they needed to understand and address. Participants accepted their GPs decision to prescribe a CT scan to identify the nature of their problem. They reported ambivalence about engaging in shared decision-making with their doctor, although many participants reported valuing the Choosing Wisely questions.

CONCLUSIONS

Shared decision-making is an important principle underpinning Choosing Wisely. Practice implementation requires understanding patients' motivations to engage in shared decision-making with a focus on attitudes, beliefs, knowledge and emotions. Systems-level support and education for healthcare practitioners in effective communication is important. However, this needs to emphasise communication with patients who have varying degrees of motivation to engage in shared decision-making and Choosing Wisely.

Physician and Patient Characteristics Associated With More Intensive End-of-Life Care

CONTEXT

Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties.

OBJECTIVE

To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL.

METHODS

We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life.

RESULTS

Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification.

CONCLUSION

Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.

Knowledge translation and health technology reassessment: identifying synergy

Background

Health Technology Reassessment (HTR) is an emerging field that shifts the focus from traditional methods of technology adoption to managing technology throughout its lifecycle. HTR is a mechanism to improve patient care and system efficiency through a reallocation of resources away from low-value care towards interventions and technologies that are high value. To achieve this, the outputs of HTR and its recommendations must be translated into practice. The evolving field of knowledge translation (KT) can provide guidance to improve the uptake of evidence-informed policies and recommendations resulting from the process of HTR. This paper argues how the theories, models and frameworks from KT could advance the HTR process.

Discussion

First, common KT theories, models and frameworks are presented. Second, facilitators and barriers to KT within the context of HTR are summarized from the literature. Facilitators and barriers to KT include ensuring a solid research evidence-base for the technology under reassessment, assessing the climate and context, understanding the social an political context, initiating linkage and exchange, having a structured HTR Process, adequate resources, and understanding the roles of researchers, knowledge users, and stakeholders can enhance knowledge translation of HTR outputs. Third, three case examples at the individual (micro), organizational (meso), and policy (macro) levels are used to illustrate to describe how a KT theory, model or framework could be applied to a HTR project. These case studies show how selecting and applying KT theories, models and frameworks can facilitate the implementation of HTR recommendations.

Conclusion

HTR and KT are synergistic processes that can be used to optimize technology use throughout its lifecycle. We argue that the application of KT theories, models and frameworks, and the assessment of barriers and facilitators to KT can facilitate translation of HTR recommendations into practice.

Understanding Waste in Health Care: Perceptions of Frontline Physicians Regarding Time Use and Appropriateness of Care They and Others Provide

BACKGROUND

Approximately 30% of total US health care spending is thought to be "wasted" on activities like unnecessary and inefficiently delivered services.

OBJECTIVES

To assess the perceptions of clinic-based physicians regarding their use of time and appropriateness of care provided.

DESIGN

Cross-sectional online survey of all Southern California Permanente Medical Group partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers.

MAIN OUTCOME MEASURES

The proportion of time spent on direct patient care tasks perceived to require the respondent's clinical/specialty training as a physician or another physician who has similar years of clinical training (vs physicians with fewer years of clinical training, nonphysicians, or automated or computerized systems), and the proportion of care provided by the respondent and by other physicians with whom they are familiar that is perceived to be appropriate (vs equivocal or inappropriate).

RESULTS

More than 61% of respondents indicated that 15% of their time spent on direct patient care could be shifted to nonphysicians, and between 10% and 16% of care provided was equivocal or inappropriate.

DISCUSSION

The low proportion of care perceived as equivocal or inappropriate indicates there is little room for reducing such care or that physicians have difficulty assessing care appropriateness. The latter suggests that attempts to reduce or to eliminate inappropriate care may be unsuccessful until physician beliefs, knowledge, or behaviors are better understood and addressed.

CONCLUSION

On the basis of these findings, it is apparent that within at least one health care system, the opportunity to increase value through task shifting and avoiding inappropriate care is more narrow than commonly perceived on a national level.

Transformation of the Health Care Industry: Curb Your Enthusiasm?

Policy Points: Policymakers seek to transform the US health care system along two dimensions simultaneously: alternative payment models and new models of provider organization. This transformation is supposed to transfer risk to providers and make them more accountable for health care costs and quality. The transformation in payment and provider organization is neither happening quickly nor shifting risk to providers. The impact on health care cost and quality is also weak or nonexistent. In the longer run, decision makers should be prepared to accept the limits on transformation and carefully consider whether to advocate solutions not yet supported by evidence.

CONTEXT

There is a widespread belief that the US health care system needs to move "from volume to value." This transformation to value (eg, quality divided by cost) is conceptualized as a two-fold movement: (1) from fee-for-service to alternative payment models; and (2) from solo practice and freestanding hospitals to medical homes, accountable care organizations, large hospital systems, and organized clinics like Kaiser Permanente.

METHODS

We evaluate whether this transformation is happening quickly, shifting risk to providers, lowering costs, and improving quality. We draw on recent evidence on provider payment and organization and their effects on cost and quality.

FINDINGS

Data suggest a low prevalence of provider risk payment models and slow movement toward new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak.

CONCLUSIONS

We need to be patient in expecting system improvements from ongoing changes in provider payment and organization. We also may need to look for improvements in other areas of the economy or to accept and accommodate prospects of modest improvements over time.

'It has saved thousands of lives, so why change it?' Content analysis of objections to cervical screening programme changes in Australia

OBJECTIVES

The incidence and mortality of cervical cancer have halved since introduction of the Australian cervical screening programme in 1991, involving 2-yearly Pap smears from ages 18-69 years. In 2017, the programme changed to 5- yearly primary human papillomavirus (HPV) testing for women aged 25-74 years. This study investigated reasons for opposition to the renewed screening programme within the open-ended comments of an online petition, 'Stop May 1st Changes to Pap Smears-Save Women's Lives', opposing the changes, which received over 70 000 signatures and almost 20 000 comments.

METHODS

Content analysis of a random sample of 2000 comments, reflecting 10% of the 19 633 comments posted in February-March 2017.

RESULTS

Nineteen codes were identified, reflecting four themes: (1) valuing women's health and rights, (2) political statements, (3) concerns about healthcare funding cuts and (4) opposition to specific components of the new screening programme. The most prevalent codes were: placing value on women's health (33%), concerns about increasing screening intervals (17%) and opposition to the changes related to personal experiences with cervical cancer or cervical abnormalities (15%). Concern about the key change in technology (HPV testing instead of Pap smears) was expressed in less than 3% of comments, and some opposition to the changes from health professionals was noted.

CONCLUSIONS

Screening changes within this selected group were perceived as threatening women's health, as a political policy created by male decision-makers and as a cost-cutting exercise. Many commenters were concerned about increased screening intervals and later screening onset, but little opposition was expressed regarding the testing technology itself. This analysis may inform public education and communication strategies for future changes to cervical screening programmes internationally, to pre-emptively address specific concerns about the changes.

[Choosing Wisely - Klug Entscheiden: conceptual and ethical considerations]

Choosing Wisely and Klug Entscheiden (KE) are recent physician-triggered campaigns that aim at identifying and reducing blatant over-treatment as well as - a specialty of KE - occurring under-treatment. This paper provides some conceptual and normative analyses of these campaigns' goals and justifications.

Shared decision making in the UK: Moving towards wider uptake

Shared decision making (SDM) is firmly on the policy agenda in the UK and a recent legal ruling has confirmed its importance. Policymakers, ethicists, professional regulators and societies, patient organisations and now the courts are committed to ensuring that SDM becomes the norm throughout the NHS, but an unfavourable economic climate makes this especially challenging. Considerable progress has been made over the last few years, with new learning from demonstration sites, various initiatives in capacity building and training, wider availability of patient decision aids, and important leadership initiatives. Enthusiasm for this way of working is growing among clinicians, patients and managers, but it could be undermined if SDM comes to be seen primarily as a means of cost control.