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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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Walters JK, Sharma A, Boyce J, Harrison R. Analysis of Centralized Efficiency Improvement Practices in Australian Public Health Systems. J Healthc Leadersh 2023; 15:313-326. [PMID: 38020720 PMCID: PMC10657544 DOI: 10.2147/jhl.s435035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023] Open
Abstract
Aim Analysis of centralized efficiency improvement practices in Australian public health systems. Introduction Public health systems seek to maximize outcomes generated for resources used through efficiency improvement (EI) in response to funding and demand pressures. Despite this focus, evidence for EI approaches at the whole-of-system level is lacking in the literature. There is an urgent need for evidence-based approaches to centralized EI to address these pressures. This study aims to address this gap by answering the research question "How is EI conceptualized and managed by central public health system management entities in Australia?". Material and Methods Document analysis was selected due to its suitability for systematically searching and appraising health system documentation, with this study following Altheide's approach focusing on whole-of-system strategic plan and management framework documents originating from Australian public health organizations. Results Conceptualization of efficiency varied substantially with no consistent definition identified, however common attributes included resource use, management, service and delivery. Forty-two of 43 documents contained approaches associated with improving efficiency at the whole of system level. Discussion While no comprehensive framework for centralized EI was evident, we identified nine core approaches which together characterize centralized EI. Together these approaches represent a comprehensive evidence-based approach to EI at the whole of system level. Conclusion The approaches to whole-of-system EI identified in this study are likely to be highly transferable across health systems internationally with approaches including strategic priority setting, incentivization, performance support, use of EI evidence, digital enablement and workforce capability development.
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Affiliation(s)
| | - Anurag Sharma
- School of Population Health, UNSW, Sydney, NSW, Australia
| | - Jamie Boyce
- HealthShare NSW, NSW Health, St Leonards, NSW, Australia
| | - Reema Harrison
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
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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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The added value of applying a disinvestment approach to the process of health technology assessment in Italy. Int J Technol Assess Health Care 2023; 39:e17. [PMID: 36861658 DOI: 10.1017/s0266462323000107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
OBJECTIVES The objective of the present policy analysis was to understand how a disinvestment approach to the process of health technology assessment (HTA), applied to the field of medical devices, might help Italian policymakers to properly spend the resources in healthcare. METHODS Previous international and national experiences in disinvestment for medical devices were reviewed. Precious insights for the rational expenditure of the resources were derived by assessing the evidence available. RESULTS The disinvestment of ineffective or inappropriate technologies or interventions with an inadequate value-for-money ratio has become a growing priority for National Health Systems. Different international disinvestment experiences of medical devices were identified and described through a rapid review. Although most of them have a strong theoretical framework, their practical application remains difficult. In Italy, there are no examples of large and complex HTA-based disinvestment practices, but their importance is becoming increasingly acknowledged, especially given the need to prioritize the funds provided by Recovery and Resilience Plan. CONCLUSIONS Anchoring decisions on health technologies without reassessing the current technological landscape through a robust HTA model might expose to the risk of not ensuring the best employment of the resources available. Thus, it is necessary to develop a strong HTA ecosystem in Italy through adequate consultation with stakeholders to enable a data-driven and evidence-based prioritization of resources toward choices characterized by high value for both patients and society as a whole.
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Falkowski A, Ciminata G, Manca F, Bouttell J, Jaiswal N, Farhana Binti Kamaruzaman H, Hollingworth S, Al-Adwan M, Heggie R, Putri S, Rana D, Mukelabai Simangolwa W, Grieve E. How Least Developed to Lower-Middle Income Countries Use Health Technology Assessment: A Scoping Review. Pathog Glob Health 2023; 117:104-119. [PMID: 35950264 PMCID: PMC9970250 DOI: 10.1080/20477724.2022.2106108] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Health Technology Assessment (HTA) is a multidisciplinary tool to inform healthcare decision-making. HTA has been implemented in high-income countries (HIC) for several decades but has only recently seen a growing investment in low- and middle-income countries. A scoping review was undertaken to define and compare the role of HTA in least developed and lower middle-income countries (LLMIC). MEDLINE and EMBASE databases were searched from January 2015 to August 2021. A matrix comprising categories on HTA objectives, methods, geographies, and partnerships was used for data extraction and synthesis to present our findings. The review identified 50 relevant articles. The matrix was populated and sub-divided into further categories as appropriate. We highlight topical aspects of HTA, including initiatives to overcome well-documented challenges around data and capacity development, and identify gaps in the research for consideration. Those areas we found to be under-studied or under-utilized included disinvestment, early HTA/implementation, system-level interventions, and cross-sectoral partnerships. We consider broad practical implications for decision-makers and researchers aiming to achieve greater interconnectedness between HTA and health systems and generate recommendations that LLMIC can use for HTA implementation. Whilst HIC may have led the way, LLMIC are increasingly beginning to develop HTA processes to assist in their healthcare decision-making. This review provides a forward-looking model that LLMIC can point to as a reference for their own implementation. We hope this can be seen as timely and useful contributions to optimize the impact of HTA in an era of investment and expansion and to encourage debate and implementation.
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Affiliation(s)
- Anna Falkowski
- Division of Communicable Disease, Michigan Department of Health and Human Services, State of Michigan, USA
| | - Giorgio Ciminata
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow
| | - Francesco Manca
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow
| | - Janet Bouttell
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow
| | - Nishant Jaiswal
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow
| | - Hanin Farhana Binti Kamaruzaman
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow.,Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia, Putrajaya
| | | | - Mariana Al-Adwan
- F. Hoffman-La Roche Ltd, Amman, Jordan and Jordan ISPOR Chapter, Amman, Jordan
| | - Robert Heggie
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow
| | - Septiara Putri
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow.,Health Policy and Administration Department, Faculty of Public Health, University of Indonesia, Depok, West Java, Indonesia
| | - Dikshyanta Rana
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow
| | - Warren Mukelabai Simangolwa
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu Natal, Durban, South Africa and Patient and Citizen Involvement in Health, Lusaka, Zambia
| | - Eleanor Grieve
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, Health Economics and Health Technology Assessment, University of Glasgow, 1 Lilybank Gardens, Glasgow
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Pu D, Bonnici R, Haines T. Engaging the consumer in disinvestment in public healthcare: Concerns, perspectives and attitudes of older adults. J Eval Clin Pract 2023; 29:320-328. [PMID: 36165636 DOI: 10.1111/jep.13769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/30/2022]
Abstract
RATIONALE Low-value care in public health can be addressed via disinvestment with the support of disinvestment research generated evidence. Consumers' views of disinvestment have rarely been explored despite the potential effects of this process on the care they will receive and the importance of consumer participation in decision-making in public healthcare. AIMS AND OBJECTIVES This study aimed to understand consumer concerns, perceptions and attitudes towards disinvestment processes, with the goal of providing recommendations to health service researchers and managers to more effectively engage consumers in shared decision-making in public healthcare. METHOD We conducted semistructured interviews using four scenarios describing the principles of disinvestment, how and why it could be undertaken, and a fifth scenario that described a real-life application of these principles. These scenarios were presented to participants in a written word document or a digital story during semistructured interviews. Participants were 18 community-dwelling older adults who were recruited via convenience sampling. Questions were addressed to the participants regarding their feelings and concerns towards disinvestment, their participation as consumers in disinvestment processes, as well as their preference for communicating information about disinvestment to patients and families. RESULTS Four major themes emerged around the negative perception of disinvestment and positive perception of research. Participants were concerned that the removal of a clinical activity was mainly the result of financial constraints in hospital systems. At times, participants indicated that disinvestment and its justifications were not easily understood. Participants expressed a need for consumer advocacy not always through themselves, but via others with more expertize; a single consumer is insufficient in representing the broader consumer perspective. Participants stressed the importance of transparency in relation to research evidence and decision-making outcomes. Face-to-face dissemination of information by expert staff was preferred, which could be supplemented with clear and concise written materials. CONCLUSION Consumers' main perception of disinvestment processes was that the removal of a clinical care activity depended on financial imperatives from hospital administration and political agendas. This tended to cause suspicion about reasons behind the removal of care, which overshadowed comprehension of the ineffective/inconclusive evidence that were key to disinvestment.
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Affiliation(s)
- Dai Pu
- National Centre for Healthy Ageing and School of Primary and Allied Healthcare, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Rachel Bonnici
- National Centre for Healthy Ageing and School of Primary and Allied Healthcare, Monash University Peninsula Campus, Frankston, Victoria, Australia.,Better Place Australia, Cheltenham, Australia
| | - Terry Haines
- National Centre for Healthy Ageing and School of Primary and Allied Healthcare, Monash University Peninsula Campus, Frankston, Victoria, Australia
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Identifying Safety Practices Perceived as Low Value: An Exploratory Survey of Healthcare Staff in the United Kingdom and Australia. J Patient Saf 2023; 19:143-150. [PMID: 36729436 PMCID: PMC9940841 DOI: 10.1097/pts.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Up to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. With increasing recognition of the problem of "safety clutter" in organizations, it is important to consider deimplementing safety practices that do not benefit patients, to create the time needed to deliver effective, person-centered, and safe care. This study surveyed healthcare staff to identify safety practices perceived to be of low value. METHODS Purposive and snowball sampling was used. Data collection was conducted from April 2018 to November 2019 (United Kingdom) and May 2020 to November 2020 (Australia). Participants completed the survey online or in hard copy to identify practices they perceived to not contribute to safe care. Responses were analyzed using content and thematic analysis. RESULTS A total of 1394 responses from 1041 participants were analyzed. Six hundred sixty-three responses were collected from 526 UK participants and 515 Australian participants contributed 731 responses. Frequently identified categories of practices identified included "paperwork," "duplication," and "intentional rounding." Five cross-cutting themes (e.g., covering ourselves) offered an underpinning rationale for why staff perceived the practices to be of low value. CONCLUSIONS Staff identified safety practices that they perceived to be low value. In healthcare systems under strain, removing existing low-value practices should be a priority. Careful evaluation of these identified safety practices is required to determine whether they are appropriate for deimplementation and, if not, to explore how to better support healthcare workers to perform them.
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Soril LJ, Elshaug AG, Esmail R, Chalkidou K, Gad M, Clement FM. Developing a How-to-Guide for Health Technology Reassessment: "The HTR Playbook". Int J Health Policy Manag 2022; 11:2525-2532. [PMID: 35065545 PMCID: PMC9818092 DOI: 10.34172/ijhpm.2021.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 12/28/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND To develop a knowledge translation (KT) tool that will provide guidance to stakeholders actively planning or considering implementation of a health technology reassessment (HTR) initiative. METHODS The KT tool is an international and collaborative endeavour between HTR researchers in Canada, Australia, and the United Kingdom. Evidence from a meta-review of documented international HTR experiences and approaches provided the conceptual framing for the KT tool. The purpose, audience, format, and overall scope and content of the tool were established through iterative discussions and consensus. An initial version of the KT tool was beta-tested with an international community of relevant stakeholders (i.e., potential users) at the Health Technology Assessment International 2018 annual meeting. RESULTS An open access workbook, referred to as the HTR playbook, was developed. As a KT tool, the HTR playbook is intended to simplify the complex HTR planning process by navigating users step-by-step through 6 strategic domains: characteristics of the candidate health technology (The Stats and Projections), stakeholders to engage (The Team), potential facilitators and/or barriers within the policy context (The Playing Field), strategic use of different levers and tools (The Offensive Plays), unintended consequences (The Defensive Plays), and metrics and methods for monitoring and evaluation (Winning the Game). CONCLUSION The HTR playbook is intended to enhance a user's ability to successfully complete a HTR by helping them systematically consider the different elements and approaches to achieve the right care for the patient population in question.
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Affiliation(s)
- Lesley J.J. Soril
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Adam G. Elshaug
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Rosmin Esmail
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Kalipso Chalkidou
- International Decision Support Initiative, London, UK
- Global Health and Development Group, School of Public Health, Imperial College London, London, UK
| | - Mohamed Gad
- International Decision Support Initiative, London, UK
- Global Health and Development Group, School of Public Health, Imperial College London, London, UK
| | - Fiona M. Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
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Lang G, Ingvarsson S, Hasson H, Nilsen P, Augustsson H. Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden. Scand J Prim Health Care 2022; 40:426-437. [PMID: 36325746 PMCID: PMC9848255 DOI: 10.1080/02813432.2022.2139467] [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: 11/05/2022] Open
Abstract
AIM The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC. DESIGN Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis. SETTING Six publicly owned primary health care centers in Stockholm. SUBJECTS The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7. MAIN OUTCOME MEASURES Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC. RESULTS Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. . CONCLUSION The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.
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Affiliation(s)
- Gabriella Lang
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- CONTACT Gabriella Lang Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, SE 171 77, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
| | - Per Nilsen
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hanna Augustsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
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Walters JK, Sharma A, Harrison R. Driving Efficiency Improvement (EI): Exploratory Analysis of a Centralised Model in New South Wales. Healthc Policy 2022; 15:1887-1894. [PMID: 36254223 PMCID: PMC9569157 DOI: 10.2147/rmhp.s383107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Public healthcare systems face rising demand coupled with reducing funding growth rates, necessitating ongoing approaches to efficiency improvement (EI). Centrally coordinated EI approaches l may support EI leaders, yet few such approaches exist internationally. This study provides evidence to inform system-wide EI by harnessing understanding of the perceptions, role demands and support requirements of key EI stakeholders in the centralised EI model implemented in New South Wales. Methods A purposive sample of key informants within NSW Health with responsibility for EI in their organisation were invited to participate. Semi-structured interviews were conducted, recorded and transcribed. A thematic analysis was undertaken using a theoretical deductive approach. Results Seventeen respondents participated who occupied EI leadership roles in metro (8) and rural (6) health services as well as non-clinical support (3) services. Four primary themes emerged on the perceptions and experiences of participants in 1. holding a unique skillset which enables them to undertake EI; 2. inheriting EI accountabilities as additional duties rather than holding dedicated EI roles; 3. the importance of senior support for EI success; and 4. feelings of isolation in undertaking EI. An additional underpinning theme that EI is not well conceptualized in public health systems also emerged, whereby EI planners felt that frontline staff generally do not consider efficiency as a component of their duties. Conclusion EI leaders provide points of authority, experience and influence across organisations within public health systems. This study finds that EI planners possess a unique skillset, can feel isolated both within their health organisation and within the broader public health system and believe that EI is poorly conceptualized amongst health staff. Centralised support for EI stakeholders across a public health system can promote knowledge sharing and capability development. Addressing the role and support requirements of key EI stakeholders is essential.
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Affiliation(s)
- James Kenneth Walters
- Patient Experience and System Performance Division, NSW Health, St Leonards, NSW, Australia,Correspondence: James Kenneth Walters, NSW Health, Level 9, 1 Reserve Road, St Leonards, NSW, Australia, Email
| | - Anurag Sharma
- School of Population Health, UNSW, Kensington, NSW, Australia
| | - Reema Harrison
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie Park, NSW, Australia
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Rotteveel AH, Lambooij MS, Over EAB, Hernández JI, Suijkerbuijk AWM, de Blaeij AT, de Wit GA, Mouter N. If you were a policymaker, which treatment would you disinvest? A participatory value evaluation on public preferences for active disinvestment of health care interventions in the Netherlands. HEALTH ECONOMICS, POLICY, AND LAW 2022; 17:428-443. [PMID: 35670359 DOI: 10.1017/s174413312200010x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Currently, it is not known what attributes of health care interventions citizens consider important in disinvestment decision-making (i.e. decisions to discontinue reimbursement). Therefore, this study aims to investigate the preferences of citizens of the Netherlands toward the relative importance of attributes of health care interventions in the context of disinvestment. METHODS A participatory value evaluation (PVE) was conducted in April and May 2020. In this PVE, 1143 Dutch citizens were asked to save at least €100 million by selecting health care interventions for disinvestment from a list of eight unlabeled health care interventions, described solely with attributes. A portfolio choice model was used to analyze participants' choices. RESULTS Participants preferred to disinvest health care interventions resulting in smaller gains in quality of life and life expectancy that are provided to older patient groups. Portfolios (i.e. combinations of health care interventions) resulting in smaller savings were preferred for disinvestment over portfolios with larger savings. CONCLUSION The disinvestment of health care interventions resulting in smaller health gains and that are targeted at older patient groups is likely to receive most public support. By incorporating this information in the selection of candidate interventions for disinvestment and the communication on disinvestment decisions, policymakers may increase public support for disinvestment.
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Affiliation(s)
- A H Rotteveel
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
- Julius Centre for Primary care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
- Erasmus School for Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - M S Lambooij
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - E A B Over
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - J I Hernández
- Faculty of Technology, Policy and Management, Delft University of Technology, Delft, The Netherlands
| | - A W M Suijkerbuijk
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - A T de Blaeij
- Centre for Safety of Substances and Products, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - G A de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
- Julius Centre for Primary care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - N Mouter
- Faculty of Technology, Policy and Management, Delft University of Technology, Delft, The Netherlands
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12
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Augustsson H, Casales Morici B, Hasson H, von Thiele Schwarz U, Schalling SK, Ingvarsson S, Wijk H, Roczniewska M, Nilsen P. National governance of de-implementation of low-value care: a qualitative study in Sweden. Health Res Policy Syst 2022; 20:92. [PMID: 36050688 PMCID: PMC9438133 DOI: 10.1186/s12961-022-00895-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The de-implementation of low-value care (LVC) is important to improving patient and population health, minimizing patient harm and reducing resource waste. However, there is limited knowledge about how the de-implementation of LVC is governed and what challenges might be involved. In this study, we aimed to (1) identify key stakeholders' activities in relation to de-implementing LVC in Sweden at the national governance level and (2) identify challenges involved in the national governance of the de-implementation of LVC. METHODS We used a purposeful sampling strategy to identify stakeholders in Sweden having a potential role in governing the de-implementation of LVC at a national level. Twelve informants from nine stakeholder agencies/organizations were recruited using snowball sampling. Semi-structured interviews were conducted, transcribed and analysed using inductive thematic analysis. RESULTS Four potential activities for governing the de-implementation of LVC at a national level were identified: recommendations, health technology assessment, control over pharmaceutical products and a national system for knowledge management. Challenges involved included various vested interests that result in the maintenance of LVC and a low overall priority of working with the de-implementation of LVC compared with the implementation of new evidence. Ambiguous evidence made it difficult to clearly determine whether a practice was LVC. Unclear roles, where none of the stakeholders perceived that they had a formal mandate to govern the de-implementation of LVC, further contributed to the challenges involved in governing that de-implementation. CONCLUSIONS Various activities were performed to govern the de-implementation of LVC at a national level in Sweden; however, these were limited and had a lower priority relative to the implementation of new methods. Challenges involved relate to unfavourable change incentives, ambiguous evidence, and unclear roles to govern the de-implementation of LVC. Addressing these challenges could make the national-level governance of de-implementation more systematic and thereby help create favourable conditions for reducing LVC in healthcare.
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Affiliation(s)
- Hanna Augustsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm, Sweden.
| | - Belén Casales Morici
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Department of Business Studies, Uppsala University, Uppsala, Sweden
| | - Henna Hasson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Sara Korlén Schalling
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Wijk
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Marta Roczniewska
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Per Nilsen
- Division of Public Health, Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
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13
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Hofmann B. Too Much, Too Mild, Too Early: Diagnosing the Excessive Expansion of Diagnoses. Int J Gen Med 2022; 15:6441-6450. [PMID: 35966506 PMCID: PMC9365059 DOI: 10.2147/ijgm.s368541] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
Abstract
Tremendous scientific and technological advances have vastly improved diagnostics. At the same time, false alarms, overdiagnosis, medicalization, and overdetection have emerged as pervasive challenges undermining the quality of healthcare and sustainable clinical practice. Despite much attention, there is no clarity on the classification and handling of excessive diagnoses. This article identifies three basic types of excessive diagnosing: too much, too mild, and too early. Correspondingly, it suggests three ways to reduce excess and advance high value care: we must stop diagnosing new phenomena, mild conditions, and early signs that do not give pain, dysfunction, and suffering.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences, Norwegian University of Science and Technology, Gjøvik, Norway.,The Centre of Medical Ethics, Faculty of Medicine, the University of Oslo, Oslo, Norway
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14
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DISINVESTMENT IN HEALTHCARE: A SCOPING REVIEW OF SYSTEMATIC REVIEWS. Int J Technol Assess Health Care 2022; 38:e69. [PMID: 35853843 DOI: 10.1017/s0266462322000514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Costa N, Blyth FM, Amorim AB, Parambath S, Shanmuganathan S, Schneider CH. Implementation initiatives to improve low back pain care in Australia: a scoping review. PAIN MEDICINE 2022; 23:1979-2009. [PMID: 35758625 DOI: 10.1093/pm/pnac102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This scoping review aimed to comprehensively review strategies for implementation of low back pain (LBP) guidelines, policies and models of care in the Australian healthcare system. METHODS A literature search was conducted in MEDLINE, EMBASE, CINAHL, Amed and Web of Science to identify studies that aimed to implement or integrate evidence-based interventions/practices to improve LBP care within Australian settings. RESULTS Twenty-five studies met the inclusion criteria. Most studies targeted primary care settings (n = 13). Other settings included tertiary care (n = 4), community (n = 4), pharmacies (n = 3). One study targeted both primary and tertiary care settings (n = 1). Only 40% of the included studies reported an underpinning framework, model or theory. Implementation strategies most frequently used were evaluative and iterative strategies (n = 14, 56%) and train and educate stakeholders (n = 13, 52%), followed by engage consumers (n = 6, 24%), develop stakeholder relationships (n = 4, 16%), change in infrastructure (n = 4, 16%) and support clinicians (n = 3, 12%). The most common implementation outcomes considered were acceptability (n = 11, 44%) and adoption (n = 10, 40%), followed by appropriateness (n = 7, 28%), cost (n = 3, 12%), feasibility (n = 1, 4%) and fidelity (n = 1, 4%). Barriers included time constraints, funding, and teamwork availability. Facilitators included funding and collaboration between stakeholders. CONCLUSIONS Implementation research targeting LBP appears to be a young field, mostly focusing on training and educating stakeholders in primary care. Outcomes on sustainability and penetration of evidence-based interventions are lacking. There is a need for implementation research guided by established frameworks that consider interrelationships between organisational and system contexts beyond the clinician-patient dyad.
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Affiliation(s)
- Nathalia Costa
- The University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Sydney, New South Wales, Australia.,The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Fiona M Blyth
- The University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Anita B Amorim
- The University of Sydney, School of Health Sciences, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sarika Parambath
- The University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Selvanaayagam Shanmuganathan
- The University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Carmen Huckel Schneider
- The University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Sydney, New South Wales, Australia
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16
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Strand L, Sandman L, Tinghög G, Nedlund AC. Withdrawing or withholding treatments in health care rationing: an interview study on ethical views and implications. BMC Med Ethics 2022; 23:63. [PMID: 35751123 PMCID: PMC9233323 DOI: 10.1186/s12910-022-00805-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background When rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in rationing situations of relative scarcity. Methods Fourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used. Results Participants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment (e.g., the treatment’s effectiveness and the patient’s medical condition) withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers. Conclusions We conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level.
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Affiliation(s)
- Liam Strand
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden.
| | - Lars Sandman
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden
| | - Gustav Tinghög
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden.,Department of Management and Engineering, Linköping University, Linköping, Sweden
| | - Ann-Charlotte Nedlund
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden
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17
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Walters JK, Sharma A, Malica E, Harrison R. Supporting efficiency improvement in public health systems: a rapid evidence synthesis. BMC Health Serv Res 2022; 22:293. [PMID: 35241066 PMCID: PMC8892107 DOI: 10.1186/s12913-022-07694-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/23/2022] [Indexed: 12/28/2022] Open
Abstract
Background Public health systems internationally are under pressure to meet increasing demand for healthcare in the context of increasing financial resource constraint. There is therefore a need to maximise health outcomes achieved with public healthcare expenditure. This paper aims to establish and synthesize the contemporary evidence base for approaches taken at a system management level to improve efficiency. Methods Rapid Evidence Assessment (REA) methodology was employed. A search strategy was developed and applied (PUBMED, MEDLINE) returning 5,377 unique titles. 172 full-text articles were screened to determine relevance with 82 publications included in the final review. Data regarding country, study design, key findings and approaches to efficiency improvement were extracted and a narrative synthesis produced. Publications covering health systems from developed countries were included. Results Identified study designs included policy reviews, qualitative reviews, mixed methods reviews, systematic reviews, literature reviews, retrospective analyses, scoping reviews, narrative papers, regression analyses and opinion papers. While findings revealed no comprehensive frameworks for system-wide efficiency improvement, a range of specific centrally led improvement approaches were identified. Elements associated with success in current approaches included dedicated central functions to drive system-wide efficiency improvement, managing efficiency in tandem with quality and value, and inclusive stakeholder engagement. Conclusions The requirement for public health systems to improve efficiency is likely to continue to increase. Reactive cost-cutting measures and short-term initiatives aimed only at reducing expenditure are unlikely to deliver sustainable efficiency improvement. By providing dedicated central system-wide efficiency improvement support, public health system management entities can deliver improved financial, health service and stakeholder outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07694-z.
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Affiliation(s)
| | | | - Emma Malica
- New South Wales Ministry of Health, St Leonards, Australia
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18
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Lea M, Hofmann BM. Dediagnosing - a novel framework for making people less ill. Eur J Intern Med 2022; 95:17-23. [PMID: 34417089 DOI: 10.1016/j.ejim.2021.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/23/2021] [Accepted: 07/30/2021] [Indexed: 01/06/2023]
Abstract
Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions including the prescription of medicines. Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to the reduction of persons' suffering and should be introduced to make people less ill. Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation, deprescribing, decommissioning, and disinvestment. Because diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient.
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Affiliation(s)
- Marianne Lea
- Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway; Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South Eastern Norway, Norway.
| | - Bjørn Morten Hofmann
- Department for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway; Centre of Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway
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19
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Haines TP, Botti M, Brusco N, O’Brien L, Redley B, Bowles KA, Hutchinson A, Mitchell D, Jellett J, Steen K, Boyd L, Webb-St Mart M, Raymond M, Hunter P, Russo P, Bonnici R, Pu D, Sevenhuysen S, Davies V, Shorr R. Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals. PLoS One 2021; 16:e0261793. [PMID: 34969050 PMCID: PMC8717976 DOI: 10.1371/journal.pone.0261793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 11/18/2022] Open
Abstract
Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.
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Affiliation(s)
- Terry P. Haines
- School of Primary and Allied Health Care & National Centre for Healthy Ageing, Monash University, Frankston, Australia
- * E-mail:
| | - Mari Botti
- School of Nursing & Midwifery, Deakin University, Geelong, Australia
| | - Natasha Brusco
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Lisa O’Brien
- Department of Occupational Therapy, Monash University, Melbourne, Australia
| | - Bernice Redley
- Centre for Quality and Patient Safety Research-Monash Health Partnership, Melbourne, Australia
- School of Nursing & Midwifery, Faculty of Health, Deakin University, Geelong, Australia
| | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Melbourne, Australia
| | - Alison Hutchinson
- Centre for Quality and Patient Safety Research-Monash Health Partnership, Melbourne, Australia
- School of Nursing & Midwifery, Faculty of Health, Deakin University, Geelong, Australia
| | - Debra Mitchell
- Allied Health Workforce, Innovation, Strategy, Education and Research (WISER) Unit, Monash Health, Clayton, Australia
| | - Joanna Jellett
- Falls Prevention Service, The Mornington Centre, Peninsula Health, Victoria, Australia
| | | | - Leanne Boyd
- Chief Nursing and Midwifery Officer, Executive Director Learning and Teaching, Eastern Health, Richmond, Australia
| | | | - Melissa Raymond
- Physiotherapy Department, Alfred Health, Melbourne, Australia
- College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
| | - Peter Hunter
- Geriatric Medicine, Alfred Health, Melbourne, Australia
| | - Phillip Russo
- School of Nursing & Midwifery, Monash University, Melbourne, Australia
- Department of Nursing Research, Cabrini Institute, Malvern, Australia
| | - Rachel Bonnici
- School of Primary and Allied Health Care & National Centre for Healthy Ageing, Monash University, Frankston, Australia
| | - Dai Pu
- School of Primary and Allied Health Care & National Centre for Healthy Ageing, Monash University, Frankston, Australia
| | | | - Vicki Davies
- Subacute Ambulatory Care Manager Peninsula Health, Frankston, Australia
| | - Ronald Shorr
- Geriatric Research Education and Clinical Center, Malcolm Randall Veterans Affairs Medical Center, Gainesville, Florida
- Department of Epidemiology, University of Florida, Gainesville, Florida
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20
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Optimizing red blood cell transfusion practices in the intensive care unit: a multi-phased health technology reassessment. Int J Technol Assess Health Care 2021; 38:e10. [DOI: 10.1017/s0266462321001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Health technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU).
Objective
The HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU.
Methods
The interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more).
Results
There was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system.
Conclusions
It was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.
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21
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Burton CR, Williams L, Bucknall T, Fisher D, Hall B, Harris G, Jones P, Makin M, Mcbride A, Meacock R, Parkinson J, Rycroft-Malone J, Waring J. Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background
Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.
Objectives
Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.
Design
A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.
Participants
In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.
Data sources
Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.
Results
The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.
Limitations
Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.
Conclusions
This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.
Study registration
This study is registered as PROSPERO CRD42017081030.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher R Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Lynne Williams
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
| | - Denise Fisher
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Beth Hall
- Library and Archives Services, Bangor University, Bangor, UK
| | - Gill Harris
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Peter Jones
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Matthew Makin
- North Manchester Care Organisation, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Anne Mcbride
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - John Parkinson
- School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | | | - Justin Waring
- School of Social Policy, University of Birmingham, Birmingham, UK
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22
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Understanding Government Decisions to De-fund Medical Services Analyzing the Impact of Problem Frames on Resource Allocation Policies. HEALTH CARE ANALYSIS 2021; 29:78-98. [PMID: 33387163 DOI: 10.1007/s10728-020-00426-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Many medical services lack robust evidence of effectiveness and may therefore be considered "unnecessary" care. Proactively withdrawing resources from, or de-funding, such services and redirecting the savings to services that have proven effectiveness would enhance overall health system performance. Despite this, governments have been reluctant to discontinue funding of services once funding is in place. The focus of this study is to understand how the framing of an issue or problem influences government decision-making related to de-funding of medical services. To achieve this, a framework describing how problem frames, or explanatory naratives, influence government policy decisions was developed and applied to actual cases. The two cases selected were the Ontario government's decisions to de-fund the drug Oxycontin and blood glucose test strips used by patients with diabetes. A qualitative content analysis of public discourse (political debate and media coverage) surrounding these two resource withdrawal examples was conducted and described using the framework. In the framework, government decision-making is a partial reflection of the visibility of the policy issue and complexity of the causal story told within a problem frame. By applying this framework and considering these two key characteristics of problem frames, we can better understand, and possibly predict, the shape and timing of government policy decisions to withdraw resources from medical services.
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Mitchell D, O'Brien L, Bardoel A, Haines T. Moving Past the Loss: A Longitudinal Qualitative Study of Health Care Staff Experiences of Disinvestment. Med Care Res Rev 2020; 79:78-89. [PMID: 33203314 DOI: 10.1177/1077558720972588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This longitudinal qualitative study examines staff experience of disinvestment from a service they are accustomed to providing to their patients. It took place alongside a disinvestment trial that measured the impact of the removal of weekend allied health services from acute wards at two hospitals. Data were gathered from repeated interviews and focus groups with 450 health care staff. We developed a grounded theory, which explains changes in staff perceptions over time and the key modifying factors. Staff appeared to experience disinvestment as loss; a key difference to other operational changes. Early staff experiences of disinvestment were primarily negative, but evolved with time and change-management strategies such as the provision of data, clear and persistent communication approaches, and forums where the big picture context of the disinvestment was robustly discussed. These allowed the disinvestment trial to be successfully implemented at two health services, with high compliance with the research protocol.
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Affiliation(s)
- Deb Mitchell
- Allied Health, Monash Health, Dandenong, Victoria, Australia
| | - Lisa O'Brien
- Monash University, Frankston, Victoria, Australia
| | - Anne Bardoel
- Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Terry Haines
- Monash University, Frankston, Victoria, Australia
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Embrett M, Randall GE, Lavis JN, Dion ML. Conceptualising characteristics of resources withdrawal from medical services: a systematic qualitative synthesis. Health Res Policy Syst 2020; 18:123. [PMID: 33115486 PMCID: PMC7592573 DOI: 10.1186/s12961-020-00630-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Terms used to describe government-led resource withdrawal from ineffective and unsafe medical services, including 'rationing' and 'disinvestment', have tended to be used interchangeably, despite having distinct characteristics. This lack of descriptive precision for arguably distinct terms contributes to the obscurity that hinders effective communication and the achievement of evidence-based decision-making. The objectives of this study are to (1) identify the various terms used to describe resource withdrawal and (2) propose definitions for the key or foundational terms, which includes a clear description of the unique characteristics of each. METHODS This is a systematic qualitative synthesis of characteristics and terms found through a search of the academic and grey literature. This approach involved identifying commonly used resource withdrawal terms, extracting data about resource withdrawal characteristics associated with each term and conducting a comparative analysis by categorising elements as antecedents, attributes or outcomes. RESULTS Findings from an analysis of 106 documents demonstrated that terms used to describe resource withdrawal are inconsistently defined and applied. The characteristics associated with these terms, mainly antecedents and attributes, are used interchangeably by many authors but are differentiated by others. Our analysis resulted in the development of a framework that organises these characteristics to demonstrate the unique attributes associated with each term. To enhance precision, these terms were classified as either policy options or patient health outcomes and refined definitions for rationing and disinvestment were developed. Rationing was defined as resource withdrawal that denies, on average, patient health benefits. Disinvestment was defined as resource withdrawal that results in, on average, improved or no change in health benefits. CONCLUSION Agreement on the definition of various resource withdrawal terms and their key characteristics is required for transparent government decision-making regarding medical service withdrawal. This systematic qualitative synthesis presents the proposed definitions of resource withdrawal terms that will promote consistency, benefit public policy dialogue and enhance the policy-making process for health systems.
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Affiliation(s)
- Mark Embrett
- Faculty of Health, School of Nursing, Dalhouise University, 5869 University Avenue, PO BOX 15000, Halifax, Nova Scotia, B3H 4R2, Canada. .,St. Francis Xavier University, 4130 University Avenue, Antigonish, Nova Scotia, B2G2W5, Canada.
| | - Glen E Randall
- Health Policy and Management, DeGroote School of Business, McMaster University, Hamilton, Ontario, L8S4M4, Canada.,McMaster University, DSB-229, 1280 Main Street West, Hamilton, Ontario, L8S 4M4, Canada
| | - John N Lavis
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8S4L6, Canada.,McMaster Health Forum, MML-417, 1280 Main St. West, Hamilton, Ontario, L8S4L6, Canada
| | - Michelle L Dion
- Department of Political Science, McMaster University, Hamilton, Ontario, L8S4L6, Canada.,Kenneth Taylor Hall (KTH) 533, 1280 Main St. West, Hamilton, Ontario, L8S4L6, Canada
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Upvall MJ, Bourgault AM, Pigon C, Swartzman CA. Exemplars Illustrating De-implementation of Tradition-Based Practices. Crit Care Nurse 2020; 39:64-69. [PMID: 31961940 DOI: 10.4037/ccn2019534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Clinical practice must be based on evidence. When evidence suggests that a certain practice may be ineffective or even harmful, that practice should be discontinued. The Choosing Wisely campaign, an initiative of the ABIM (American Board of Internal Medicine) Foundation, is intended to bring attention to tradition-based practices, or "sacred cows," which lack evidence to support their ongoing use. The complex process of discontinuing or reducing the use of tradition-based practices is known as "de-implementation." Recognizing the importance of de-implementation is necessary to fully understand evidence-based practice. This article explores the de-implementation process, examining its barriers and facilitators. Three critical care exemplars of tradition-based practices are presented and examined through the lens of de-implementation. Barriers and facilitators related to de-implementing these tradition-based practices are described, with an emphasis on the roles of various stakeholders and the need to overcome cognitive dissonance and psychological bias.
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Affiliation(s)
- Michele J Upvall
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
| | - Annette M Bourgault
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
| | - Cody Pigon
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
| | - Christine A Swartzman
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
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Understanding the public's role in reducing low-value care: a scoping review. Implement Sci 2020; 15:20. [PMID: 32264926 PMCID: PMC7137456 DOI: 10.1186/s13012-020-00986-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/23/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Low-value care initiatives are rapidly growing; however, it is not clear how members of the public should be involved. The objective of this scoping review was to systematically examine the literature describing public involvement in initatives to reduce low-value care. METHODS Evidence sources included MEDLINE, EMBASE, and CINAHL databases from inception to November 26, 2019, grey literature (CADTH Tool), reference lists of included articles, and expert consultation. Citations were screened in duplicate and included if they referred to the public's perception and/or involvement in reducing low-value care. Public included patients or citizens without any advanced healthcare knowledge. Low-value care included medical tests or treatments that lack efficacy, have risks that exceed benefit, or are not cost-effective. Extracted data pertained to study characteristics, low-value practice, clinical setting, and level of public involvement (i.e., patient-clinician interaction, research, or policy-making). RESULTS The 218 included citations were predominantly original research (n = 138, 63%), published since 2010 (n = 192, 88%), originating from North America (n = 146, 67%). Most citations focused on patient engagement within the patient-clinician interaction (n = 156, 72%), using tools that included shared decision-making (n = 66, 42%) and patient-targeted educational materials (n = 72, 46%), and reported both reductions in low-value care and improved patient perceptions regarding low-value care. Fewer citations examined public involvement in low-value care policy-making (n = 33, 15%). Among citations that examined perspectives regarding public involvement in initiatives to reduce low-value care (n = 10, 5%), there was consistent support for the utility of tools applied within the patient-clinician interaction and less consistent support for involvement in policy-making. CONCLUSIONS Efforts examining public involvement in low-value care concentrate within the patient-clinician interaction, wherein patient-oriented educational materials and shared decision-making tools have been commonly studied and are associated with reductions in low-value care. This contrasts with inclusion of the public in low-value care policy decisions wherein tools to promote engagement are less well-developed and involvement not consistently viewed as valuable. TRIAL REGISTRATION Open Science Framework (https://osf.io/6fsxm).
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Bail K, Merrick E, Redley B, Gibson J, Davey R, Currie M. “Blind leading the blind”: Qualitative evaluation of unanticipated difficulties during nurse testing of a hospital health information system. Collegian 2020. [DOI: 10.1016/j.colegn.2019.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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An evidence-based framework for identifying technologies of no or low-added value (NLVT). Int J Technol Assess Health Care 2019; 36:50-57. [PMID: 31831086 DOI: 10.1017/s0266462319000734] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To synthetize the state of the art of methods for identifying candidate technologies for disinvestment and propose an evidence-based framework for executing this task. METHODS An interpretative review was conducted. A systematic literature search was performed to identify secondary or tertiary research related to disinvestment initiatives and/or any type of research that specifically described one or more methods for identifying potential candidates technologies, services, or practices for disinvestment. An iterative and critical analysis of the methods described alongside the disinvestment initiatives was performed. RESULTS Seventeen systematic reviews on disinvestment or related terms (health technology reassessment or medical reversal) were retrieved and methods of 45 disinvestment initiatives were compared. On the basis of this evidence, we proposed a new framework for identifying these technologies based on the wide definition of evidence provided by Lomas et al. The framework comprises seven basic approaches, eleven triggers and thirteen methods for applying these triggers, which were grouped in embedded and ad hoc methods. CONCLUSIONS Although identification methods have been described in the literature and tested in different contexts, the proliferation of terms and concepts used to describe this process creates considerable confusion. The proposed framework is a rigorous and flexible tool that could guide the implementation of strategies for identifying potential candidates for disinvestment.
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Mitton C, Seixas BV, Peacock S, Burgess M, Bryan S. Health Technology Assessment as Part of a Broader Process for Priority Setting and Resource Allocation. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:573-576. [PMID: 31161365 DOI: 10.1007/s40258-019-00488-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Over the last two decades, economic evaluation of health technologies has developed enormously, affirming its importance within the pursuit of efficiency in the management of health care systems. One concern that has been raised with health technology assessment (HTA) has been its operationalization within the realm of decision making. Here, we suggest a mechanism by which HTA can be understood as an input into a broader framework for priority setting and resource allocation. When HTA is seen in this light, topics that at times have had some lack of clarity, such as public engagement and disinvestment, simply become steps in the overall decision-making process.
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Affiliation(s)
- Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Brayan V Seixas
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
| | - Stuart Peacock
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, BC, Canada
| | - Michael Burgess
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- W. Maurice Young Centre for Applied Ethics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Stirling Bryan
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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Sipilä R, Mäkelä M, Komulainen J. Highlighting the need for de-implementation - Choosing Wisely recommendations based on clinical practice guidelines. BMC Health Serv Res 2019; 19:638. [PMID: 31488146 PMCID: PMC6729023 DOI: 10.1186/s12913-019-4460-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 08/26/2019] [Indexed: 12/03/2022] Open
Abstract
Background The Choosing Wisely campaign has spread to many countries. Methods for developing recommendations are inconsistent. We describe our process of developing such recommendations from a comprehensive national set of clinical practice guidelines (Current Care, CC) and the results of a one-year Choosing Wisely Finland project. Methods Two of the authors drafted the quality and process criteria for all the Choosing Wisely Finland recommendations. The quality criteria were relevance, feasibility, evidence-based and strength. These were discussed in editors’ meetings and subsequently revised. Two different processes for developing recommendations within national clinical practice guidelines were designed and piloted (processes A and B). Process A was based on a published guideline. The recommendations are drafted by an editor and revised and approved by the guideline development group. In process B the development of the recommendations is integrated with guideline production or update. Choosing Wisely recommendations were then drafted for half of the published CC Guidelines. An additional process (process C) was designed for producing independent recommendations outside a guideline. Results At least one Choosing Wisely recommendation could be identified from 39 out of 52 reviewed guidelines. Of the 106 recommendations drafted, 62 (58%) were accepted for publication. The main reasons for rejection were inability to give a strong recommendation (n = 18, 41%) and insufficient relevance (n = 14, 32%). Two thirds (n = 41, 66%) of the published recommendations were based on high to moderate level of evidence, and 18% (n = 11) on low or very low level of evidence, whereas for the rest, the quality of evidence was not critically appraised. Conclusions Choosing Wisely recommendations can be produced systematically from existing clinical practice guidelines. The rigorous methods of evidence-based medicine ensure high-quality recommendations. We welcome the use of our processes and methods describes in this article by other guideline-producing organizations. Electronic supplementary material The online version of this article (10.1186/s12913-019-4460-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Raija Sipilä
- Current Care Guidelines, The Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Marjukka Mäkelä
- Current Care Guidelines, The Finnish Medical Society Duodecim, Helsinki, Finland.,Department of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Jorma Komulainen
- Current Care Guidelines, The Finnish Medical Society Duodecim, Helsinki, Finland
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Moes F, Houwaart E, Delnoij D, Horstman K. Collective constructions of 'waste': epistemic practices for disinvestment in the context of Dutch social health insurance. BMC Health Serv Res 2019; 19:633. [PMID: 31488152 PMCID: PMC6727536 DOI: 10.1186/s12913-019-4434-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/16/2019] [Indexed: 11/10/2022] Open
Abstract
Background Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders’ reluctance to engage in what can be perceived as ‘rationing’. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the ‘Appropriate Care’ program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work? Method We conducted ethnographic research into the National Health Care Institute’s epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants. Results The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions. Conclusions This case shows that – apart from the right data and adequate expertise – disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute’s Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of ‘waste’ in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of ‘waste’ in public health expenditure. Electronic supplementary material The online version of this article (10.1186/s12913-019-4434-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Floortje Moes
- Research School CAPHRI, Department of Health, Ethics and Society, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands.
| | - Eddy Houwaart
- Research School CAPHRI, Department of Health, Ethics and Society, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Diana Delnoij
- Erasmus School of Health Policy and Management, PO Box 1738, 3000 DR, Rotterdam, the Netherlands.,National Health Care Institute, P.O. Box 320, 1110 AH, Diemen, the Netherlands
| | - Klasien Horstman
- Research School CAPHRI, Department of Health, Ethics and Society, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
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Merlo G, Page K, Zardo P, Graves N. Applying an Implementation Framework to the Use of Evidence from Economic Evaluations in Making Healthcare Decisions. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:533-543. [PMID: 31049847 DOI: 10.1007/s40258-019-00477-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE There is a need for the application of theory in understanding the use of evidence from economic evaluations in healthcare decision making. The purpose of this study is to review the published literature on the use of evidence from economic evaluations for healthcare decision making and to map the findings to the Consolidated Framework for Implementation Research (CFIR). METHODS A systematic search strategy was used to identify studies investigating the factors that determine the use of evidence from economic evaluation in healthcare decision making. Barriers and facilitators identified in the included studies were mapped across the five CFIR domains, with the "intervention" referring to the use of economic evaluations in decision making. Gaps, inconsistencies and emergent relations were identified through the mapping process. RESULTS Fifty-three studies met eligibility criteria and were included in the review. The CFIR constructs associated with the Intervention Characteristics and those associated with the knowledge and beliefs of users of economic evaluations were widely cited in the identified barriers and facilitators. Other constructs from the CFIR had not been reported in the literature, such as 'organisational networks' and 'individual stage of change'. Most of the stages in the implementation process as described by the CFIR were reflected in the identified barriers and facilitators. DISCUSSION By categorising barriers and facilitators into domains, the CFIR provides a systematic approach to assess how these factors interact. Literature gaps in the literature regarding the use of economic evaluation in healthcare decision making were identified, specifically issues regarding organisational networks and the role of feedback. CONCLUSIONS Through mapping findings from studies of the use of evidence from economic evaluations in healthcare decision making, we present an implementation framework based on the CFIR for understanding the use of economic evaluations into practice.
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Affiliation(s)
- Gregory Merlo
- Queensland University of Technology, Institute of Health and Biomedical Innovation, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia.
| | - Katie Page
- Queensland University of Technology, Institute of Health and Biomedical Innovation, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
| | - Pauline Zardo
- Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Nicholas Graves
- Queensland University of Technology, Institute of Health and Biomedical Innovation, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
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Public perspectives on disinvestments in drug funding: results from a Canadian deliberative public engagement event on cancer drugs. BMC Public Health 2019; 19:977. [PMID: 31331312 PMCID: PMC6647147 DOI: 10.1186/s12889-019-7303-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 07/10/2019] [Indexed: 11/16/2022] Open
Abstract
Background Decisions relating to the funding of new drugs are becoming increasingly challenging due to a combination of aging populations, rapidly increasing list prices, and greater numbers of drug-indication pairs being brought to market. This is especially true in cancer, where rapid list price inflation is coupled with steeply rising numbers of incident cancer cases. Within a publicly funded health care system, there is increasing recognition that resource allocation decisions should consider the reassessment of, and potential disinvestment from, currently funded interventions alongside new investments. Public input into the decision-making process can help legitimize the outcomes and ensure priority-setting processes are aligned with public priorities. Methods In September 2014, a public deliberation event was held in Vancouver, Canada, to obtain public input on the topic of cancer drug funding. Twenty-four members of the general public were tasked with making collective recommendations for policy-makers about the principles that should guide funding decisions for cancer drugs in the province of British Columbia. Deliberative questions and decision aids were used to elicit individuals’ willingness to make trade-offs between expenditures and health outcomes. Results Participants discussed the implications of disinvestment decisions from cancer drugs in terms of its impact on patient choice, fairness and quality of life. Their discussions indicate that in order for a decision to disinvest from currently-funded cancer drugs to be acceptable, it must align with three main principles: the decision must be accompanied by significant gains, described both in terms of cost savings and opportunities to re-invest elsewhere in the health care system; those who are currently prescribed a cancer drug should be allowed to continue their course of treatment (referred to as a continuance clause, or “grandfathering” approach); and it must consider how access to care for specialized populations is impacted. Conclusions The results from this deliberation event provide insight into what is acceptable to British Columbians with respect to disinvestment decisions for cancer drugs. These recommendations can be considered within wider health system decision-making frameworks for funding decisions relating to all drugs, as well as for cancer drugs.
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Osorio D, Zuriguel-Pérez E, Romea-Lecumberri S, Tiñena-Amorós M, Martínez-Muñoz M, Barba-Flores Á. Selecting and quantifying low-value nursing care in clinical practice: A questionnaire survey. J Clin Nurs 2019; 28:4053-4061. [PMID: 31287603 DOI: 10.1111/jocn.14989] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/11/2019] [Accepted: 06/30/2019] [Indexed: 01/13/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the opinion of hospital nurses on a group of recommendations aimed at reducing low-value nursing care and, based on these results, to detect low-value practices probably existing in the hospital. BACKGROUND Low-value nursing care refers to clinical practices with poor or no benefit for patients that may be harmful and a waste of resources. Detecting these practices and understanding nurses' perceptions are essential to developing effective interventions to reduce them. METHODS We conducted a survey in a tertiary hospital. STROBE guidelines were followed. The questionnaire appraised nurses' agreement, subjective adherence and perception of usefulness of a group of recommendations to reduce low-value nursing care from Choosing Wisely and other initiatives. Practices described in recommendations with an agreement over 70% and a subjective adherence under 70% were categorised as low-value practices probably existing in the hospital. RESULTS A total of 265 nurses from eight areas of care participated in the survey. The response rate by area ranged between 2%-55%. From the 38 recommendations evaluated, agreement was 96% (95% confidence interval [95%CI], 95%-97%), median subjective adherence was 80% (95%CI, 80%-85%), and usefulness was 90% (95%CI, 89%-92%). Based on these results, we detected seven (0-15) low-value practices probably existing in our hospital, mostly on general practice, pregnancy care and wound care. CONCLUSIONS We found a great understanding of low-value care between nurses, given the high agreement to recommendations and perception of usefulness. However, several low-value practices may be present in nursing care, requiring actions to reduce them, for instance, reviewing institutional protocols and involving patients in de-implementation. RELEVANCE TO CLINICAL PRACTICE Hospitals and other settings should be aware of low-value practices and take actions to identify and reduce them. A survey may be a simple and helpful way to start this process.
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Affiliation(s)
- Dimelza Osorio
- Health Services Research Group-Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Center for Biomedical Research in the Epidemiology and Public Health Network (CIBERESP), Barcelona, Spain
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Mitchell D, O'Brien L, Bardoel A, Haines T. Understanding Health Professional Responses to Service Disinvestment: A Qualitative Study. Int J Health Policy Manag 2019; 8:403-411. [PMID: 31441277 PMCID: PMC6706972 DOI: 10.15171/ijhpm.2019.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/06/2019] [Indexed: 11/10/2022] Open
Abstract
Background: Disinvestment from inefficient health services may be a potential solution to rising healthcare costs, but there has been poor uptake of disinvestment recommendations. This Australian study aims to understand how health professionals react when confronted with a plan to disinvest from a health service they previously provided to their patients.
Methods: This qualitative study took place prior to the disinvestment phase of a trial which removed weekend allied health services from acute hospital wards, to evaluate the effectiveness and cost effectiveness of the service. Observations and focus groups were used to collect data from 156 participants which was analysed thematically.
Results: Initial reactions to the disinvestment were almost universally negative, with staff extremely concerned about the impact on the safety and quality of patient care and planning ways to circumvent the trial. Removal of existing services was perceived as a loss and created a direct threat to some clinicians’ professional identity. With time, discussion, and understanding of the project’s context, some staff moved towards acceptance and perceived the trial as an opportunity, particularly given the service was to be reinstated after the disinvestment.
Conclusion: Clinicians and health service managers are protective of the services they deliver and can create barriers to disinvestment. Even when services are removed to ascertain their value, health professionals may continue to provide services to their patients. Measuring the impact of the disinvestment may assist staff to accept the removal of a service.
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Affiliation(s)
- Deb Mitchell
- Monash Health Community, Monash Health, Dandenong, VIC, Australia
| | - Lisa O'Brien
- Occupational Therapy Department, School of Primary and Allied Health Care, Monash University, Frankston, VIC, Australia
| | - Anne Bardoel
- Department of Management and Marketing, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University, Frankston, VIC, Australia
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Hofmann B, Skolbekken JA, Getz L. The name of the game: Is preventive screening "cancer screening?". Eur J Clin Invest 2019; 49:e13096. [PMID: 30829397 DOI: 10.1111/eci.13096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Bjørn Hofmann
- Department of Health Sciences, Norwegian University of Science and Technology, NTNU, Gjøvik, Norway
| | - John-Arne Skolbekken
- Department of Public Health and Nursing, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Linn Getz
- Department of Public Health and Nursing, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
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Haines S, Savic M, Carter A. Advancing Medicine Ethically: Important Considerations for Innovative Practice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:38-40. [PMID: 31135311 DOI: 10.1080/15265161.2019.1602186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Specchia ML, La Torre G, Calabrò GE, Villari P, Grilli R, Federici A, Ricciardi W, de Waure C. Disinvestment in cancer care: a survey investigating European countries' opinions and views. Eur J Public Health 2019. [PMID: 29538676 DOI: 10.1093/eurpub/cky033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The current economic context calls for rationalizing health resources that can be pursued through disinvestment from low value health technologies to invest in the best performing ones, ensuring high healthcare quality. Oncology is a field where, because of high costs of health technologies and rapid innovation, disinvestment is crucial. Methods On this basis, the research team investigated through a survey, based on a questionnaire, opinions and views of representatives of European countries about disinvestment, in terms of fields of application, potential advocates and barriers, specifically focusing on cancer care. Results A total of 17 questionnaires were filled in (response rate: 32.1%). The survey showed disinvestment is applied in several countries as a tool for containing health care expenditures and identifying obsolete technologies/ineffective interventions. Clinicians' resistance to change and industries' opposition are recognized as the most important barriers to the implementation of disinvestment policies. Potential targets of disinvestment in cancer are seen in diagnostic and therapeutic areas. Conclusion Despite the agreement on fields of waste and of disinvestment policies, operational methods to put disinvestment in place are lacking. Since they should rely on an inclusive assessment of the technology, Health Technology Assessment may represent a good approach.
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Affiliation(s)
- Maria Lucia Specchia
- Section of Hygiene - Institute of Public Health, Università Cattolica del Sacro Cuore, IRCCS Fondazione Policlinico "Agostino Gemelli", Rome, Italy
| | - Giuseppe La Torre
- Department of Public Health and Infectious Diseases, Sapienza Università di Roma, Rome, Italy
| | - Giovanna Elisa Calabrò
- Section of Hygiene - Institute of Public Health, Università Cattolica del Sacro Cuore, IRCCS Fondazione Policlinico "Agostino Gemelli", Rome, Italy
| | - Paolo Villari
- Department of Public Health and Infectious Diseases, Sapienza Università di Roma, Rome, Italy
| | - Roberto Grilli
- Department of Clinical Governance, Local Health Authority of Reggio Emilia, Italy
| | - Antonio Federici
- General Directorate for Health Prevention, Ministry of Health, Rome, Italy
| | - Walter Ricciardi
- Section of Hygiene - Institute of Public Health, Università Cattolica del Sacro Cuore, IRCCS Fondazione Policlinico "Agostino Gemelli", Rome, Italy
| | - Chiara de Waure
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
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Disinvestment Activities and Candidates in the Health Technology Assessment Community: An Online Survey. Int J Technol Assess Health Care 2019; 35:189-194. [PMID: 31006390 DOI: 10.1017/s0266462319000229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES As healthcare decision makers continue to face challenges in health services delivery to their patients, disinvestment programs are being established for a sustainable healthcare system. This study aimed to collect data and information by means of a survey of disinvestment candidates and ongoing disinvestment projects in the health technology assessment (HTA) community. METHODS An online survey was conducted to collect information on disinvestment candidates and activities from members of the Health Technology Assessment International Disinvestment & Early Awareness Interest Group, the EuroScan International Network and International Network of Agencies for Health Technology Assessment. RESULTS Among the 362 invitees, twenty-four unique responses were received, and almost 70 percent were involved in disinvestment initiatives. The disinvestment candidates identified represented a range of health technologies. Evidence or signaling of clinical ineffectiveness or inappropriate use typically led to the nomination of disinvestment candidates. Health technology assessments and reassessments were usually conducted to evaluate the technology in question, and decisions usually led to the limited use of the technology. Barriers to disinvestment decisions included the strength of interest and advocacy groups, insufficient data for assessments, a systematic decision process and political challenges, while obstacles to their implementation were clinicians' reluctance and insufficient funding and incentives. CONCLUSIONS The survey results suggested that disinvestment activities are occurring in the HTA community, especially in the public sector. Future research can further investigate the processes and methods used to reach and implement disinvestment decisions from our survey respondents and explore to form closer ties between the HTA and clinical communities.
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Health care staff responses to disinvestment-A systematic search and qualitative thematic synthesis. Health Care Manage Rev 2019; 46:44-54. [PMID: 30807375 DOI: 10.1097/hmr.0000000000000239] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Health care services must deliver high-quality, evidence-based care that represents sound value. Disinvestment is the process of withdrawing resources from any existing health care practices that deliver low gain for their cost and reallocating these toward practices that are more effective, efficient, and cost-effective, thus benefiting patients and the community. PURPOSE This is the first review to examine the responses of health care staff to disinvestment and investigate the factors that increase the likelihood of these staff accepting disinvestment or reallocation of resources from the health services they provide. METHODS We conducted a systematic search of five electronic databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework. A critical appraisal process of the quality of the included studies was performed by two authors. We undertook a thematic synthesis of the qualitative data to develop an overarching narrative. RESULTS Twelve studies were identified for synthesis and all found that the disinvestment process was challenging and controversial for those health care staff involved. Negative staff reactions to disinvestment identified were anxiety, disempowerment, distrust, and feelings of being dismissed and disrespected. Engagement with disinvestment was observed when staff were invited to participate in a process they considered transparent and in the best interests of the community. PRACTICE RECOMMENDATIONS Health care staff have a strong professional identity associated with autonomy in their decision making in the provision of health care services. Disinvestment from a service that health care staff can usually choose to provide threatens this identity. Engaging clinical champions to lead change, using rigorous patient outcome data, and transparent decision-making processes may assist health care staff to embrace a new identity as innovators and accept disinvestment in low-value health care.
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Osorio D, Ribera A, Solans-Domènech M, Arroyo-Moliner L, Ballesteros M, Romea-Lecumberri S. Healthcare professionals' opinions, barriers and facilitators towards low-value clinical practices in the hospital setting. GACETA SANITARIA 2019; 34:459-467. [PMID: 30745093 DOI: 10.1016/j.gaceta.2018.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore healthcare professionals' opinions about low-value practices, identify practices of this kind possibly present in the hospital and barriers and facilitators to reduce them. Low-value practices include those with little or no clinical benefit that may harm patients or lead to a waste of resources. METHOD Using a mixed methodology, we carried out a survey and two focus groups in a tertiary hospital. In the survey, we assessed doctors' agreement, subjective adherence and perception of usefulness of 134 recommendations to reduce low-value practices from local and international initiatives. We also identified low-value practices possibly present in the hospital. In the focus groups with professionals from surgical and medical fields, using a phenomenological approach, we identified additional low-value practices, barriers and facilitators to reduce them. RESULTS 169 doctors of 25 specialties participated (response rate: 7%-100%). Overall agreement with recommendations, subjective adherence and usefulness were 83%, 90% and 70%, respectively. Low-value practices form 22 recommendations (16%) were considered as possibly present in the hospital. In the focus groups, the professionals identified seven more. Defensive medicine and scepticism due to contradictory evidence were the main barriers. Facilitators included good leadership and coordination between professionals. CONCLUSIONS High agreement with recommendations to reduce low-value practices and high perception of usefulness reflect great awareness of low-value care in the hospital. However, there are several barriers to reduce them. Interventions to reduce low-value practices should foster confidence in decision-making processes between professionals and patients and provide trusted evidence.
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Affiliation(s)
- Dimelza Osorio
- Vall d'Hebron University Hospital, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Spain; Health Services Research Group, Institut de Recerca Vall d'Hebron, Barcelona, Spain.
| | - Aida Ribera
- CIBER de Epidemiología y Salud Pública (CIBERESP), Spain; Cardiovascular Epidemiology Unit, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Maite Solans-Domènech
- CIBER de Epidemiología y Salud Pública (CIBERESP), Spain; Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain
| | - Liliana Arroyo-Moliner
- Instituto de Innovación Social, Dpto. Ciencias Sociales, ESADE Business & Law School, Barcelona, Spain
| | - Mónica Ballesteros
- Vall d'Hebron University Hospital, Barcelona, Spain; Health Services Research Group, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Soledad Romea-Lecumberri
- Vall d'Hebron University Hospital, Barcelona, Spain; Health Services Research Group, Institut de Recerca Vall d'Hebron, Barcelona, Spain
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Applying the 'COST' (Culture, Oversight, Systems Change, and Training) Framework to De-Adopt the Neutropenic Diet. Am J Med 2019; 132:42-47. [PMID: 30145223 DOI: 10.1016/j.amjmed.2018.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/03/2018] [Accepted: 08/03/2018] [Indexed: 12/16/2022]
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Aldakhil AM, Nassani AA, Abro MMQ, Zaman K. Food-beverage-tobacco consumption, smoking prevalence, and high-technology exports influenced healthcare sustainability agenda across the globe. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2018; 25:33249-33263. [PMID: 30255272 DOI: 10.1007/s11356-018-3277-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/18/2018] [Indexed: 06/08/2023]
Abstract
The objective of the study is to analyze the long-run, causal, and inter-temporal relationships between food-beverage-tobacco consumption, smoking prevalence in male and females, and high-technology exports and their resulting impact on global healthcare sustainability agenda in a panel of 19 European, North American, and Asian countries during a period of 1990-2016. The results show that the sample countries are largely affected by high mass consumption of food, beverages, and tobacco, due to which the health spending is very high in their economies that increase healthcare costs and mortality rates accordingly. The relationship between death rate and per capita income is found negative in a panel of selected countries, where high death rates substantially decrease country's per capita income. The Granger causality estimates confirm the unidirectional causality running from (i) high-technology exports to CO2 emissions, (ii) smoking prevalence of male and female to health expenditures, (iii) industrial value added to mortality, (iv) health expenditures to per capita income, (v) per capita income to death rates, and (vi) food, beverages, and tobacco consumption to mortality indicators, whereas, the inter-temporal causation confirmed that lifetime risk of maternal death will largely influence health expenditures in a panel of selected countries for the next 10-year time period.
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Affiliation(s)
- Abdullah Mohammed Aldakhil
- Department of Management, College of Business Administration, King Saud University, Riyadh, Saudi Arabia
| | - Abdelmohsen A Nassani
- Department of Management, College of Business Administration, King Saud University, Riyadh, Saudi Arabia
| | | | - Khalid Zaman
- Department of Economics, University of Wah, Quaid Avenue, Wah Cantonment, Pakistan.
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Haas R, O'Brien L, Bowles KA, Haines T. Health professionals' perceptions of the allied health role in the acute setting following hip and knee joint replacement surgery: a qualitative study. Disabil Rehabil 2018; 42:93-101. [PMID: 30183431 DOI: 10.1080/09638288.2018.1493542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: To describe health professionals' perceptions of the role of allied health during the acute phase following elective lower limb joint replacement surgery to inform the development of efficient allied health service models.Methods: This was a qualitative descriptive study conducted using semi-structured focus groups and thematic analysis. Participants were 25 medical, nursing, and allied health professionals working on two orthopaedic wards in a tertiary hospital in Victoria, Australia. Focus groups elicited staff perceptions regarding the aims and roles of acute allied health intervention following hip and knee replacement, how these services are currently provided, and how these services can best be provided. This study was undertaken alongside two stepped wedge cluster randomised controlled trials during which existing weekend allied health services were to be temporarily removed with opportunity to contribute to a stakeholder-driven model of these services.Results: The main theme that emerged was a sense of unrealised potential amongst health professionals in terms of patient outcomes following hip and knee joint replacement surgery arising from tension between perceptions of actual versus ideal allied health practice. Assessing function and planning for discharge accordingly was perceived to be a higher priority than intervening to improve functional independence.Conclusion: Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in patients following lower limb replacement surgery than current practice in this setting that prioritises discharge.Implications for RehabilitationAllied health service delivery in the acute phase following hip and knee joint replacement needs to balance the needs of the health service with those of the patients.Prioritising allied health intervention to low functioning and complex patients could be a more efficient use of allied health expertise in this population than current practice, which is to prioritise discharge.There may be more scope for nurses to be involved in promoting early postoperative mobilisation following joint replacement surgery, especially in uncomplicated cases.
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Affiliation(s)
- Romi Haas
- Physiotherapy Department, Monash University and Monash Health Allied Health Research Unit, Melbourne, Australia
| | - Lisa O'Brien
- Occupational Therapy Department, Monash University and Monash Health Allied Health Research Unit, Melbourne, Australia
| | - Kelly-Ann Bowles
- Department of Community Emergency Health and Paramedics, Monash University and Monash Health Allied Health Research Unit, Melbourne, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University and Monash Health Allied Health Research Unit, Melbourne, Australia
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45
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Soril LJJ, Seixas BV, Mitton C, Bryan S, Clement FM. Moving low value care lists into action: prioritizing candidate health technologies for reassessment using administrative data. BMC Health Serv Res 2018; 18:640. [PMID: 30111308 PMCID: PMC6094474 DOI: 10.1186/s12913-018-3459-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/09/2018] [Indexed: 11/25/2022] Open
Abstract
Background Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR). Methods An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC). Results The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] “do not do” recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely “Top 5” lists) were identified. Using appropriate coding systems for BC’s administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment. Conclusions This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level. Electronic supplementary material The online version of this article (10.1186/s12913-018-3459-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Brayan V Seixas
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Stirling Bryan
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,British Columbia SUPPORT Unit, Vancouver, BC, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
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46
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Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. Am J Med 2018; 131:760-763. [PMID: 29601803 DOI: 10.1016/j.amjmed.2018.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/21/2018] [Accepted: 03/01/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Arjun Gupta
- Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas; Parkland Hospital, Dallas, Tex
| | - Zhouwen Tang
- Parkland Hospital, Dallas, Tex; Division of Gastroenterology, University Texas Southwestern Medical Center, Dallas; Digestive & Liver Specialists of Houston, Tex
| | - Deepak Agrawal
- Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas; Parkland Hospital, Dallas, Tex; Division of Gastroenterology, University Texas Southwestern Medical Center, Dallas.
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Harris C, Allen K, Ramsey W, King R, Green S. Sustainability in Health care by Allocating Resources Effectively (SHARE) 11: reporting outcomes of an evidence-driven approach to disinvestment in a local healthcare setting. BMC Health Serv Res 2018; 18:386. [PMID: 29843702 PMCID: PMC5975394 DOI: 10.1186/s12913-018-3172-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 05/01/2018] [Indexed: 11/12/2022] Open
Abstract
Background This is the final paper in a thematic series reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was established to explore a systematic, integrated, evidence-based organisation-wide approach to disinvestment in a large Australian health service network. This paper summarises the findings, discusses the contribution of the SHARE Program to the body of knowledge and understanding of disinvestment in the local healthcare setting, and considers implications for policy, practice and research. Discussion The SHARE program was conducted in three phases. Phase One was undertaken to understand concepts and practices related to disinvestment and the implications for a local health service and, based on this information, to identify potential settings and methods for decision-making about disinvestment. The aim of Phase Two was to implement and evaluate the proposed methods to determine which were sustainable, effective and appropriate in a local health service. A review of the current literature incorporating the SHARE findings was conducted in Phase Three to contribute to the understanding of systematic approaches to disinvestment in the local healthcare context. SHARE differed from many other published examples of disinvestment in several ways: by seeking to identify and implement disinvestment opportunities within organisational infrastructure rather than as standalone projects; considering disinvestment in the context of all resource allocation decisions rather than in isolation; including allocation of non-monetary resources as well as financial decisions; and focusing on effective use of limited resources to optimise healthcare outcomes. Conclusion The SHARE findings provide a rich source of new information about local health service decision-making, in a level of detail not previously reported, to inform others in similar situations. Multiple innovations related to disinvestment were found to be acceptable and feasible in the local setting. Factors influencing decision-making, implementation processes and final outcomes were identified; and methods for further exploration, or avoidance, in attempting disinvestment in this context are proposed based on these findings. The settings, frameworks, models, methods and tools arising from the SHARE findings have potential to enhance health care and patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12913-018-3172-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC, Australia.
| | - Kelly Allen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC, Australia
| | - Wayne Ramsey
- Medical Services and Quality, Monash Health, Melbourne, VIC, Australia
| | - Richard King
- Medicine Program, Monash Health, Melbourne, VIC, Australia
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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UNTANGLING, UNBUNDLING, AND MOVING FORWARD: FRAMING HEALTH TECHNOLOGY REASSESSMENT IN THE CHANGING CONCEPTUAL LANDSCAPE. Int J Technol Assess Health Care 2018; 34:212-217. [PMID: 29616604 DOI: 10.1017/s0266462318000120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Health technology reassessment (HTR) is a policy process to manage health technologies throughout their lifecycle and ensure their ongoing optimal use. However, within an ever-evolving field, HTR is only one of many concepts associated with the optimization of health technologies. There is limited understanding of how other concepts and processes might differ and/or be interrelated. This study aims to describe the concepts underlying the various technology optimization processes and to reconcile their relationships within the HTR process. METHODS A synthesis of the literature on approaches to HTR was completed. An inductive synthesis approach was completed to catalogue common concepts and themes. Expert stakeholders were consulted to develop a schematic to diagrammatically depict the relationships among concepts and frame them within the HTR process. RESULTS A practical schematic was developed. Common concepts and themes were organized under six major domains that address the following discussion questions: (i) what is the value of the existing technology?; (ii) what is the current utilization gap?; (iii) what are the available tools and resources?; (iv) what are the levers for change?; (v) what is the desired outcome?; and (vi) who are the foundational actors? CONCLUSIONS Using these six questions to frame the issues faced by HTR will advance the common understanding of HTR, as well as improve implementation of HTR initiatives. These questions will clearly identify the process required to move forward within a complex healthcare system.
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Voorn VMA, van Bodegom-Vos L, So-Osman C. Towards a systematic approach for (de)implementation of patient blood management strategies. Transfus Med 2018; 28:158-167. [PMID: 29508467 DOI: 10.1111/tme.12520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 12/14/2022]
Abstract
Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.
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Affiliation(s)
- V M A Voorn
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.,Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - L van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - C So-Osman
- Unit Transfusion Medicine, Sanquin, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
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Harris C, Garrubba M, Melder A, Voutier C, Waller C, King R, Ramsey W. Sustainability in Health care by Allocating Resources Effectively (SHARE) 8: developing, implementing and evaluating an evidence dissemination service in a local healthcare setting. BMC Health Serv Res 2018; 18:151. [PMID: 29499702 PMCID: PMC5833068 DOI: 10.1186/s12913-018-2932-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 02/12/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND This is the eighth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE Program was a systematic, integrated, evidence-based program for disinvestment within a large Australian health service. One of the aims was to explore methods to deliver existing high quality synthesised evidence directly to decision-makers to drive decision-making proactively. An Evidence Dissemination Service (EDS) was proposed. While this was conceived as a method to identify disinvestment opportunities, it became clear that it could also be a way to review all practices for consistency with current evidence. This paper reports the development, implementation and evaluation of two models of an in-house EDS. METHODS Frameworks for development of complex interventions, implementation of evidence-based change, and evaluation and explication of processes and outcomes were adapted and/or applied. Mixed methods including a literature review, surveys, interviews, workshops, audits, document analysis and action research were used to capture barriers, enablers and local needs; identify effective strategies; develop and refine proposals; ascertain feedback and measure outcomes. RESULTS Methods to identify, capture, classify, store, repackage, disseminate and facilitate use of synthesised research evidence were investigated. In Model 1, emails containing links to multiple publications were sent to all self-selected participants who were asked to determine whether they were the relevant decision-maker for any of the topics presented, whether change was required, and to take the relevant action. This voluntary framework did not achieve the aim of ensuring practice was consistent with current evidence. In Model 2, the need for change was established prior to dissemination, then a summary of the evidence was sent to the decision-maker responsible for practice in the relevant area who was required to take appropriate action and report the outcome. This mandatory governance framework was successful. The factors influencing decisions, processes and outcomes were identified. CONCLUSION An in-house EDS holds promise as a method of identifying disinvestment opportunities and/or reviewing local practice for consistency with current evidence. The resource-intensive nature of delivery of the EDS is a potential barrier. The findings from this study will inform further exploration.
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Affiliation(s)
- Claire Harris
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
- Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC Australia
| | - Angela Melder
- Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC Australia
| | | | - Cara Waller
- Centre for Clinical Effectiveness, Monash Health, Melbourne, VIC Australia
| | - Richard King
- Medicine Program, Monash Health, Melbourne, VIC Australia
| | - Wayne Ramsey
- Medical Services and Quality, Monash Health, Melbourne, VIC Australia
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