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Beks H, Clayden S, Wong Shee A, Manias E, Versace VL, Beauchamp A, Mc Namara KP, Alston L. Low-value health care, de-implementation, and implications for nursing research: A discussion paper. Int J Nurs Stud 2024; 156:104780. [PMID: 38744150 DOI: 10.1016/j.ijnurstu.2024.104780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 03/13/2024] [Accepted: 04/19/2024] [Indexed: 05/16/2024]
Abstract
Globally, the nursing profession constitutes the largest proportion of the health workforce; however, it is challenged by widespread workforce shortages relative to need. Strategies to promote recruitment of the nursing workforce are well-established, with a lesser focus on strategies to alleviate the burden on the existing workforce. This burden may be exacerbated by the impact of low-value health care, characterised as health care that provides little or no benefit for patients, or has the potential to cause harm. Low-value health care is a global problem, a major contributor to the waste of healthcare resources, and a key focus of health system reform. Evidence of variation in low-value health care has been identified across countries and system levels. Research on low-value health care has largely focused on the medical profession, with a paucity of research examining either low-value health care or the de-implementation of low-value health care from a nursing perspective. The objective of this paper is to provide a scholarly discussion of the literature around low-value health care and de-implementation, with the purpose of identifying implications for nursing research. With increasing pressures on the global nursing workforce, research identifying low-value health care and developing approaches to de-implement this care, is crucial.
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Affiliation(s)
- H Beks
- Deakin Rural Health, Deakin University, Australia.
| | - S Clayden
- Deakin Rural Health, Deakin University, Australia; South West Healthcare, Australia
| | - A Wong Shee
- Deakin Rural Health, Deakin University, Australia; Grampians Health, Australia
| | - E Manias
- Deakin Rural Health, Deakin University, Australia; School of Nursing and Midwifery, Monash University, Australia
| | - V L Versace
- Deakin Rural Health, Deakin University, Australia
| | - A Beauchamp
- School of Rural Health, Monash University, Australia
| | | | - L Alston
- Deakin Rural Health, Deakin University, Australia; Colac Area Health, Australia
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Kjelle E, Brandsæter IØ, Andersen ER, Hofmann B. Sustainability in healthcare by reducing low-value imaging - A narrative review. Radiography (Lond) 2024; 30 Suppl 1:30-34. [PMID: 38870571 DOI: 10.1016/j.radi.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES This narrative review aims to present the concept of value in imaging and explore why we conduct low-value procedures, how to reduce this wasteful use, and what we could gain from reducing low-value imaging. KEY FINDINGS Imaging of low value to the patient contributes to thousands of metric tons of CO2 emissions, costing several billion US dollars annually. With a 20% reduction in low-value imaging, we would reduce the waste of resources related to 7.2 million procedures and, at the same time, reduce the risk of incidentalomas, overdiagnosis, and overtreatment and reduce wait times for patients in need of imaging services of high value. Multi-component initiatives targeting barriers in all levels of society and healthcare are needed to reduce low-value imaging. Radiographers are key actors in medical imaging and can make substantial contributions to this effort by, together with the radiologists, referrers, and managers, ensuring that all imaging procedures conducted are sustainable along four dimensions of sustainability: value, cost, risk, and environment. CONCLUSION Efforts to secure sustainable imaging considering the four crucial dimensions (value, cost, radiation, and environment) should be made at all levels of society and healthcare, from governmental management to the individual healthcare worker. Radiographers are vital in obtaining sustainability to ensure only sustainable imaging procedures are conducted. IMPLICATIONS FOR PRACTICE When assessing the appropriateness of imaging procedures, we need to consider the environment, safety, effectiveness, and efficiency. To obtain this, we need a collective and coordinated effort locally, nationally, and internationally to deliver sustainable imaging services.
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Affiliation(s)
- E Kjelle
- Department of Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802 Gjøvik Norway; Department of Optometry, Radiography, and Lighting Design at the University of South-Eastern Norway (USN) at Drammen, Post Office Box 4, 3199 Borre, Norway.
| | - I Ø Brandsæter
- Department of Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802 Gjøvik Norway
| | - E R Andersen
- Department of Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802 Gjøvik Norway
| | - B Hofmann
- Department of Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802 Gjøvik Norway; Centre of Medical Ethics at the University of Oslo, Centre of Medical Ethics, Postbox 1130, Blindern, 0318 Oslo, Norway
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Harness ED, Goldberg ZN, Shah YB, Krishnan AS, Jayanti V, Nash DB. The Academic Payvider Model: Care and Coverage. Popul Health Manag 2024; 27:160-167. [PMID: 38442303 DOI: 10.1089/pop.2023.0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
The US health care system has significant room for growth to achieve the Quintuple Aim. Reforming the relationship between payers and providers is pivotal to enhancing value-based care (VBC). The Payvider model, a joint approach to care and coverage rooted in vertical integration, is a potential solution. The authors aimed to investigate academic medical institutions adopting this model, termed Academic Payviders. All Association of American Medical Colleges (AAMC)-member allopathic medical schools were evaluated to identify programs meeting the inclusion criteria of offering both medical care and insurance coverage to patients via partnership with a payer or ownership of, or by, a payer. Twenty-five Academic Payvider systems were identified from 171 total AAMC-member programs. Most programs were founded after 2009 (n = 20), utilized a provider-dominant structural model (n = 17), and offered health plans to patients via Medicare Advantage (n = 23). Passage of the Affordable Care Act, recent trends in health care consolidation, and increased political and financial prioritization of social determinants of health (SDOH) may help to explain the rise of this care and coverage model. The Academic Payvider movement could advance academic medicine toward greater acceptance of VBC via innovations in medical education, resource stewardship in residency, and the establishment of innovative leadership positions at the administrative level.
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Affiliation(s)
- Erika D Harness
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Zachary N Goldberg
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Jefferson College of Population Health, Philadelphia, Pennsylvania, USA
| | - Yash B Shah
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Akshay S Krishnan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Varun Jayanti
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David B Nash
- Jefferson College of Population Health, Philadelphia, Pennsylvania, USA
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Rung JM, Aliu O, Barrett TS, LeJeune K, Farah TG. Prevalence and Cost of Routine Preoperative Care for Low-Risk Cataract Surgery a Decade after Choosing Wisely. Ophthalmology 2024; 131:577-588. [PMID: 38092081 DOI: 10.1016/j.ophtha.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/07/2023] [Accepted: 12/01/2023] [Indexed: 01/30/2024] Open
Abstract
PURPOSE Examine the frequency and cost of procedural clearance tests and examinations in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the United States. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts postsurgical adverse events. DESIGN Retrospective healthcare claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania. PARTICIPANTS Members aged ≥ 65 years who were continuously enrolled 6 months before and after undergoing cataract surgery from 2018 to 2021 and had approved surgery claims. METHODS Preoperative exams or tests occurring in the 30 days before surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., Current Procedural Terminology codes for blood panels and preprocedural International Classification of Diseases, 10th Revision, Clinical Modification codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling. MAIN OUTCOME MEASURES Total costs, prevalence, and strength of association as indicated by odds ratios. RESULTS Up to 42% of members undergoing cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed in isolation or along with clearance visits. The combined costs for the preoperative visits and tests were $4.3 million (approximately $107-$114 per impacted member). There was little difference in member characteristics between those receiving and not receiving preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member's care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two. CONCLUSIONS Rates of routine preoperative testing before cataract surgery appear similar to those prior to the implementation of the Choosing Wisely campaign, which was meant to reduce this use. Additionally, preoperative evaluations, many likely unnecessary, were common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
| | - Oluseyi Aliu
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Keith LeJeune
- Highmark Health, Pittsburgh, Pennsylvania; Allegheny Health Network, Pittsburgh, Pennsylvania
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Hernes SS, Høiberg M, Gallefoss F, Thoresen C, Tjomsland O. Intervention for reducing the overuse of upper endoscopy in patients <45 years: a protocol for a stepwise intervention programme. BMJ Open Qual 2024; 13:e002649. [PMID: 38684346 PMCID: PMC11086486 DOI: 10.1136/bmjoq-2023-002649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/12/2024] [Indexed: 05/02/2024] Open
Abstract
Utilisation rates for healthcare services vary widely both within and between nations. Moreover, healthcare providers with insurance-based reimbursement systems observe an effect of social determinants of health on healthcare utilisation rates and outcomes. Even in countries with publicly funded universal healthcare such as Norway, utilisation rates for medical and surgical interventions vary between and within health regions and hospitals.Most interventions targeting overuse and high utilisation rates are based on the assumption that knowledge of areas of unwarranted variation in healthcare automatically will lead to a reduction in unwarranted variation. Recommendations regarding how to reduce this variation are often not very detailed or prominent.This paper describes a protocol for reducing the overuse of upper endoscopy in a Norwegian health region. The protocol uses a combination of digital tools and psychological methods targeting behavioural change in order to alter healthcare workers' approach to patient care.The aim of the planned intervention is to evaluate the effectiveness of a multifaceted set of interventions to reduce the overuse of upper endoscopy in patients under 45 years. A secondary aim is to evaluate the specific effect of the various parts of the intervention.
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Affiliation(s)
- Susanne Sorensen Hernes
- Department of Geriatrics and Internal medicine, Sorlandet Hospital Arendal, Kristiansand, Agder, Norway
- Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Mikkel Høiberg
- Department of Endocrinology, Sorlandet Hospital Arendal, Arendal, Norway
| | - Frode Gallefoss
- Department of Clinical Sciences, University of Bergen, Bergen, Norway
- Department of Pulmonology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | | | - Ole Tjomsland
- Director of Quality and Specialist Areas, South-Eastern Norway Regional Health Authority, Hamar, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Rockwell MS, Oyese EG, Singh E, Vinson M, Yim I, Turner JK, Epling JW. Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings. BMJ Open 2024; 14:e078808. [PMID: 38631836 PMCID: PMC11029194 DOI: 10.1136/bmjopen-2023-078808] [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: 08/12/2023] [Accepted: 03/12/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES Potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) utilisation persists at undesirable rates worldwide. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research. DESIGN Scoping review. DATA SOURCES PubMed, CINAHL, Embase, Cochrane Central and Google Scholar (1 January 2000 to 31 May 2022). STUDY SELECTION Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilisation in healthcare settings. DATA EXTRACTION Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilisation. RESULTS From 7818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the USA (35.3%), with randomised controlled trial as the most common design (55.9%). Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%) but were rarely (14.9%) guided by an implementation model, framework or theory. Academic detailing, clinical decision support or electronic medical record interventions, performance reports and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%), history of gastrointestinal disorders (47.1%), or history of kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter (OTC) NSAIDs in addition to prescription. The majority of studies (76.2%) reported a reduction in the utilisation of potentially harmful NSAIDs. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation. CONCLUSION Many varied interventions to de-implement potentially harmful NSAIDs have been applied in healthcare settings worldwide. Based on these findings and identified knowledge gaps, further efforts to comprehensively evaluate the effectiveness of interventions and the combination of intervention characteristics associated with effective de-implementation are needed. In addition, future work should be guided by de-implementation theory, focus on OTC NSAIDs and incorporate patient-focused strategies and outcomes, including the evaluation of unintended consequences of the intervention.
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Affiliation(s)
- Michelle S Rockwell
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Emma G Oyese
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Eshika Singh
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Matthew Vinson
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Isaiah Yim
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Jamie K Turner
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - John W Epling
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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Tyack Z, Carter H, Allen M, Senanayake S, Warhurst K, Naicker S, Abell B, McPhail SM. Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review. BMJ Open 2024; 14:e078761. [PMID: 38604625 PMCID: PMC11015208 DOI: 10.1136/bmjopen-2023-078761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/15/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes. DESIGN Scoping review. DATA SOURCES Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions. ELIGIBILITY CRITERIA We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings. DATA EXTRACTION AND SYNTHESIS Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework. RESULTS Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework. CONCLUSIONS Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.
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Affiliation(s)
- Zephanie Tyack
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hannah Carter
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Michelle Allen
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sameera Senanayake
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kym Warhurst
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
| | - Sundresan Naicker
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Metro South Health, Brisbane, Queensland, Australia
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Fischer K, Ugalde IT. Pediatric Emergency Medicine Joins Choosing Wisely, But Is It Enough? Ann Emerg Med 2024:S0196-0644(24)00137-9. [PMID: 38597848 DOI: 10.1016/j.annemergmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/01/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Kayleigh Fischer
- Department of Emergency Medicine, McGovern Medical School, UTHealth, Houston, TX
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School, UTHealth, Houston, TX.
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Tian EJ, Nguyen C, Chung L, Morris C, Kumar S. The Effectiveness of Public Awareness Initiatives Aimed at Encouraging the Use of Evidence-Based Recommendations by Health Professionals: A Systematic Review. J Patient Saf 2024; 20:147-163. [PMID: 38372511 DOI: 10.1097/pts.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Public awareness initiatives have attracted growing attention globally, as a strategy to reduce low-value care and disinformation. However, knowledge gap remains in determining their effects. The aim of this systematic review was to summarize existing evidence to date on global effectiveness of public awareness initiatives. METHODS Primary quantitative studies focusing on passive delivery of public awareness initiatives that targeted health professionals were included. Eligible studies were identified through search of MEDLINE, Embase, Emcare, the Cochrane Library, PsycINFO, Business Source Complete, Emerald Insight, and Google (initially on December 19, 2018, followed by updated search between July 8-10, 2019, and then between March 8-9, 2022) and the reference list of relevant studies. Methodological quality of included studies was assessed using modified McMaster critical appraisal tool. A narrative synthesis of the study outcomes was conducted. RESULTS Twenty studies from United States, United Kingdom, Canada, Australia, and multicountry were included. Nineteen studies focused on Choosing Wisely initiative and one focused on National Institute of Clinical Excellence reminders. Most studies investigated one recommendation of a specialty. The findings showed conflicting evidence on the effectiveness of public awareness initiatives, suggesting passive delivery has limited success in reducing low-value care among health professionals. CONCLUSIONS This review highlights the complexity of change in an established practice pattern in health care. As passive delivery of public awareness initiatives has limited potential to initiate and sustain change, wide-ranging intervention components need to be integrated for a successful implementation.
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Affiliation(s)
| | - Cathy Nguyen
- UniSA Business, University of South Australia, University of South Australia, Adelaide, Australia
| | - Lilian Chung
- From the UniSA Allied Health and Human Performance
| | - Chloe Morris
- From the UniSA Allied Health and Human Performance
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Wu S, Magwood O, Dong Q, Wei X. Evaluating population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings: A systematic review protocol. PLoS One 2024; 19:e0300780. [PMID: 38498514 PMCID: PMC10947694 DOI: 10.1371/journal.pone.0300780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Inappropriate antibiotic use contributes significantly to the global challenge of antimicrobial resistance. While government-initiated population-level interventions are fundamental in addressing this issue, their full potential remains to be explored. This systematic review aims to assess the effectiveness of such interventions in reducing inappropriate antibiotic use among antibiotic providers and users in healthcare and community settings. METHODS We will conduct a systematic literature search across multiple databases and grey literature sources. We will include studies which evaluate the effectiveness of population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings in both high-income and low- and middle-income countries. This includes government-initiated measures targeting antibiotic use through education, restriction, incentivization, coercion, training, persuasion, context modification, behavior modeling, or barrier reduction. Two reviewers will independently perform screening to select eligible studies, followed by data extraction. The outcomes of interest are various measures of antibiotic prescription and consumption, such as Defined Daily Dose (DDD) or number of prescriptions per year. We anticipate including a broad range of study designs and outcome measures. Therefore, we will narratively synthesize results using the categories of the population-level policy interventions of the Behavior Change Wheel Framework. We will organize outcome data by economic contexts, target populations, and implementation settings. DISCUSSION This review will strengthen the evidence base for the use of population-level interventions to address inappropriate antibiotic use. Drawing lessons from global experiences, the findings will provide valuable guidance to health policymakers, public health authorities, and researchers on tailoring interventions to specific economic contexts, populations, and settings, thereby enhancing their capacity to drive substantial improvement in appropriate antibiotic use.
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Affiliation(s)
- Shishi Wu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Olivia Magwood
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Faculty of Health Sciences, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Quanfang Dong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Horný M, Chang D, Christensen EW, Rula EY, Duszak R. Decomposition of medical imaging spending growth between 2010 and 2021 in the US employer-insured population. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae030. [PMID: 38756926 PMCID: PMC10986240 DOI: 10.1093/haschl/qxae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 05/18/2024]
Abstract
Medical imaging, identified as a potential driver of unsustainable US health care spending growth, was subject to policies to reduce prices and use in low-value settings. Meanwhile, the Affordable Care Act increased access to preventive services-many involving imaging-for employer-sponsored insurance (ESI) beneficiaries. We used a large insurance claims database to examine imaging spending trends in the ESI population between 2010 and 2021-a period of considerable policy and benefits changes. Nominal spending on imaging increased 35.9% between 2010 and 2021, but as a share of total health care spending fell from 10.5% to 8.9%. The 22.5% growth of nominal imaging prices was below inflation, 24.3%, as measured by the Consumer Price Index. Other key contributors to imaging spending growth were increased use (7.4 percentage points [pp]), shifts toward advanced modalities (4.0 pp), and demographic changes (3.5 pp). Shifts in care settings and provider network participation resulted in 2.5-pp and 0.3-pp imaging spending decreases, respectively. In sum, imaging spending decreased as a share of all health care spending and relative to inflation, as intended by concurrent cost-containment policies.
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Affiliation(s)
- Michal Horný
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, GA 30322, United States
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA 30322, United States
| | - Daniel Chang
- Department of Radiology and Imaging Sciences, School of Medicine, Emory University, Atlanta, GA 30322, United States
| | - Eric W Christensen
- Harvey L. Neiman Health Policy Institute, Reston, VA 20191, United States
- Health Services Management, University of Minnesota, St. Paul, MN 55108, United States
| | - Elizabeth Y Rula
- Harvey L. Neiman Health Policy Institute, Reston, VA 20191, United States
| | - Richard Duszak
- Department of Radiology, School of Medicine, University of Mississippi, Jackson, MS 39216, United States
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El Fadel O, Goldberg ZN, Jain A, Venkat N, Upadhyaya A, Mack S, Kaminski M, Papanagnou D, Ziring D, Hayden G. Integrating Choosing Wisely, Value-Based Care Principles, Into Undergraduate Medical Education: A Pilot Study. Cureus 2024; 16:e56912. [PMID: 38528995 PMCID: PMC10963070 DOI: 10.7759/cureus.56912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Healthcare spending represents a large portion of the GDP of the United States. Value-based care (VBC) seeks to decrease waste in health care spending, yet this concept is insufficiently taught to medical students. The Choosing Wisely Students and Trainees Advocating for Resource Stewardship (STARS) campaign promotes initiatives that integrate knowledge of VBC into undergraduate medical education (UME). This study sought to determine the most effective strategy to educate medical students on key principles of VBC as taught by the STARS campaign. METHODS Choosing Wisely principles were incorporated into the UME curriculum of an academic medical institution via the creation of eight new learning objectives (LOs) for case-based learning (CBL) sessions and lectures. Medical students completed an annual 10-question survey from 2019 to 2022 and 10 formal examination questions during the preclinical (years 1 and 2) curriculum after exposure to varying quantities of LOs. Pearson correlation, chi-square, and logistic regression were employed to determine the association between increased LOs in the curriculum and (1) campaign awareness and (2) knowledge of VBC principles. RESULTS A total of 700 survey responses over a four-year period (2019 to 2022) were analyzed. Student awareness of the campaign and knowledge of VBC principles increased year over year during the survey period (39% to 92% and 64% to 74%, respectively). There were significant associations between increased LOs in the curriculum and (1) campaign awareness (0.828, p<0.0001) and (2) knowledge of VBC principles (0.934, p<0.001). Students also performed well on formal examination questions related to VBC principles (mean: 81.5% and mean discrimination index: 0.18). CONCLUSION Integration of VBC-focused LOs is significantly associated with awareness of the Choosing Wisely STARS campaign and knowledge of VBC principles taught by the campaign. Collaborative initiatives to increase exposure to VBC education may improve students' knowledge of these principles during medical school.
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Affiliation(s)
- Omar El Fadel
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | | | - Amiti Jain
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Nitya Venkat
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Anjali Upadhyaya
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Shale Mack
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Mitchell Kaminski
- Family and Community Medicine, Thomas Jefferson University, Philadelphia, USA
| | | | - Deborah Ziring
- Internal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Geoffrey Hayden
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
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Persell SD, Petito LC, Lee JY, Meeker D, Doctor JN, Goldstein NJ, Fox CR, Rowe TA, Linder JA, Chmiel R, Peprah YA, Brown T. Reducing Care Overuse in Older Patients Using Professional Norms and Accountability : A Cluster Randomized Controlled Trial. Ann Intern Med 2024; 177:324-334. [PMID: 38315997 DOI: 10.7326/m23-2183] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Effective strategies are needed to curtail overuse that may lead to harm. OBJECTIVE To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients. DESIGN 18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753). SETTING 60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022. PARTICIPANTS 371 primary care clinicians and their older adult patients from participating practices. INTERVENTION Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability. MEASUREMENTS Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A1c (HbA1c) less than 7%. RESULTS At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]). LIMITATION A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation. CONCLUSION Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Stephen D Persell
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; and Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.D.P., J.A.L.)
| | - Lucia C Petito
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (L.C.P.)
| | - Ji Young Lee
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | | | - Jason N Doctor
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California (J.N.D.)
| | - Noah J Goldstein
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California (N.J.G., C.R.F.)
| | - Craig R Fox
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California (N.J.G., C.R.F.)
| | - Theresa A Rowe
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | - Jeffrey A Linder
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; and Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.D.P., J.A.L.)
| | - Ryan Chmiel
- Information Services, Northwestern Memorial HealthCare, Chicago, Illinois (R.C.)
| | - Yaw Amofa Peprah
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | - Tiffany Brown
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
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Born KB, Levinson W, Vaux E. Choosing Wisely and the climate crisis: a role for clinicians. BMJ Qual Saf 2024; 33:200-204. [PMID: 37268407 DOI: 10.1136/bmjqs-2023-015928] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/14/2023] [Indexed: 06/04/2023]
Affiliation(s)
- Karen B Born
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Emma Vaux
- Department of Renal Medicine, Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
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Ganguli I, Chant ED, Orav EJ, Mehrotra A, Ritchie CS. Health Care Contact Days Among Older Adults in Traditional Medicare : A Cross-Sectional Study. Ann Intern Med 2024; 177:125-133. [PMID: 38252944 PMCID: PMC10923005 DOI: 10.7326/m23-2331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Days spent obtaining health care outside the home can represent not only access to needed care but also substantial time, effort, and cost, especially for older adults and their care partners. Yet, these "health care contact days" have not been characterized. OBJECTIVE To assess composition of, variation and patterns in, and factors associated with contact days among older adults. DESIGN Cross-sectional study. SETTING Nationally representative 2019 Medicare Current Beneficiary Survey data linked to claims. PARTICIPANTS Community-dwelling adults aged 65 years and older in traditional Medicare. MEASUREMENTS Ambulatory contact days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility); multivariable mixed-effects Poisson regression to identify patient factors associated with contact days. RESULTS In weighted results, 6619 older adults (weighted: 29 694 084) had means of 17.3 ambulatory contact days (SD, 22.1) and 20.7 total contact days (SD, 27.5) in the year; 11.1% had 50 or more total contact days. Older adults spent most contact days on ambulatory care, including primary care visits (mean [SD], 3.5 [5.0]), specialty care visits (5.7 [9.6]), tests (5.3 [7.2]), imaging (2.6 [3.9]), procedures (2.5 [6.4]), and treatments (5.7 [13.3]). Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Factors associated with more ambulatory contact days included younger age, female sex, White race, non-Hispanic ethnicity, higher income, higher educational attainment, urban residence, more chronic conditions, and care-seeking behaviors (for example, "go to the doctor…as soon as (I)…feel bad"). LIMITATION Study population limited to those in traditional Medicare. CONCLUSION On average, older adults spent 3 weeks in the year getting care outside the home. These contact days were mostly ambulatory and varied widely not only by number of chronic conditions but also by sociodemographic factors, geography, and care-seeking behaviors. These results show factors beyond clinical need that may drive overuse and underuse of contact days and opportunities to optimize this person-centered measure to reduce patient burdens, for example, via care coordination. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Emma D Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (E.D.C.)
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Ateev Mehrotra
- Harvard University, Boston; and Beth Israel Deaconess Medical Center, Boston, Massachusetts (A.M.)
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston; and Harvard University, Boston, Massachusetts (C.S.R.)
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16
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Kurz M, Guerra-Alejos BC, Min JE, Barker B, Pauly B, Urbanoski K, Nosyk B. Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia. Implement Sci 2024; 19:3. [PMID: 38184548 PMCID: PMC10771688 DOI: 10.1186/s13012-023-01331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Characterizing the diffusion of adopted changes in policy and clinical practice can inform enhanced implementation strategies to ensure prompt uptake in public health emergencies and other rapidly evolving disease areas. A novel guidance document was introduced at the onset of the COVID-19 pandemic in British Columbia (BC), Canada, which supported clinicians to prescribe opioids, stimulants, and benzodiazepines. We aimed to determine the extent to which uptake and discontinuation of an initial attempt at a prescribed safer supply (PSS) program were influenced through networks of prescribers. METHODS We executed a retrospective population-based study using linked health administrative data that captured all clinicians who prescribed to at least one client with a substance use disorder from March 27, 2020, to August 31, 2021. Our main exposure was the prescribing patterns of an individuals' peers, defined as the proportion of a prescribers' professional network (based on shared clients), which had previously prescribed PSS, updated monthly. The primary outcome measured whether a clinician had prescribed their initial PSS prescription during a given calendar month. The secondary outcome was the discontinuation of PSS prescribing, defined as an absence for PSS prescriptions for at least 3 months. We estimated logistic regression models using generalized estimated equations on monthly repeated measurements to determine and characterize the extent to which peer networks influenced the initiation and discontinuation of PSS prescribing, controlling for network, clinician, and caseload characteristics. Innovators were defined as individuals initiating PSS prior to May 2020, and early adopters were individuals initiating PSS after. RESULTS Among 14,137 prescribers treating clients with substance use disorder, there were 228 innovators of prescribed safer supply and 1062 early adopters through the end of study follow-up, but 653 (50.6%) were no longer prescribing by August 2021. Prescribers with over 20% of peers whom had adopted PSS had a nearly fourfold higher adjusted odds of PSS prescribing themselves (aOR: 3.79, 95% CI: (3.15, 4.56)), compared to those with no connected safer supply prescribers. CONCLUSIONS The uptake of PSS in BC was highly dependent on the behavior of prescribers' peer networks. Future implementation strategies to support PSS or other policies would benefit from leveraging networks of prescribers.
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Affiliation(s)
- Megan Kurz
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada
| | | | - Jeong Eun Min
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
| | - Brittany Barker
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada
- First Nations Health Authority, Vancouver, BC, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Bernadette Pauly
- Department of Nursing, University of Victoria, Victoria, BC, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Karen Urbanoski
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Bohdan Nosyk
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada.
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada.
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Kripalani S, Norton WE. Methodological progress note: De-implementation of low-value care. J Hosp Med 2024; 19:57-61. [PMID: 38093492 PMCID: PMC10842822 DOI: 10.1002/jhm.13257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/26/2023] [Accepted: 11/29/2023] [Indexed: 01/04/2024]
Abstract
De-implementation is the process of reducing or stopping the use of ineffective, harmful, or low-value healthcare services that provide little or no benefit to patients. This article reviews relevant frameworks for planning and evaluating de-implementation initiatives, describes unique barriers, and provides effective strategies for de-implementation in Hospital Medicine.
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Affiliation(s)
- Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
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18
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Campbell HM, Murata AE, Henrie AM, Conner TA. Combination Therapy Use and Associated Events in Clinical Practice Following Dissemination of Trial Findings: A De-Implementation Study Using Interrupted Time Series Analysis. Clin Ther 2024; 46:40-49. [PMID: 37953077 DOI: 10.1016/j.clinthera.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 07/04/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE It takes 17 years, on average, for trial results to be implemented into practice. Using data from the Department of Veterans Affairs (VA), this study assessed the potential impact on clinical practice of the dissemination of findings from a randomized, controlled trial reporting harm with the use of combination therapy. Communication between research and VA Pharmacy Benefits Management Services (PBM) provided the impetus for communication from the PBM about the findings of the trial in accordance with policy. METHODS In this de-implementation study, interrupted time series analysis was used for assessing prescribing patterns and adverse clinical events before and after the dissemination of the trial findings. The de-implementation strategy was multicomponent and multilevel. Strategies were aligned with categories outlined in the Expert Recommendations for Implementing Change: train and educate stakeholders, use evaluative and iterative strategies, develop stakeholder inter-relationships, change infrastructure, provide interactive assistance, and engage consumers. VA patients with type 2 diabetes mellitus, chronic kidney disease stages 1 to 3, and a moderate or severe albuminuria who received care between July 2008 and November 2017 were included. Patients were subgrouped according to treatment with an angiotensin-converting enzyme inhibitor + angiotensin receptor blocker. The primary end point was the prevalence of combination therapy use. Secondary end points were the incidences of acute kidney injury and hyperkalemia. FINDINGS This study followed 712,245 patients, 9297 of whom used combination therapy. Data were available from 428,535 and 283,710 patients pre- and post-intervention, respectively; among these, 8324 and 973 patients used combination therapy, the median ages were 66 and 68 years, and 96.92% and 98.82% were men. One month following communication from the PBM, the reductions in combination therapy users, acute kidney injury events, and hyperkalemia were 331.94 (95% CI, 500.27-163.32), 36.58% (95% CI, 31.90%-41.95%), and 25.49% (95% CI, 14.17%-36.07%) per 100,000 patients per month, respectively (all, P < 0.001), whereas before the communication, these changes were +14.84 (95% CI, 10.27-19.42), -3.46% (95% CI, 3.18-3.74), and -3.27% (95% CI, 2.66%-3.87%) (all, P < 0.001). IMPLICATIONS The apparent speed and impact of the implementation of changes resulting from the dissemination of trial findings into VA clinical practice are encouraging. The speed of implementation was much faster than average for health care providers in the United States. Established communications between research and clinical practice, as well as established policy and communications between PBM and clinical practice, may be a model for other health care organizations.
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Affiliation(s)
- Heather M Campbell
- Clinical Research Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, New Mexico; College of Pharmacy, University of New Mexico, Albuquerque, New Mexico.
| | - Allison E Murata
- Clinical Research Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, New Mexico
| | - Adam M Henrie
- Clinical Research Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, New Mexico; College of Pharmacy, University of New Mexico, Albuquerque, New Mexico
| | - Todd A Conner
- Clinical Research Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, New Mexico; College of Pharmacy, University of New Mexico, Albuquerque, New Mexico
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Metusela C, Mullan J, Kobel C, Rhee J, Batterham M, Barnett S, Bonney A. CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change? BMC Health Serv Res 2023; 23:1346. [PMID: 38042789 PMCID: PMC10693689 DOI: 10.1186/s12913-023-10374-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future. METHODS This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework. RESULTS Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions. CONCLUSIONS Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).
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Affiliation(s)
- Christine Metusela
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia.
| | - Judy Mullan
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Conrad Kobel
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Joel Rhee
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Marijka Batterham
- School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, Australia
| | - Stephen Barnett
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Andrew Bonney
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
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Paz-Martin D, Arnal-Velasco D. Can we nudge to reduce the perioperative low value care? Decision making factors influencing safe practice implementation. Curr Opin Anaesthesiol 2023; 36:698-705. [PMID: 37767927 DOI: 10.1097/aco.0000000000001315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
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.
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Affiliation(s)
| | - Daniel Arnal-Velasco
- Unit of Anesthesiology and Reanimation, Hospital Universitario Fundacion Alcorcon, Alcorcon, Spain
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21
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Benítez TM, Kim YJ, Kong L, Wang L, Chung KC. Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair. Surgery 2023; 174:1281-1289. [PMID: 37586892 DOI: 10.1016/j.surg.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. METHODS This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. RESULTS 16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84). CONCLUSION Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.
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Affiliation(s)
- Trista M Benítez
- University of Michigan Medical School, Ann Arbor, MI; Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. https://www.twitter.com/benitez_trista
| | - You J Kim
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Rush University Medical College, Chicago, IL. https://www.twitter.com/kim_youj
| | - Lingxuan Kong
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
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Tjomsland O, Thoresen C, Ingebrigtsen T, Søreide E, Frich JC. Reducing unwarranted variation: can a 'clinical dashboard' be helpful for hospital executive boards and top-level leaders? BMJ LEADER 2023:leader-2023-000749. [PMID: 38053259 DOI: 10.1136/leader-2023-000749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 11/03/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND/AIM In the past decades, there has been an increasing focus on defining, identifying and reducing unwarranted variation in clinical practice. There have been several attempts to monitor and reduce unwarranted variation, but the experience so far is that these initiatives have failed to reach their goals. In this article, we present the initial process of developing a safety, quality and utilisation rate dashboard ('clinical dashboard') based on a selection of data routinely reported to executive boards and top-level leaders in Norwegian specialist healthcare. METHODS We used a modified version of Wennberg's categorisation of healthcare delivery to develop the dashboard, focusing on variation in (1) effective care and patient safety and (2) preference-sensitive and supply-sensitive care. RESULTS Effective care and patient safety are monitored with outcome measures such as 30-day mortality after hospital admission and 5-year cancer survival, whereas utilisation rates for procedures selected on cost and volume are used to follow variations in preference-sensitive and supply-sensitive care. CONCLUSION We argue that selecting quality indicators of patient safety, quality and utilisation rates and presenting them in a dashboard may help executive hospital boards and top-level leaders to focus on unwarranted variation.
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Affiliation(s)
- Ole Tjomsland
- Helse Sor-Ost RHF, Hamar, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | | | - Tor Ingebrigtsen
- Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Australian Institute of Health Innovation, Centre for Clinical Governance Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Eldar Søreide
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Critical Care and Anaesthesiology Research Group, Helse Stavanger HF, Stavanger, Norway
| | - Jan C Frich
- Universitetet i Oslo Avdeling for samfunnsmedisin, Oslo, Norway
- Diakonhjemmet Hospital, Oslo, Norway
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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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Harris AHS, Finlay AK, Hagedorn HJ, Manfredi L, Jones G, Kamal RN, Sears ED, Hawn M, Eisenberg D, Pershing S, Mudumbai S. Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. J Gen Intern Med 2023; 38:3209-3215. [PMID: 37407767 PMCID: PMC10651557 DOI: 10.1007/s11606-023-08287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/14/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described. OBJECTIVE We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice. DESIGN Qualitative study of semi-structured telephone interviews. PARTICIPANTS We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate. APPROACH Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations. KEY RESULTS Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures). CONCLUSIONS We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.
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Affiliation(s)
- Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA.
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Luisa Manfredi
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Gabrielle Jones
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Robin N Kamal
- Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Erika D Sears
- Center for Clinical Management Research, VA Ann Arbor Health Care System , Ann Arbor, MI, USA
- University of Michigan Department of Surgery, Ann Arbor, MI, USA
| | - Mary Hawn
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dan Eisenberg
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Stanford -Surgical Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Suzann Pershing
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Seshadri Mudumbai
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Conte de Oliveira MD, Fernandes HDS, Vasconcelos AL, Russo FADP, Malheiro DT, Colombo G, Pelegrini P, Berwanger O, Teich V, Marra A, Menezes FGD, Cendoroglo Neto M, Klajner S. Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies. BMJ Open Qual 2023; 12:e002178. [PMID: 37963671 PMCID: PMC10649569 DOI: 10.1136/bmjoq-2022-002178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/01/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Vanessa Teich
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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King AJ, Tang L, Davis BS, Preum SM, Bukowski LA, Zimmerman J, Kahn JM. Machine learning-based prediction of low-value care for hospitalized patients. INTELLIGENCE-BASED MEDICINE 2023; 8:100115. [PMID: 38130744 PMCID: PMC10735238 DOI: 10.1016/j.ibmed.2023.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Objective Low-value care (i.e., costly health care treatments that provide little or no benefit) is an ongoing problem in United States hospitals. Traditional strategies for reducing low-value care are only moderately successful. Informed by behavioral science principles, we sought to use machine learning to inform a targeted prompting system that suggests preferred alternative treatments at the point of care but before clinicians have made a decision. Methods We used intravenous administration of albumin for fluid resuscitation in intensive care unit (ICU) patients as an exemplar of low-value care practice, identified using the electronic health record of a multi-hospital health system. We divided all ICU episodes into 4-h periods and defined a set of relevant clinical features at the period level. We then developed two machine learning models: a single-stage model that directly predicts if a patient will receive albumin in the next period; and a two-stage model that first predicts if any resuscitation fluid will be administered and then predicts albumin only among the patients with a high probability of fluid use. Results We examined 87,489 ICU episodes divided into approximately 1.5 million 4-h periods. The area under the receiver operating characteristic curve was 0.86 for both prediction models. The positive predictive value was 0.21 (95% confidence interval: 0.20, 0.23) for the single-stage model and 0.22 (0.20, 0.23) for the two-stage model. Applying either model in a targeted prompting system could prevent 10% of albumin administrations, with an attending physician receiving one prompt every 4.2 days of ICU service. Conclusion Prediction of low-value care is feasible and could enable a point-of-care, targeted prompting system that offers suggestions ahead of the moment of need before clinicians have already decided. A two-stage approach does not improve performance but does interject new levers for the calibration of such a system.
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Affiliation(s)
- Andrew J. King
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Billie S. Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sarah M. Preum
- Department of Computer Science, Dartmouth College, Hanover, NH, USA
| | - Leigh A. Bukowski
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John Zimmerman
- Human-Computer Interaction Institute, Carnegie Mellon University School of Computer Science, Pittsburgh, PA, USA
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Bonney A, Kobel C, Mullan J, Metusela C, Rhee JJ, Barnett S, Batterham M. Randomised trial of general practitioner online education for prescribing and test ordering. BMJ Open Qual 2023; 12:e002351. [PMID: 37857521 PMCID: PMC10603404 DOI: 10.1136/bmjoq-2023-002351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION Potentially inappropriate medicine prescriptions and low-value diagnostic testing pose risks to patient safety and increases in health system costs. The aim of the Clinical and Healthcare Improvement through My Health Record usage and Education in General Practice study was to evaluate a scalable online quality improvement intervention, integrating online education regarding a national shared electronic health record and rational prescribing, pathology and imaging ordering by Australian general practitioners (GPs). METHODS The study was a parallel three-arm randomised trial comprising a prescribing education arm, a pathology education arm and an imaging education arm. Currently practising GPs in Australia were eligible to participate and randomised on a 1:1:1 basis to the study arms after consenting. The response to the intervention in reducing potentially unnecessary medicine prescriptions and tests in each arm was assessed using the other two arms as controls. The primary outcome was the cost per 100 consultations of predefined medication prescriptions, pathology and radiology test ordering 6 months following the intervention, compared with 6 months prior. Outcomes were assessed on intention-to-treat and post hoc per-protocol bases using multilevel regression models, with the analysts blinded to allocation. RESULTS In total, 106 GPs were enrolled and randomised (prescribing n=35, pathology n=36, imaging n=35). Data were available for 97 GPs at the end of trial (prescribing n=33, pathology n=32, imaging n=32) with 44 fully completing the intervention. In intention-to-treat analysis, there were no significant differences in the rates of change in costs across the three arms. Per protocol, there was a statistically significant difference in the rate of change in pathology costs (p=0.03). In the pathology arm, the rate of increase in pathology costs was significantly lower by $A187 (95% CI -$A340, -$A33) than the prescribing arm, and non-significantly $A9 (95% CI -$A128, $A110) lower than the imaging arm. DISCUSSION This study provides some evidence for reductions in costs for low-value pathology test ordering in those that completed the relevant online education. The study experienced slow uptake and low completion of the education intervention during the COVID-19 pandemic. Changes were not significant for the primary endpoint, which included all participants. Improving completion rates and combining real-time feedback on prescribing or test ordering may increase the overall effectiveness of the intervention. Given the purely online delivery of the education, there is scope for upscaling the intervention, which may provide cost-effectiveness benefits. TRIAL REGISTRATION NUMBER ACTRN12620000010998.
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Affiliation(s)
- Andrew Bonney
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Conrad Kobel
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Judy Mullan
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Christine Metusela
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joel J Rhee
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Barnett
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Marijka Batterham
- School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, New South Wales, Australia
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Dunsmore J, Duncan E, MacLennan S, N'Dow J, MacLennan S. Effectiveness of de-implementation strategies for low-value prescribing in secondary care: a systematic review. Implement Sci Commun 2023; 4:115. [PMID: 37723589 PMCID: PMC10507868 DOI: 10.1186/s43058-023-00498-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/06/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND/AIMS Considerable efforts have been made to improve guideline adherence in healthcare through de-implementation, such as decreasing the prescription of inappropriate medicines. However, we have limited knowledge about the effectiveness, barriers, facilitators and consequences of de-implementation strategies targeting inappropriate medication prescribing in secondary care settings. This review was conducted to understand these factors to contribute to better replication and optimisation of future de-implementation efforts to reduce low-value care. METHODS A systematic review of randomised control trials was conducted. Papers were identified through CINAHL, EMBASE, MEDLINE and Cochrane register of controlled trials to February 2021. Eligible studies were randomised control trials evaluating behavioural strategies to de-implement inappropriate prescribing in secondary healthcare. Risk of bias was assessed using the Cochrane Risk of Bias tool. Intervention characteristics, effectiveness, barriers, facilitators and consequences were identified in the study text and tabulated. RESULTS Eleven studies were included, of which seven were reported as effectively de-implementing low-value prescribing. Included studies were judged to be mainly at low to moderate risk for selection biases and generally high risk for performance and reporting biases. The majority of these strategies were clinical decision support at the 'point of care'. Clinical decision support tools were the most common and effective. They were found to be a low-cost and simple strategy. However, barriers such as clinician's reluctance to accept recommendations, or the clinical setting were potential barriers to their success. Educational strategies were the second most reported intervention type however the utility of educational strategies for de-implementation remains varied. Multiple barriers and facilitators relating to the environmental context, resources and knowledge were identified across studies as potentially influencing de-implementation. Various consequences were identified; however, few measured the impact of de-implementation on usual appropriate practice. CONCLUSION This review offers insight into the intervention strategies, potential barriers, facilitators and consequences that may affect the de-implementation of low-value prescribing in secondary care. Identification of these key features helps understand how and why these strategies are effective and the wider (desirable or undesirable) impact of de-implementation. These findings can contribute to the successful replication or optimisation of strategies used to de-implement low-value prescribing practices in future. TRIAL REGISTRATION The review protocol was registered at PROSPERO (ID: CRD42021243944).
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Affiliation(s)
| | - Eilidh Duncan
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sara MacLennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
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Glynn J, Jones T, Bell M, Blazeby J, Burton C, Conefrey C, Donovan JL, Farrar N, Morley J, McNair A, Owen-Smith A, Rule E, Thornton G, Tucker V, Williams I, Rooshenas L, Hollingworth W. Did the evidence-based intervention (EBI) programme reduce inappropriate procedures, lessen unwarranted variation or lead to spill-over effects in the National Health Service? PLoS One 2023; 18:e0290996. [PMID: 37656701 PMCID: PMC10473535 DOI: 10.1371/journal.pone.0290996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 08/20/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Health systems are under pressure to maintain services within limited resources. The Evidence-Based Interventions (EBI) programme published a first list of guidelines in 2019, which aimed to reduce inappropriate use of interventions within the NHS in England, reducing potential harm and optimising the use of limited resources. Seventeen procedures were selected in the first round, published in April 2019. METHODS We evaluated changes in the trends for each procedure after its inclusion in the EBI's first list of guidelines using interrupted time series analysis. We explored whether there was any evidence of spill-over effects onto related or substitute procedures, as well as exploring changes in geographical variation following the publication of national guidance. RESULTS Most procedures were experiencing downward trends in the years prior to the launch of EBI. We found no evidence of a trend change in any of the 17 procedures following the introduction of the guidance. No evidence of spill-over increases in substitute or related procedures was found. Geographic variation in the number of procedures performed across English CCGs remained at similar levels before and after EBI. CONCLUSIONS The EBI programme had little success in its aim to further reduce the use of the 17 procedures it deemed inappropriate in all or certain circumstances. Most procedure rates were already decreasing before EBI and all continued with a similar trend afterwards. Geographical variation in the number of procedures remained at a similar level post EBI. De-adoption of inappropriate care is essential in maintaining health systems across the world. However, further research is needed to explore context specific enablers and barriers to effective identification and de-adoption of such inappropriate health care to support future de-adoption endeavours.
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Affiliation(s)
- Joel Glynn
- Health Economics Bristol, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Timothy Jones
- Health Economics Bristol, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Mike Bell
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
- Bristol Biomedical Research Centre, University of Bristol, Bristol, United Kingdom
| | - Jane Blazeby
- Bristol Biomedical Research Centre, University of Bristol, Bristol, United Kingdom
| | - Christopher Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, United Kingdom
| | - Carmel Conefrey
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jenny L. Donovan
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Nicola Farrar
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Josie Morley
- Health Economics Bristol, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Angus McNair
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Amanda Owen-Smith
- Health Economics Bristol, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ellen Rule
- Gloucestershire Integrated Care Board (ICB), Brockworth, United Kingdom
| | - Gail Thornton
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Victoria Tucker
- Bristol, North Somerset and South Gloucestershire Integrated Care Board (ICB), Bristol, United Kingdom
| | - Iestyn Williams
- Health Services Management Centre, University of Birmingham, Birmingham, United Kingdom
| | - Leila Rooshenas
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - William Hollingworth
- Health Economics Bristol, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Heus P, van Dulmen SA, Weenink JW, Naaktgeboren CA, Takada T, Verkerk EW, Kamm I, van der Laan MJ, Hooft L, Kool RB. What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies. J Healthc Qual 2023; 45:261-271. [PMID: 37428942 PMCID: PMC10461725 DOI: 10.1097/jhq.0000000000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
BACKGROUND Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear. PURPOSE To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies. METHODS Analysis of 121 RCTs (1990-2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored. RESULTS Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%-42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied. CONCLUSIONS AND IMPLICATIONS Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.
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Lang E, Nożewski J. Why we all need Choosing Wisely? Intern Emerg Med 2023; 18:1613-1616. [PMID: 37477819 DOI: 10.1007/s11739-023-03356-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Eddy Lang
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jakub Nożewski
- Department of Emergency Medicine, John Biziel's Clinical Hospital No 2, Street: Ujejskiego 75, 85-168, Bydgoszcz, Poland.
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Muscat DM, Thompson R, Cvejic E, Smith J, Chang EHF, Tracy M, Zadro J, Lindner R, McCaffery KJ. Randomized Trial of the Choosing Wisely Consumer Questions and a Shared Decision-Making Video Intervention on Decision-Making Outcomes. Med Decis Making 2023; 43:642-655. [PMID: 37403779 PMCID: PMC10422858 DOI: 10.1177/0272989x231184461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/06/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Despite widespread use, there are few studies evaluating the consumer Choosing Wisely questions. METHODS We evaluated the impact of the Choosing Wisely questions on consumers' decision-making outcomes. Adults living in Australia were presented with a hypothetical low-value care scenario. Using a 2×2×2 between-subjects factorial design, they were randomized to either the Choosing Wisely questions ("Questions"), a shared decision-making (SDM) preparation video ("Video"), both interventions, or control (no intervention). Primary outcomes were 1) self-efficacy to ask questions and be involved in decision-making and 2) intention to engage in SDM. RESULTS A total of 1,439 participants (45.6% with "inadequate" health literacy) were eligible and included in the analysis. Intention to engage in SDM was higher in people randomized to the Video (mean difference [MD] = 0.24 [scale 0-6], 95% confidence interval [CI]: 0.14, 0.35), Questions (MD = 0.12, 95% CI: 0.01, 0.22), and both interventions (MD = 0.33, 95% CI: 0.23-0.44, P < 0.001, d = 0.28) compared with control. Combining interventions had a greater impact than presenting the Questions alone (MD = 0.22, 95% CI: 0.11, 0.32; P < 0.001). Those who received the Video or both interventions reported lower intention to follow the low-value treatment plan without further questioning (all P < 0.05) and more positive attitudes toward SDM (all P < 0.05) compared with control. Intervention acceptability was high in all study arms (>80%), but proactive access was low (1.7%-20.8%). Compared with control, participants who received one or both interventions asked more questions that mapped to the Choosing Wisely questions (all P < .001). There were no main effects of either intervention on self-efficacy or knowledge. CONCLUSIONS The Choosing Wisely questions and a video to promote SDM may improve intention to engage in SDM and support patients in identifying questions that align with the Choosing Wisely campaign (with some additional benefits of the video intervention). TRIAL REGISTRATION ANZCTR376477. HIGHLIGHTS We conducted a randomized controlled trial online with adults living in Australia to test the effectiveness of the consumer Choosing Wisely questions and a shared decision-making (SDM) preparation video.Both interventions improved intention to engage in SDM and supported participants to identify questions that align with the Choosing Wisely campaign.There were some additional benefits of the Video intervention in reducing willingness to accept low-value treatment for low-back pain without asking questions; however, neither intervention changed participants' self-efficacy to ask questions and be involved in decision-making nor affected perceptions of preparedness to engage in SDM or knowledge of rights to be involved in health care decision-making.The simple, low-cost nature of the interventions may make them appropriate for implementation within a suite of approaches to address low-value care at a population level.
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Affiliation(s)
- Danielle Marie Muscat
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, University of Sydney, New South Wales, Australia
| | - Rachel Thompson
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Health Sciences, University of Sydney, New South Wales, Australia
| | - Erin Cvejic
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, University of Sydney, New South Wales, Australia
| | - Jenna Smith
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, University of Sydney, New South Wales, Australia
| | - Edward Hoi-fan Chang
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, New South Wales, Australia
| | - Marguerite Tracy
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, New South Wales, Australia
| | - Joshua Zadro
- Faculty of Medicine and Health, School of Public Health, Institute for Musculoskeletal Health, University of Sydney, New South Wales, Australia
| | | | - Kirsten J. McCaffery
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, University of Sydney, New South Wales, Australia
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Ganguli I, Crawford ML, Usadi B, Mulligan KL, O'Malley AJ, Yang CWW, Fisher ES, Morden NE. Who's Accountable? Low-Value Care Received By Medicare Beneficiaries Outside Of Their Attributed Health Systems. Health Aff (Millwood) 2023; 42:1128-1139. [PMID: 37549329 PMCID: PMC10860675 DOI: 10.1377/hlthaff.2022.01319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Policy makers and payers increasingly hold health systems accountable for spending and quality for their attributed beneficiaries. Low-value care-medical services that offer little or no benefit and have the potential for harm in specific clinical scenarios-received outside of these systems could threaten success on both fronts. Using national Medicare data for fee-for-service beneficiaries ages sixty-five and older and attributed to 595 US health systems, we describe where and from whom they received forty low-value services during 2017-18 and identify factors associated with out-of-system receipt. Forty-three percent of low-value services received by attributed beneficiaries originated from out-of-system clinicians: 38 percent from specialists, 4 percent from primary care physicians, and 1 percent from advanced practice clinicians. Recipients of low-value care were more likely to obtain that care out of system if age 75 or older (versus ages 65-74), male (versus female), non-Hispanic White (versus other races or ethnicities), rural dwelling (versus metropolitan dwelling), more medically complex, or experiencing lower continuity of care. However, out-of-system service receipt was not associated with recipients' health systems' accountable care organization status. Health systems might improve quality and reduce spending for their attributed beneficiaries by addressing out-of-system receipt of low-value care-for example, by improving continuity.
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Affiliation(s)
- Ishani Ganguli
- Ishani Ganguli , Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | - Nancy E Morden
- Nancy E. Morden, UnitedHealthcare, Minnetonka, Minnesota
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Rockwell MS, Oyese EG, Singh E, Vinson M, Yim I, Turner JK, Epling JW. A Scoping Review of Interventions to De-implement Potentially Harmful Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in Healthcare Settings. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.29.23293362. [PMID: 37546911 PMCID: PMC10402245 DOI: 10.1101/2023.07.29.23293362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Objectives Potentially harmful nonsteroidal anti-inflammatory drugs (NSAIDs) utilization persists at undesirable rates throughout the world. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research. Design Scoping review. Data Sources PubMed, CINAHL, Embase, Cochrane Central, and Google Scholar (2000-2022). Study Selection Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilization in healthcare settings. Data Extraction Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilization. Results From 7,818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the U.S. (35.3%), with randomized controlled trial as the most common design (55.9%). The majority of studies (76.2%) reported a reduction in the utilization of potentially harmful NSAIDs. Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%). Academic detailing, clinical decision support or electronic medical record interventions, performance reports, and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%) or history of gastrointestinal disorders (47.1%) or kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter NSAIDs in addition to prescription. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation. Conclusion Many varied interventions are effective in de-implementing potentially harmful NSAIDs in healthcare settings. Efforts to adapt, scale, and disseminate these interventions are needed. In addition, future interventions should address over-the-counter NSAIDs, which are broadly available and widely used. Evaluating unintended consequences of interventions, including patient-focused outcomes, is another important priority.
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Affiliation(s)
- Michelle S Rockwell
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Emma G Oyese
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Eshika Singh
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | | | - Isaiah Yim
- Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Jamie K Turner
- Translational Biology, Medicine, and Health Graduate Program, Virginia Tech, Roanoke, VA
| | - John W Epling
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
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Rockwell MS, Armbruster SD, Capucao JC, Russell KB, Rockwell JA, Perkins KE, Huffstetler AN, Mafi JN, Fendrick AM. Reallocating Cervical Cancer Preventive Service Spending from Low- to High-Value Clinical Scenarios. Cancer Prev Res (Phila) 2023; 16:385-391. [PMID: 36976753 PMCID: PMC10320459 DOI: 10.1158/1940-6207.capr-22-0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/16/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023]
Abstract
Timely follow-up care after an abnormal cervical cancer screening test result is critical to the prevention and early diagnosis of cervical cancer. The current inadequate and inequitable delivery of these potentially life-saving services is attributed to several factors, including patient out-of-pocket costs. Waiving of consumer cost-sharing for follow-up testing (e.g., colposcopy and related cervical services) is likely to improve access and uptake, especially among underserved populations. One approach to defray the incremental costs of providing more generous coverage for follow-up testing is reducing expenditures on "low-value" cervical cancer screening services. To explore the potential fiscal implications of a policy that redirects cervical cancer screening resources from potentially low- to high-value clinical scenarios, we analyzed 2019 claims from the Virginia All-Payer Claims Database to quantify (i) total spending on low-value cervical cancer screening and (ii) out-of-pocket costs associated with colposcopy and related cervical services among commercially insured Virginians. In a cohort of 1,806,921 female patients (ages 48.1 ± 24.8 years), 295,193 claims for cervical cancer screening were reported, 100,567 (34.0%) of which were determined to be low-value ($4,394,361 total; $4,172,777 for payers and $221,584 out-of-pocket [$2/patient]). Claims for 52,369 colposcopy and related cervical services were reported ($40,994,016 total; $33,457,518 for payers and $7,536,498 out-of-pocket [$144/patient]). These findings suggest that reallocating savings incurred from unnecessary spending to fund more generous coverage of necessary follow-up care is a feasible approach to enhancing cervical cancer prevention equity and outcomes. PREVENTION RELEVANCE Out-of-pocket fees are a barrier to follow-up care after an abnormal cervical cancer screening test. Among commercially insured Virginians, out-of-pocket costs for follow-up services averaged $144/patient; 34% of cervical cancer screenings were classified as low value. Reallocating low-value cervical cancer screening expenditures to enhance coverage for follow-up care can improve screening outcomes. See related Spotlight, p. 363.
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Affiliation(s)
- Michelle S. Rockwell
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Shannon D. Armbruster
- Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | | | | | | | - Karen E. Perkins
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Alison N. Huffstetler
- The Robert Graham Center, Washington, District of Columbia
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - John N. Mafi
- Division of Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - A. Mark Fendrick
- Center for Value-Based Insurance Design, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Rockwell MS, Frazier MC, Stein JS, Dulaney KA, Parker SH, Davis GC, Rockwell JA, Castleman BL, Sunstein CR, Epling JW. A "sludge audit" for health system colorectal cancer screening services. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:e222-e228. [PMID: 37523455 PMCID: PMC11186110 DOI: 10.37765/ajmc.2023.89402] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVES "Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services. STUDY DESIGN Mixed methods sludge audit. METHODS We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes. RESULTS Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients. CONCLUSIONS Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.
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Affiliation(s)
- Michelle S Rockwell
- Department of Family and Community Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, Ste 102, Roanoke, VA 24016.
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Verkerk EW, Boekkooi JAH, Pels EGM, Kool RB. Exploring patients' perceptions of low-value care: An interview study. PATIENT EDUCATION AND COUNSELING 2023; 111:107687. [PMID: 36958071 DOI: 10.1016/j.pec.2023.107687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 02/15/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Clinicians consider patients' expectations and demands as a major driver of low-value care. However, little is known about the patients' perspective. We aimed to explore patients' perceptions of low-value care. METHODS We performed semi-structured interviews with 24 patients from the Netherlands and explored their ideas of and experiences with low-value care, and their perception of its consequences and solutions. The interviews were analysed using inductive thematic analysis. RESULTS Patients considered several types of care to be of low value, such as duplicate care, care that does not fit their preferences, inefficient care, and care that could have been prevented. The main causes of low-value care according to patients are poor clinician-patient communication and adhering to protocols instead of tailoring care to the individual patient. Consequences of low-value care were a burden for the patient, higher healthcare costs, and less room for high-value care. CONCLUSION Patients' view of low-value care extends beyond care that is medically ineffective. Their experiences could help to identify opportunities to reduce the (perceived) use of low-value care. PRACTICE IMPLICATIONS Future de-implementation studies could benefit from engaging patients. Dutch patients understand the importance of reducing low-value care and could be strong advocates for de-implementation programs.
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Affiliation(s)
- Eva W Verkerk
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Julia A H Boekkooi
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
| | - Elmar G M Pels
- Department of Medical Specialist Care, Netherlands Patients Federation, Utrecht, the Netherlands.
| | - Rudolf B Kool
- Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.
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Shapiro LM, Welch JM, Zhuang T, Fogel N, Ruch DS. The Use and Downstream Associations of Magnetic Resonance Imaging for Lateral Epicondylitis. J Hand Surg Am 2023:S0363-5023(23)00176-4. [PMID: 37191600 PMCID: PMC10651792 DOI: 10.1016/j.jhsa.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 03/09/2023] [Accepted: 03/22/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Low-value imaging is associated with wasteful health care spending and patient harm. The routine use of magnetic resonance imaging (MRI) for the work-up of lateral epicondylitis is an example of low-value imaging. As such, our aim was to investigate the use of MRIs ordered for lateral epicondylitis, the characteristics of those undergoing an MRI, and the downstream associations of MRI with other care. METHODS We identified patients aged ≥18 years with a diagnosis of lateral epicondylitis between 2010 and 2019 using a Humana claims database. We identified patients with a Current Procedural Terminology code corresponding to an elbow MRI. We analyzed the use and downstream treatment cascades in those undergoing MRI. Multivariable logistic regression models were used to assess the odds of undergoing an MRI, adjusting for age, sex, insurance type, and comorbidity index. Separate multivariable logistic regression analyses were used to determine the association between undergoing an MRI and the incidence of secondary outcomes (eg, receiving surgery). RESULTS A total of 624,102 patients met the inclusion criteria. Of 8,209 (1.3%) patients undergoing MRI, 3,584 (44%) underwent it within 90 days after diagnosis. There was notable regional variation in MRI use. The MRIs were ordered most frequently by primary care specialties and for younger, female, commercially insured, and patients with more comorbidities. Performance of an MRI was associated with an increase in downstream treatments, including surgery (odds ratio [OR], 9.58 [9.12-10.07]), injection (OR, 2.90 [2.77-3.04]), therapy (OR, 1.81 [1.72-1.91]), and cost ($134 per patient). CONCLUSIONS Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. CLINICAL RELEVANCE The routine use of MRI for lateral epicondylitis is low. Understanding interventions to minimize such low-value care in lateral epicondylitis can be used to inform improvement efforts to minimize low-value care for other conditions.
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Affiliation(s)
- Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA.
| | | | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University; Redwood City, CA
| | - Nathaniel Fogel
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University; Redwood City, CA
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Batcup C, Breth-Petersen M, Dakin T, Barratt A, McGain F, Newell BR, Pickles K. Behavioural change interventions encouraging clinicians to reduce carbon emissions in clinical activity: a systematic review. BMC Health Serv Res 2023; 23:384. [PMID: 37081553 PMCID: PMC10116654 DOI: 10.1186/s12913-023-09370-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 04/04/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Clinical activity accounts for 70-80% of the carbon footprint of healthcare. A critical component of reducing emissions is shifting clinical behaviour towards reducing, avoiding, or replacing carbon-intensive healthcare. The objective of this systematic review was to find, map and assess behaviour change interventions that have been implemented in healthcare settings to encourage clinicians to reduce greenhouse gas emissions from their clinical activity. METHODS Studies eligible for inclusion were those reporting on a behaviour change intervention to reduce carbon emissions via changes in healthcare workplace behaviour. Six databases were searched in November 2021 (updated February 2022). A pre-determined template was used to extract data from the studies, and risk of bias was assessed. The behaviour change techniques (BCTs) used in the interventions were coded using the BCT Taxonomy. RESULTS Six full-text studies were included in this review, and 14 conference abstracts. All studies used a before-after intervention design. The majority were UK studies (n = 15), followed by US (n = 3) and Australia (n = 2). Of the full-text studies, four focused on reducing the emissions associated with anaesthesia, and two aimed at reducing unnecessary test ordering. Of the conference abstracts, 13 focused on anaesthetic gas usage, and one on respiratory inhalers. The most common BCTs used were social support, salience of consequences, restructuring the physical environment, prompts and cues, feedback on outcome of behaviour, and information about environmental consequences. All studies reported success of their interventions in reducing carbon emissions, prescribing, ordering, and financial costs; however, only two studies reported the magnitude and significance of their intervention's success. All studies scored at least one item as unclear or at risk of bias. CONCLUSION Most interventions to date have targeted anaesthesia or pathology test ordering in hospital settings. Due to the diverse study outcomes and consequent inability to pool the results, this review is descriptive only, limiting our ability to conclude the effectiveness of interventions. Multiple BCTs were used in each study but these were not compared, evaluated, or used systematically. All studies lacked rigour in study design and measurement of outcomes. REVIEW REGISTRATION The study was registered on Prospero (ID number CRD42021272526) (Breth-Petersen et al., Prospero 2021: CRD42021272526).
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Affiliation(s)
- Carys Batcup
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Matilde Breth-Petersen
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Thomas Dakin
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Alexandra Barratt
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
| | - Forbes McGain
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia
- Western Health, Department of Critical Care Medicine, University of Melbourne, Melbourne, Australia
| | - Ben R Newell
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Kristen Pickles
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Sydney, Australia.
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Balafas S, Gagliano V, Di Serio C, Guidugli GA, Saporito A, Gabutti L, Ferrari P. Differential impact of transfusion guidelines on blood transfusion practices within a health network. Sci Rep 2023; 13:6264. [PMID: 37069210 PMCID: PMC10109235 DOI: 10.1038/s41598-023-33549-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/14/2023] [Indexed: 04/19/2023] Open
Abstract
Whether clinical practice guidelines have a significant impact on practice is unclear. The effect of guideline recommendations on clinical practice often a lags behind the date of publication. We evaluated by means of a data-driven approach if and when the guidelines on red blood cell transfusions (RBCTs) issued by Swiss Smarter Medicine in 2016 had an impact on RBCTs practice within a hospital network, where awareness of guidelines was promoted mainly among internal medicine specialties. Data on RBCTs performed in a Swiss hospital network from January 2014 to April 2021 were analyzed by hospital site and specialty to assess whether guidelines led to a decrease in inappropriate RBCTs. RBCTs were defined as "inappropriate" if patients had a hemoglobin level ≥ 70 g/L without or ≥ 80 g/L with significant cardiovascular comorbidities. Changes in the rate of inappropriate transfusions were analyzed with an advanced statistical approach that included generalized additive models. Overall prior to March 2017 there were more inappropriate than appropriate RBCTs, but after October 2017 the opposite could be observed. A change-point in the time trend was estimated from transfusion data to occur in the time interval between March and October 2017. This change was mainly driven by practice changes in the medical wards, while no significant change was observed in the critical care, surgical and oncology wards. Change in practice varied by hospital site. In conclusion, our results show that a significant change in the RBCTs practice at the hospital level occurred approximately 18 months after national guidelines were issued.
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Affiliation(s)
- Spyros Balafas
- University Centre of Statistics in the Biomedical Sciences CUSSB, UniSR, Milan, Italy
- Vita-Salute San Raffaele University, UniSR, Milan, Italy
| | - Vanessa Gagliano
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Clelia Di Serio
- University Centre of Statistics in the Biomedical Sciences CUSSB, UniSR, Milan, Italy
- Vita-Salute San Raffaele University, UniSR, Milan, Italy
- Faculty of Biomedicine, Università Della Svizzera Italiana, Lugano, Switzerland
| | | | - Andrea Saporito
- Faculty of Biomedicine, Università Della Svizzera Italiana, Lugano, Switzerland
- Division of Anesthesiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Luca Gabutti
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedicine, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Paolo Ferrari
- Faculty of Biomedicine, Università Della Svizzera Italiana, Lugano, Switzerland.
- Clinical School, University of New South Wales, Sydney, Australia.
- Department of Nephrology, Ente Ospedaliero Cantonale (EOC), 6900, Lugano, Switzerland.
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Sharma D, Agarwal P, Agrawal V, Bajaj J, Yadav SK. Low Value Surgical Care: Are We Choosing Wisely? Indian J Surg 2023. [DOI: 10.1007/s12262-023-03739-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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Atallah FC, Caruso P, Nassar Junior AP, Torelly AP, Amendola CP, Salluh JIF, Romano TG. High-value care for critically ill oncohematological patients: what do we know thus far? CRITICAL CARE SCIENCE 2023; 35:84-96. [PMID: 37712733 PMCID: PMC10275311 DOI: 10.5935/2965-2774.20230405-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/26/2023] [Indexed: 09/16/2023]
Abstract
The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.
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Affiliation(s)
- Fernanda Chohfi Atallah
- Discipline of Anaesthesiology, Pain and Intensive Care, Escola
Paulista de Medicina, Universidade Federal de São Paulo - São Paulo
(SP), Brazil
| | - Pedro Caruso
- AC Camargo Cancer Center - São Paulo (SP), Brazil
| | | | - Andre Peretti Torelly
- Hospital Santa Rita - Santa Casa de Misericórdia de Porto
Alegre - Porto Alegre (RS), Brazil
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43
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Kherad O, Carneiro AV. General health check-ups: To check or not to check? A question of choosing wisely. Eur J Intern Med 2023; 109:1-3. [PMID: 36609089 DOI: 10.1016/j.ejim.2022.12.021] [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: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023]
Abstract
In high-income countries, regular general health check-ups are part of the fabric of the health care systems. The hidden concept of general health check-ups, promoted for more than a century, is to identify diseases at a stage at which early intervention can be effective. However, there has been little evidence to support the benefits of such checkups. Choosing wisely (CW) campaigns may represent a tremendous opportunity to eventually shift patients and physicians away from the non-evidence based yet firmly entrenched practice of the general health check-up. As campaign leaders and members of the CW working group of the European Federation of Internal Medicine, we want to join the discussion by giving our perspective based on the best available evidence.
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Affiliation(s)
- Omar Kherad
- Internal Medicine Division, La Tour Hospital and University of Geneva, Switzerland.
| | - Antonio Vaz Carneiro
- Institute for Evidence Based Healthcare, Faculdade de Medicina, Universidade de Lisboa, Portugal
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Rabbani N, Ma SP, Li RC, Winget M, Weber S, Boosi S, Pham TD, Svec D, Shieh L, Chen JH. Targeting repetitive laboratory testing with electronic health records-embedded predictive decision support: A pre-implementation study. Clin Biochem 2023; 113:70-77. [PMID: 36623759 PMCID: PMC9936847 DOI: 10.1016/j.clinbiochem.2023.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/07/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Unnecessary laboratory testing contributes to patient morbidity and healthcare waste. Despite prior attempts at curbing such overutilization, there remains opportunity for improvement using novel data-driven approaches. This study presents the development and early evaluation of a clinical decision support tool that uses a predictive model to help providers reduce low-yield, repetitive laboratory testing in hospitalized patients. METHODS We developed an EHR-embedded SMART on FHIR application that utilizes a laboratory test result prediction model based on historical laboratory data. A combination of semi-structured physician interviews, usability testing, and quantitative analysis on retrospective laboratory data were used to inform the tool's development and evaluate its acceptability and potential clinical impact. KEY RESULTS Physicians identified culture and lack of awareness of repeat orders as key drivers for overuse of inpatient blood testing. Users expressed an openness to a lab prediction model and 13/15 physicians believed the tool would alter their ordering practices. The application received a median System Usability Scale score of 75, corresponding to the 75th percentile of software tools. On average, physicians desired a prediction certainty of 85% before discontinuing a routine recurring laboratory order and a higher certainty of 90% before being alerted. Simulation on historical lab data indicates that filtering based on accepted thresholds could have reduced ∼22% of repeat chemistry panels. CONCLUSIONS The use of a predictive algorithm as a means to calculate the utility of a diagnostic test is a promising paradigm for curbing laboratory test overutilization. An EHR-embedded clinical decision support tool employing such a model is a novel and acceptable intervention with the potential to reduce low-yield, repetitive laboratory testing.
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Affiliation(s)
- Naveed Rabbani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA.
| | - Stephen P Ma
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ron C Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Marcy Winget
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Susan Weber
- Technology and Digital Solutions, Stanford University School of Medicine, Stanford, CA, USA
| | - Srinivasan Boosi
- Technology and Digital Solutions, Stanford University School of Medicine, Stanford, CA, USA
| | - Tho D Pham
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - David Svec
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Shieh
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA; Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
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45
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Patey AM, Soong C. Top-down and bottom-up approaches to low-value care. BMJ Qual Saf 2023; 32:65-68. [PMID: 36517225 DOI: 10.1136/bmjqs-2022-014977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Soong
- Division of General Internal Medicine, Sinai Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Center for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
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46
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Richie C, Kesselheim AS, Jones DS. Climate change and the prescription pad. Lancet 2023; 401:178-179. [PMID: 36566765 DOI: 10.1016/s0140-6736(22)02545-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Cristina Richie
- Ethics and Philosophy of Technology Section, Delft University of Technology, 2628 BX Delft, Netherlands.
| | - Aaron S Kesselheim
- Harvard Medical School, Boston, MA, USA; Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David S Jones
- Harvard Medical School, Boston, MA, USA; Department of the History of Science, Harvard University, Cambridge, MA, USA
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47
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Trapani S, Montemaggi A, Indolfi G. Choosing Wisely in pediatric healthcare: A narrative review. Front Pediatr 2023; 10:1071088. [PMID: 36704146 PMCID: PMC9871764 DOI: 10.3389/fped.2022.1071088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Background It has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment. Methods In this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare. Results To date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe. Discussion We reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.
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Affiliation(s)
- Sandra Trapani
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Giuseppe Indolfi
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department NEUROFARBA, University of Florence, Florence, Italy
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Gangathimmaiah V, Evans R, Moodley N, Sen Gupta T, Drever N, Cardona M, Carlisle K. Identification of barriers, enablers and interventions to inform deimplementation of low-value care in emergency medicine practice: A protocol for a mixed methods scoping review informed by the Theoretical Domains Framework. BMJ Open 2022; 12:e062755. [PMID: 36368755 PMCID: PMC9660707 DOI: 10.1136/bmjopen-2022-062755] [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] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Low-value care can lead to patient harm, misdirected clinician time and wastage of finite healthcare resources. Despite worldwide endeavours, deimplementing low-value care has proved challenging. Multifaceted, context and barrier-specific interventions are essential for successful deimplementation. The aim of this literature review is to summarise the evidence about barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. METHODS AND ANALYSIS A mixed methods scoping review using the Arksey and O'Malley framework will be conducted. MEDLINE, CINAHL, EMBASE, EMCare, Scopus and grey literature will be searched from inception. Primary studies will be included. Barriers, enablers and interventions will be mapped to the domains of the Theoretical Domains Framework. Study selection, data collection and quality assessment will be performed by two independent reviewers. NVivo software will be used for qualitative data analysis. Mixed Methods Appraisal Tool will be used for quality assessment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework will be used to present results. ETHICS AND DISSEMINATION Ethics approval is not required for this scoping review. This review will generate an evidence summary regarding barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. This review will facilitate discussions about deimplementation with relevant stakeholders including healthcare providers, consumers and managers. These discussions are expected to inform the design and conduct of planned future projects to identify context-specific barriers and enablers then codesign, implement and evaluate barrier-specific interventions.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Douglas, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry and Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Townsville Public Health Unit, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
- EBP Professorial Unit, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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49
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Affiliation(s)
- Rani Marx
- Initiative for Slow Medicine, Berkeley, CA, USA
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50
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Raudasoja AJ, Falkenbach P, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Komulainen J, Sipilä R, Tikkinen KAO. Randomized controlled trials in de-implementation research: a systematic scoping review. Implement Sci 2022; 17:65. [PMID: 36183140 PMCID: PMC9526943 DOI: 10.1186/s13012-022-01238-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare costs are rising, and a substantial proportion of medical care is of little value. De-implementation of low-value practices is important for improving overall health outcomes and reducing costs. We aimed to identify and synthesize randomized controlled trials (RCTs) on de-implementation interventions and to provide guidance to improve future research. METHODS MEDLINE and Scopus up to May 24, 2021, for individual and cluster RCTs comparing de-implementation interventions to usual care, another intervention, or placebo. We applied independent duplicate assessment of eligibility, study characteristics, outcomes, intervention categories, implementation theories, and risk of bias. RESULTS Of the 227 eligible trials, 145 (64%) were cluster randomized trials (median 24 clusters; median follow-up time 305 days), and 82 (36%) were individually randomized trials (median follow-up time 274 days). Of the trials, 118 (52%) were published after 2010, 149 (66%) were conducted in a primary care setting, 163 (72%) aimed to reduce the use of drug treatment, 194 (85%) measured the total volume of care, and 64 (28%) low-value care use as outcomes. Of the trials, 48 (21%) described a theoretical basis for the intervention, and 40 (18%) had the study tailored by context-specific factors. Of the de-implementation interventions, 193 (85%) were targeted at physicians, 115 (51%) tested educational sessions, and 152 (67%) multicomponent interventions. Missing data led to high risk of bias in 137 (60%) trials, followed by baseline imbalances in 99 (44%), and deficiencies in allocation concealment in 56 (25%). CONCLUSIONS De-implementation trials were mainly conducted in primary care and typically aimed to reduce low-value drug treatments. Limitations of current de-implementation research may have led to unreliable effect estimates and decreased clinical applicability of studied de-implementation strategies. We identified potential research gaps, including de-implementation in secondary and tertiary care settings, and interventions targeted at other than physicians. Future trials could be improved by favoring simpler intervention designs, better control of potential confounders, larger number of clusters in cluster trials, considering context-specific factors when planning the intervention (tailoring), and using a theoretical basis in intervention design. REGISTRATION OSF Open Science Framework hk4b2.
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Affiliation(s)
- Aleksi J Raudasoja
- Faculty of Medicine, University of Helsinki, Helsinki, Finland. .,Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, Oulu, Finland.,University of Oulu, Oulu, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea & Westminster NHS Foundation Trust, London, UK.,Department of Epidemiology & Biostatistics, Imperial College London, London, UK
| | - Herney A Garcia-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Tampere University Hospital and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Hatanpää Health Center, City of Tampere, Finland.,Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Eero Raittio
- Oral Health Care, Tampere, Finland.,Institute of Dentistry, University of Eastern Finland, Kuopio, Finland.,Nordic Healthcare Group Ltd., Helsinki, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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