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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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Ambasta A, Holroyd-Leduc JM, Pokharel S, Mathura P, Shih AWY, Stelfox HT, Ma I, Harrison M, Manns B, Faris P, Williamson T, Shukalek C, Santana M, Omodon O, McCaughey D, Kassam N, Naugler C. Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization. Implement Sci 2024; 19:45. [PMID: 38956637 PMCID: PMC11221016 DOI: 10.1186/s13012-024-01376-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/23/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada. METHODS We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes. DISCUSSION The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work. TRIAL REGISTRATION This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic. CLINICALTRIALS gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.
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Affiliation(s)
- Anshula Ambasta
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- Department of Anesthesia, Pharmacology and Therapeutics, Therapeutics Initiative, University of British Columbia, Vancouver, V6T 1Z4, Canada.
| | - Jayna M Holroyd-Leduc
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Surakshya Pokharel
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Pamela Mathura
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Andrew Wei-Yeh Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Henry T Stelfox
- Faculty of Medicine and Dentistry, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Irene Ma
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Braden Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Caley Shukalek
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Maria Santana
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Onyebuchi Omodon
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Deirdre McCaughey
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Narmin Kassam
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Chris Naugler
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
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Harris B, Kern K, Benner C, Moses J, Artinian H. Quality Improvement Project Reducing Sputum Cultures for Pediatric Patients With a Tracheostomy. Hosp Pediatr 2024; 14:564-572. [PMID: 38916049 DOI: 10.1542/hpeds.2023-007125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND AND OBJECTIVES Current research implies overuse of diagnostic testing and overtreatment in children with tracheostomies. There are no guidelines for obtaining sputum cultures for these patients, yet they are commonly obtained without significantly affecting management or outcomes. The aim of our quality improvement project was to decrease rate of sputum cultures in this population by 50%, from 64% to 32%. METHODS This was a single-center quality improvement project conducted in a pediatric emergency department (ED). Key drivers included: Standardized decision-making, appropriate culture collection, knowledge regarding colonization versus clinically relevant growth, and viral versus bacterial infections in this population. The study team developed an algorithm, used modification to electronic medical records orders, and provided education to drive change. Six months of preintervention and 12 months postintervention data were collected. Run charts/statistical process charts were created for the rate of cultures, length of stay, and return to the ED. RESULTS There were 159 patient encounters and the rate of sputum cultures decreased from 64% at baseline to 25% without change in length of stay or increased rate at which patients returned to the ED, including during local coronavirus disease 2019 and respiratory syncytial virus surges. We observed nonrandom data patterns after introduction of algorithm resulting in centerline shifts. CONCLUSIONS The study team was able to introduce an algorithm coinciding with a reduction in number of sputum cultures obtained. Next steps would be determining safety and efficacy of such an algorithm over a larger population.
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Affiliation(s)
- Baila Harris
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Kristina Kern
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Christopher Benner
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - James Moses
- Quality, Safety, and Experience, Corewell Health, Grand Rapids, Michigan
| | - Hovig Artinian
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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Shin S, Kim Y, Choi J, Park JY. Deliberative process of health technology reassessment by health technology assessment agency in Korea. Int J Technol Assess Health Care 2024; 40:e28. [PMID: 38738417 DOI: 10.1017/s026646232400014x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
In 2019, the National Evidence-based Healthcare Collaborating Agency (NECA) in Korea established a health technology reassessment (HTR) system to manage the life cycle of health technologies and develop operational measures promoting the efficient use of healthcare resources. The purpose of this study is to introduce the detailed implementation process and practical functional methods of the HTR implemented by NECA.The HTR is a structured multidisciplinary method for analyzing health technologies currently used in the healthcare system based on the latest information on parameters, such as clinical safety, effectiveness, and cost-effectiveness of optimizing the use of healthcare resources as well as social and ethical issues. All decision-making stages of the HTR are carefully reviewed and transparently managed. The HTR committee makes significant decisions, and the subcommittee decides the details related to the assessment process.Since the pilot began in 2018, 262 cases have been reassessed, of which, 126 cases (48.1 percent) were health services not covered by the National Health Insurance (NHI). Over the past 5 years, approximately 130 recommendations for the in-use technologies were determined by the HTR committee. In the near future, it will be necessary to officially develop and establish a Korean HTR system and a legal foundation to optimize the NHI system.
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Affiliation(s)
- Sangjin Shin
- Division of Healthcare Technology Assessment Research, National Evidence-based healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Yunjung Kim
- Division of Healthcare Technology Assessment Research, National Evidence-based healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Jieun Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Jung Yul Park
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Wendt B, Cremers M, Ista E, van Dijk M, Schoonhoven L, Nieuwboer MS, Vermeulen H, Van Dulmen SA, Huisman-de Waal G. Low-value home-based nursing care: A national survey study. J Adv Nurs 2024; 80:1891-1901. [PMID: 37983754 DOI: 10.1111/jan.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/13/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
AIMS To explore potential areas of low-value home-based nursing care practices, their prevalence and related influencing factors of nurses and nursing assistants working in home-based nursing care. DESIGN A quantitative, cross-sectional design. METHODS An online survey with questions containing scaled frequencies on five-point Likert scales and open questions on possible related influencing factors of low-value nursing care. The data collection took place from February to April 2022. Descriptive statistics and linear regression were used to summarize and analyse the results. RESULTS A nationwide sample of 776 certified nursing assistants, registered nurses and nurse practitioners responded to the survey. The top five most delivered low-value care practices reported were: (1) 'washing the client with water and soap by default', (2) 'application of zinc cream, powders or pastes when treating intertrigo', (3) 'washing the client from head to toe daily', (4) 're-use of a urinary catheter bag after removal/disconnection' and (5) 'bladder irrigation to prevent clogging of urinary tract catheter'. The top five related influencing factors reported were: (1) 'a (general) practitioner advices/prescribes it', (2) 'written in the client's care plan', (3) 'client asks for it', (4) 'wanting to offer the client something' and (5) 'it is always done like this in the team'. Higher educational levels and an age above 40 years were associated with a lower provision of low-value care. CONCLUSION According to registered nurses and certified nursing assistants, a number of low-value nursing practices occurred frequently in home-based nursing care and they experienced multiple factors that influence the provision of low-value care such as (lack of) clinical autonomy and handling clients' requests, preferences and demands. The results can be used to serve as a starting point for a multifaceted de-implementation strategy. REPORTING METHOD STROBE checklist for cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION No Patient or Public Contribution. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Nursing care is increasingly shifting towards the home environment. Not all nursing care that is provided is effective or efficient and this type of care can therefore be considered of low-value. Reducing low-value care and increasing appropriate care will free up time, improve quality of care, work satisfaction, patient safety and contribute to a more sustainable healthcare system.
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Affiliation(s)
- Benjamin Wendt
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Milou Cremers
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erwin Ista
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Monique van Dijk
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lisette Schoonhoven
- Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Minke S Nieuwboer
- Academy of Health and Vitality, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Simone A Van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Getty Huisman-de Waal
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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Conombo B, Guertin JR, Hoch JS, Grimshaw J, Bérubé M, Malo C, Berthelot S, Lauzier F, Stelfox HT, Turgeon AF, Archambault P, Belcaid A, Moore L. Implementation of an audit and feedback module targeting low-value clinical practices in a provincial trauma quality assurance program: a cost-effectiveness study. BMC Health Serv Res 2024; 24:479. [PMID: 38632593 PMCID: PMC11025277 DOI: 10.1186/s12913-024-10969-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness. METHODS We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided. RESULTS Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered. CONCLUSION A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers' willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.
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Affiliation(s)
- Blanchard Conombo
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
| | - Jason R Guertin
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
| | - Jeffrey S Hoch
- Division of Health Policy and Management, Department of Public Health Sciences, University of California at Davis, Davis, CA, USA
| | - Jeremy Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Christian Malo
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
- Centre de Recherche Intégrée Pour Un Système Apprenant en Santé Et Services Sociaux, Centre Intégré de Santé Et de Services Sociaux de Chaudière-Appalaches, Lévis, Québec, Canada
| | - François Lauzier
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
- VITAM-Centre de Recherche en Santé Durable, Québec City, Québec, Canada
| | - Amina Belcaid
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Quebec University Hospital, Centre de Recherche du CHU de Québec-Université Laval, 18E Rue, Local H-012a, Québec City, Québec, 1401G1J 1Z4, Canada.
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Sanchez A, Pijoan JI, Sainz de Rozas R, Lekue I, San Vicente R, Quindimil JA, Rotaeche R, Etxeberria A, Mozo C, Martinez-Cengotitabengoa M, Monge M, Gómez-Ramírez C, Samper R, Ogueta Lana M, Celorrio S, Merino-Inda N, Llarena M, Gonzalez Saenz de Tejada M, García-Alvarez A, Grandes G. De-imFAR phase II project: a study protocol for a cluster randomised implementation trial to evaluate the effectiveness of de-implementation strategies to reduce low-value statin prescribing in the primary prevention of cardiovascular disease. BMJ Open 2024; 14:e078692. [PMID: 38631840 PMCID: PMC11029292 DOI: 10.1136/bmjopen-2023-078692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION This study aims to reduce potentially inappropriate prescribing (PIP) of statins and foster healthy lifestyle promotion in cardiovascular disease (CVD) primary prevention in low-risk patients. To this end, we will compare the effectiveness and feasibility of several de-implementation strategies developed following the structured design process of the Behaviour Change Wheel targeting key determinants of the clinical decision-making process in CVD prevention. METHODS AND ANALYSIS A cluster randomised implementation trial, with an additional control group, will be launched, involving family physicians (FPs) from 13 Integrated Healthcare Organisations (IHOs) of Osakidetza-Basque Health Service with non-zero incidence rates of PIP of statins in 2021. All FPs will be exposed to a non-reflective decision assistance strategy based on reminders and decision support tools. Additionally, FPs from two of the IHOs will be randomly assigned to one of two increasingly intensive de-implementation strategies: adding a decision information strategy based on knowledge dissemination and a reflective decision structure strategy through audit/feedback. The target population comprises women aged 45-74 years and men aged 40-74 years with moderately elevated cholesterol levels but no diagnosed CVD and low cardiovascular risk (REGICOR<7.5%), who attend at least one appointment with any of the participating FPs (May 2022-May 2023), and will be followed until May 2024. We use the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate outcomes. The main outcome will be the change in the incidence rate of PIP of statins and healthy lifestyle counselling in the study population 12 and 24 months after FPs' exposure to the strategies. Moreover, FPs' perception of their feasibility and acceptability, and patient experience regarding the quality of care received will be evaluated. ETHICS AND DISSEMINATION The study was approved by the Basque Country Clinical Research Ethics Committee and was registered in ClinicalTrials.gov (NCT04022850). Results will be disseminated in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04022850.
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Affiliation(s)
- Alvaro Sanchez
- Primary Care Research Unit of Bizkaia, Deputy Directorate of Healthcare Assistance, Osakidetza-Basque Health Service, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Jose Ignacio Pijoan
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Clinical Epidemiology Unit, Osakidetza-Basque Health Service, Barakaldo, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Rita Sainz de Rozas
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Itxasne Lekue
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Primary Care Pharmacy Unit, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Ricardo San Vicente
- Zumarraga Health Center, Goierri-Alto Urola Integrated Health Organization, Osakidetza-Basque Health Service, Zumarraga, Spain
| | - Jose Antonio Quindimil
- Sestao Health Center, Barakaldo-Sestao Integrated Health Organization, Osakidetza-Basque Health Service, Sestao, Spain
| | - Rafael Rotaeche
- Primary Care Research Unit of Gipuzkoa, Organization of Integrated Health Services of Gipuzkoa, Osakidetza-Basque Health Service, Biogipuzkoa Health Research Institute, Donostia-San Sebastian, Spain
| | - Arritxu Etxeberria
- Primary Care Pharmacy, Donostialdea Integrated Health Organization, Osakidetza-Basque Health Service, Hernani, Spain
| | - Carmela Mozo
- Primary Care Pharmacy, Donostialdea Integrated Health Organization, Osakidetza-Basque Health Service, Hernani, Spain
| | - Monica Martinez-Cengotitabengoa
- School of Pharmacy, University of the Basque Country, Vitoria-Gasteiz, Spain
- Primary Care Pharmacy Unit, Barakaldo-Sestao Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Monica Monge
- Muskiz Health Center, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Muskiz, Spain
| | - Cristina Gómez-Ramírez
- Cardiology Department, Cruces University Hospital, Ezkerraldea-Enkarterri-Cruces Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Ricardo Samper
- Corporate Pharmacy Service, Directorate of Healthcare Assistance, Central Services, Osakidetza-Basque Health Service, Vitoria-Gasteiz, Spain
| | - Mikel Ogueta Lana
- Subdirectorate of Quality and Health Information Systems, Central Services, Osakidetza-Basque Health Service, Vitoria-Gasteiz, Spain
| | - Sara Celorrio
- Barakaldo-Sestao Integrated Health Organization, Osakidetza-Basque Health Service, Barakaldo, Spain
| | | | - Marta Llarena
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Marta Gonzalez Saenz de Tejada
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Arturo García-Alvarez
- Primary Care Research Unit of Bizkaia, Deputy Directorate of Healthcare Assistance, Osakidetza-Basque Health Service, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
| | - Gonzalo Grandes
- Primary Care Research Unit of Bizkaia, Deputy Directorate of Healthcare Assistance, Osakidetza-Basque Health Service, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Barakaldo, Spain
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Tyack Z, Carter H, Allen M, Senanayake S, Warhurst K, Naicker S, Abell B, McPhail SM. Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review. BMJ Open 2024; 14:e078761. [PMID: 38604625 PMCID: PMC11015208 DOI: 10.1136/bmjopen-2023-078761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/15/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes. DESIGN Scoping review. DATA SOURCES Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions. ELIGIBILITY CRITERIA We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings. DATA EXTRACTION AND SYNTHESIS Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework. RESULTS Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework. CONCLUSIONS Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.
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Affiliation(s)
- Zephanie Tyack
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hannah Carter
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Michelle Allen
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sameera Senanayake
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kym Warhurst
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
| | - Sundresan Naicker
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Metro South Health, Brisbane, Queensland, Australia
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9
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Parvar SY, Mojgani P, Lankarani KB, Poursaeed F, Mohamadi Jahromi LS, Mishra V, Abbasi A, Shahabi S. Barriers and facilitators to reducing low-value care for the management of low back pain in Iran: a qualitative multi-professional study. BMC Public Health 2024; 24:204. [PMID: 38233835 PMCID: PMC10792884 DOI: 10.1186/s12889-023-17597-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Low back pain (LBP) is a prevalent musculoskeletal disorder with a wide range of etiologies, ranging from self-limiting conditions to life-threatening diseases. Various modalities are available for the diagnosis and management of patients with LBP. However, many of these health services, known as low-value care (LVC), are unnecessary and impose undue financial costs on patients and health systems. The present study aimed to explore the perceptions of service providers regarding the facilitators and barriers to reducing LVC in the management of LBP in Iran. METHODS This qualitative descriptive study interviewed a total of 20 participants, including neurosurgeons, physiatrists, orthopedists, and physiotherapists, who were selected through purposive and snowball sampling strategies. The collected data were analyzed using the thematic content analysis approach. RESULTS Thirty-nine sub-themes, with 183 citations, were identified as barriers, and 31 sub-themes, with 120 citations, were defined as facilitators. Facilitators and barriers to reducing LVC for LBP, according to the interviewees, were categorized into five themes, including: (1) individual provider characteristics; (2) individual patient characteristics; (3) social context; (4) organizational context; and (5) economic and political context. The ten most commonly cited barriers included unrealistic tariffs, provider-induced demand, patient distrust, insufficient time allocation, a lack of insurance coverage, a lack of a comprehensive referral system, a lack of teamwork, cultural challenges, a lack of awareness, and defensive medicine. Barriers such as adherence to clinical guidelines, improving the referral system, improving the cultural status of patients, and facilitators such as strengthening teamwork, developing an appropriate provider-patient relationship, improving the cultural status of the public, motivating the patients, considering an individualized approach, establishing a desirable payment mechanism, and raising the medical tariffs were most repeatedly stated by participants. CONCLUSION This study has pointed out a great number of barriers and facilitators that shape the provision of LVC in the management of LBP in Iran. Therefore, it is essential for relevant stakeholders to consider these findings in order to de-implement LVC interventions in the process of LBP management.
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Affiliation(s)
- Seyedeh Yasamin Parvar
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parviz Mojgani
- Iran-Helal Institute of Applied Science and Technology, Tehran, Iran
- Research Center for Emergency and Disaster Resilience, Red Crescent Society of The Islamic Republic of Iran, Tehran, Iran
| | - Kamran Bagheri Lankarani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fereshteh Poursaeed
- Transitional Doctor of Physical Therapy Program, College of Professional Studies, Northeastern University, Boston, USA
| | - Leila Sadat Mohamadi Jahromi
- Department of Physical Medicine and Rehabilitation, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vinaytosh Mishra
- College of Healthcare Management and Economics, Gulf Medical University, Ajman, UAE
| | - Alireza Abbasi
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saeed Shahabi
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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11
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Eckhardt H, Felgner S, Dreger M, Fuchs S, Ermann H, Rödiger H, Rombey T, Busse R, Henschke C, Panteli D. Utilization of innovative medical technologies in German inpatient care: does evidence matter? Health Res Policy Syst 2023; 21:100. [PMID: 37784100 PMCID: PMC10546629 DOI: 10.1186/s12961-023-01047-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 08/26/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND The reimbursement of new technologies in inpatient care is not always linked to a requirement for evidence-based evaluation of patient benefit. In Germany, every new technology approved for market was until recently eligible for reimbursement in inpatient care unless explicitly excluded. The aim of this work was (1) to investigate the type of evidence that was available at the time of introduction of 25 innovative technologies and how this evidence evolved over time, and (2) to explore the relationship between clinical evidence and utilization for these technologies in German inpatient care. METHODS This study combined different methods. A systematic search for evidence published between 2003 and 2017 was conducted in four bibliographic databases, clinical trial registries, resources for clinical guidelines, and health technology assessment-databases. Information was also collected on funding mechanisms and safety notices. Utilization was measured by hospital procedures captured in claims data. The body of evidence, funding and safety notices per technology were analyzed descriptively. The relationship between utilization and evidence was explored empirically using a multilevel regression analysis. RESULTS The number of included publications per technology ranges from two to 498. For all technologies, non-comparative studies form the bulk of the evidence. The number of randomized controlled clinical trials per technology ranges from zero to 19. Some technologies were utilized for several years without an adequate evidence base. A relationship between evidence and utilization could be shown for several but not all technologies. CONCLUSIONS This study reveals a mixed picture regarding the evidence available for new technologies, and the relationship between the development of evidence and the use of technologies over time. Although the influence of funding and safety notices requires further investigation, these results re-emphasize the need for strengthening market approval standards and HTA pathways as well as approaches such as coverage with evidence development.
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Affiliation(s)
- Helene Eckhardt
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany.
| | - Susanne Felgner
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Marie Dreger
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Sabine Fuchs
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Hanna Ermann
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Hendrikje Rödiger
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Tanja Rombey
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Cornelia Henschke
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Dimitra Panteli
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
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12
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Dunsmore J, Duncan E, MacLennan S, N'Dow J, MacLennan S. Effectiveness of de-implementation strategies for low-value prescribing in secondary care: a systematic review. Implement Sci Commun 2023; 4:115. [PMID: 37723589 PMCID: PMC10507868 DOI: 10.1186/s43058-023-00498-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/06/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND/AIMS Considerable efforts have been made to improve guideline adherence in healthcare through de-implementation, such as decreasing the prescription of inappropriate medicines. However, we have limited knowledge about the effectiveness, barriers, facilitators and consequences of de-implementation strategies targeting inappropriate medication prescribing in secondary care settings. This review was conducted to understand these factors to contribute to better replication and optimisation of future de-implementation efforts to reduce low-value care. METHODS A systematic review of randomised control trials was conducted. Papers were identified through CINAHL, EMBASE, MEDLINE and Cochrane register of controlled trials to February 2021. Eligible studies were randomised control trials evaluating behavioural strategies to de-implement inappropriate prescribing in secondary healthcare. Risk of bias was assessed using the Cochrane Risk of Bias tool. Intervention characteristics, effectiveness, barriers, facilitators and consequences were identified in the study text and tabulated. RESULTS Eleven studies were included, of which seven were reported as effectively de-implementing low-value prescribing. Included studies were judged to be mainly at low to moderate risk for selection biases and generally high risk for performance and reporting biases. The majority of these strategies were clinical decision support at the 'point of care'. Clinical decision support tools were the most common and effective. They were found to be a low-cost and simple strategy. However, barriers such as clinician's reluctance to accept recommendations, or the clinical setting were potential barriers to their success. Educational strategies were the second most reported intervention type however the utility of educational strategies for de-implementation remains varied. Multiple barriers and facilitators relating to the environmental context, resources and knowledge were identified across studies as potentially influencing de-implementation. Various consequences were identified; however, few measured the impact of de-implementation on usual appropriate practice. CONCLUSION This review offers insight into the intervention strategies, potential barriers, facilitators and consequences that may affect the de-implementation of low-value prescribing in secondary care. Identification of these key features helps understand how and why these strategies are effective and the wider (desirable or undesirable) impact of de-implementation. These findings can contribute to the successful replication or optimisation of strategies used to de-implement low-value prescribing practices in future. TRIAL REGISTRATION The review protocol was registered at PROSPERO (ID: CRD42021243944).
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Affiliation(s)
| | - Eilidh Duncan
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sara MacLennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
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13
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Friedman NR, Watkins L, Barnard-Brak L, Barber A, White SW. De-implementation of Low-Value Practices for Autism Spectrum Disorder. Clin Child Fam Psychol Rev 2023; 26:690-705. [PMID: 37452164 DOI: 10.1007/s10567-023-00447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
Due to a variety of factors, Autism Spectrum Disorder (ASD) has long been tethered to use of low-value practice (LVP), arguably moreso than any other psychiatric or neurodevelopmental condition. Although dissemination of empirically supported treatments (EST) for autistic individuals has expanded markedly over the past decade, there has not been concomitant reduction in the use of LVP. It is critical that clinicians and scientists not only promote the implementation of EST, but also facilitate the de-implementation (abandonment and/or divestment) of ineffective or harmful practices. In this review, we describe a data-driven approach that can be used to identify LVP, drawing from established criteria for identification of evidence-based treatments (e.g., APA Division 12, National Clearinghouse on Autism Evidence and Practice; SAMHSA), as well as broader considerations such as social validity, cost, and parsimony. Herein, a data-based approach to LVP identification is proposed with a goal of improving quality of service access. Within an implementation science framework, we identify specific facilitators that sustain LVP use, and recommendations for subsequent de-implementation strategies are offered.
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Affiliation(s)
- Nicole R Friedman
- Center for Youth Development and Intervention, University of Alabama, 101 McMillan Bldg, Box 870348, Tuscaloosa, AL, 35487, USA
- Department of Psychology, University of Alabama, Tuscaloosa, AL, USA
| | - Laci Watkins
- Department of Special Education, University of Alabama, Tuscaloosa, AL, USA
- Department of Educational Psychology, Texas A&M University, College Station, TX, USA
| | - Lucy Barnard-Brak
- Department of Special Education, University of Alabama, Tuscaloosa, AL, USA
| | - Angela Barber
- Department of Communication Sciences and Disorders, Samford University, Birmingham, AL, USA
| | - Susan W White
- Center for Youth Development and Intervention, University of Alabama, 101 McMillan Bldg, Box 870348, Tuscaloosa, AL, 35487, USA.
- Department of Psychology, University of Alabama, Tuscaloosa, AL, USA.
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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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Kern-Goldberger AR, Hamm RF, Raghuraman N, Srinivas SK. Reducing Alarm Fatigue in Maternal Monitoring on Labor and Delivery: A Commentary on Deimplementation in Obstetrics. Am J Perinatol 2023; 40:1378-1382. [PMID: 35235954 PMCID: PMC10134101 DOI: 10.1055/a-1785-9175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hospital labor and delivery floors frequently operate like intensive care units (ICUs)-with continuous data feeds pouring into central monitoring stations against a background of blaring alarms. Yet the majority of obstetric patients are healthy and do not require ICU-level care. Despite limited organizational recommendations guiding the frequency of vital sign measurement, continuous pulse oximetry is used widely for laboring patients. There is also no evidence that morbidity prevention is linked to specific frequencies of vital sign monitoring in low-risk patients. In fact, studies examining the performance of maternal early warnings systems based on vital signs suggest that these may not reliably provide actionable information regarding maternal physiologic status. Furthermore, it is very possible that intrapartum maternal overmonitoring can impact care negatively by generating alarm fatigue, causing providers to miss actual abnormal vital signs that may precede morbidity. KEY POINTS: · Labor and delivery units may engage in maternal physiologic overmonitoring.. · Overmonitoring increases risk for alarm fatigue.. · Deimplementing low-value care may improve obstetric outcomes..
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Affiliation(s)
- Adina R. Kern-Goldberger
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca F. Hamm
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Sindhu K. Srinivas
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Heus P, van Dulmen SA, Weenink JW, Naaktgeboren CA, Takada T, Verkerk EW, Kamm I, van der Laan MJ, Hooft L, Kool RB. What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies. J Healthc Qual 2023; 45:261-271. [PMID: 37428942 PMCID: PMC10461725 DOI: 10.1097/jhq.0000000000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
BACKGROUND Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear. PURPOSE To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies. METHODS Analysis of 121 RCTs (1990-2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored. RESULTS Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%-42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied. CONCLUSIONS AND IMPLICATIONS Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.
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Guan Y, Haardörfer R, McBride CM, Escoffery C, Lipscomb J. Testing Theory-Based Messages to Encourage Women at Average Risk for Breast Cancer to Consider Biennial Mammography Screening. Ann Behav Med 2023; 57:696-707. [PMID: 37155576 DOI: 10.1093/abm/kaad018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND The US Preventive Services Task Force does not recommend routine annual mammography screening for women aged 40-49 at average risk. Little research has been done to develop theory-based communication interventions to facilitate informed decision-making about reducing potentially low-value mammography screening. PURPOSE Evaluate the effects of theory-based persuasive messages on women's willingness to consider delaying screening mammography until age 50 or have mammograms biennially. METHODS We conducted a randomized controlled communication experiment online with a population-based sample of U.S. women aged 40-49 (N = 383) who screened to be at average risk for breast cancer. Women were randomly assigned to the following messaging summaries: annual mammography risks in 40s (Arm 1, n = 124), mammography risks plus family history-based genetic risk (Arm 2, n = 120), and mammography risks, genetic risk, and behavioral alternatives (Arm 3, n = 139). Willingness to delay screening or reduce screening frequency was assessed post-experiment by a set of 5-point Likert scale items. RESULTS Women in Arm 3 reported significantly greater willingness to delay screening mammography until age 50 (mean = 0.23, SD = 1.26) compared with those in Arm 1 (mean = -0.17, SD = 1.20; p = .04). There were no significant arm differences in willingness to reduce screening frequency. Exposure to the communication messages significantly shifted women's breast cancer-related risk perceptions without increasing unwarranted cancer worry across all three arms. CONCLUSIONS Providing women with screening information and options may help initiate challenging discussions with providers about potentially low-value screening.
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Affiliation(s)
- Yue Guan
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Regine Haardörfer
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Colleen M McBride
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Falkenbach P, Raudasoja AJ, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Tikkinen KAO, Sipilä R, Turpeinen M, Komulainen J. Reporting of costs and economic impacts in randomized trials of de-implementation interventions for low-value care: a systematic scoping review. Implement Sci 2023; 18:36. [PMID: 37605243 PMCID: PMC10440866 DOI: 10.1186/s13012-023-01290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND De-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research. METHODS We searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool. RESULTS We screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%). CONCLUSION De-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers. TRIAL REGISTRATION OSF (Open Science Framework): https://osf.io/ueq32 .
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Affiliation(s)
- Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, University of Oulu, Oulu, Finland.
| | - Aleksi J Raudasoja
- Finnish Medical Society Duodecim, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Herney A Garcia-Perdomo
- Department of Surgery, Division of Urology/Uro-Oncology, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Faculty of Medicine and Health Technologies, Imaging Centre, Tampere University Hospital, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Wellbeing Services County of Pirkanmaa, Unit of Health Sciences, Faculty of Social Sciences, Hatanpää Health Center, Tampere University, Tampere, Finland
| | - Eero Raittio
- Department of Dentistry and Oral Health, Oral Health Care, Institute of Dentistry, Aarhus University, University of Eastern, Kuopio, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Miia Turpeinen
- Oulu University Hospital, University of Oulu, Oulu, Finland
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Geurkink TH, Marang-van de Mheen PJ, Nagels J, Poolman RW, Nelissen RG, van Bodegom-Vos L. Impact of Active Disinvestment on Decision-Making for Surgery in Patients With Subacromial Pain Syndrome: A Qualitative Semi-structured Interview Study Among Hospital Sales Managers and Orthopedic Surgeons. Int J Health Policy Manag 2023; 12:7710. [PMID: 38618816 PMCID: PMC10590240 DOI: 10.34172/ijhpm.2023.7710] [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: 09/29/2022] [Accepted: 07/31/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Withdrawal of reimbursement for low-value care through a policy change, ie, active disinvestment, is considered a potentially effective de-implementation strategy. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may be effective is unclear. This study explored how the active disinvestment initiative regarding subacromial decompression (SAD) surgery for subacromial pain syndrome (SAPS) in the Netherlands influenced clinical decision-making around surgery, including the perspectives of orthopedic surgeons and hospital sales managers. METHODS We performed 20 semi-structured interviews from November 2020 to October 2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals across the Netherlands as relevant stakeholders in the active disinvestment process. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion. RESULTS Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative for SAPS. The first theme was that the active disinvestment represented a "Too small piece of the pie" indicating little financial consequences for the hospital as it was merely used in negotiations with healthcare insurers to reduce costs, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in the overall healthcare insurer agreements. The second theme was "They [healthcare insurer] got it wrong," as the evidence and guidelines had been incorrectly interpreted, the active disinvestment was at odds with clinician experiences and beliefs and was perceived as a reduction in their professional autonomy. CONCLUSION The two overarching themes and their underlying factors highlight the complexity for active disinvestment initiatives to be effective. Future de-implementation initiatives including active disinvestment should engage relevant stakeholders at an early stage to incorporate their different perspectives, gain support and increase the probability of success.
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Affiliation(s)
- Timon H. Geurkink
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Perla J. Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem Nagels
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Moore L, Bérubé M, Belcaid A, Turgeon AF, Taljaard M, Fowler R, Yanchar N, Mercier É, Paquet J, Stelfox HT, Archambault P, Berthelot S, Guertin JR, Haas B, Ivers N, Grimshaw J, Lapierre A, Ouyang Y, Sykes M, Witteman H, Lessard-Bonaventure P, Gabbe B, Lauzier F. Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial. Implement Sci 2023; 18:27. [PMID: 37420284 DOI: 10.1186/s13012-023-01279-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care. METHODS We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios. DISCUSSION On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm. TRIAL REGISTRATION This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Faculty of Nursing, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Amina Belcaid
- Institut national d'excellence en santé et services sociaux, Bd Laurier, Québec, Qc, 2535, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Robert Fowler
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, On, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, 3280 Hospital Dr. NW, Calgary, Ab, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jérôme Paquet
- Department of Surgery, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr. NW, Calgary, Al, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jason R Guertin
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, 149 College St, Toronto, On, Canada
| | - Noah Ivers
- Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4Th Floor, Toronto, On, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Alexandra Lapierre
- Faculty of Nursing, Université de Montréal, Chem. de La Côte-Sainte-Catherine, Montréal, Qc, 2375, Canada
| | - Yongdong Ouyang
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Michael Sykes
- Department of Nursing, Midwifery, and Health, Northumbria University, Ellison PI, Newcastle, UK
| | - Holly Witteman
- Department of Family and Emergency Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Paule Lessard-Bonaventure
- Department of Surgery, Division of Neurosurgery, Université Laval, 1050 Av. de La Médecine, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Rd, Melbourne, Victoria, VIC 3004, Australia
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
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21
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Jorgensen SCJ, McIntyre M, Curran J, So M. Vancomycin Therapeutic Drug Monitoring: A Cross-Sectional Survey of Canadian Hospitals. Can J Hosp Pharm 2023; 76:203-208. [PMID: 37409147 PMCID: PMC10284285 DOI: 10.4212/cjhp.3337] [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: 07/07/2023]
Abstract
Background Little is known about the current landscape of vancomycin therapeutic drug monitoring (TDM) in Canadian hospitals, which operate within publicly funded health care systems. Objectives To determine current TDM practices for vancomycin and associated challenges and to gather perceptions about TDM based on area under the concentration-time curve (AUC) in Canadian hospitals. Methods An electronic survey was distributed to hospital pharmacists in spring 2021 through multiple national and provincial antimicrobial stewardship, public health, and pharmacy organizations. The survey gathered data about hospital characteristics, TDM methods, inclusion criteria for patient selection, pharmacokinetic and pharmacodynamic targets, vancomycin susceptibility testing and reporting, and perceived barriers and challenges. Results In total, 120 pharmacists from 10 of the 13 provincial and territorial jurisdictions in Canada, representing 12.5% of Canadian acute care hospitals (n = 962), completed at least 90% of survey questions. The predominant TDM method was trough-based (107/119, 89.9%); another 10.1% of respondents (12/119) reported performing AUC-based TDM (with or without trough-based TDM), and 17.9% (19/106) of those not already using AUC-based TDM were considering implementing it within 1 to 2 years. Among hospitals performing trough-based TDM, 60.5% (66/109) targeted trough levels between 15 and 20 mg/L for serious infections with methicillin-resistant Staphylococcus aureus. One-quarter of the respondents using this method (27/109, 24.8%) agreed that trough-based TDM was of uncertain benefit, and about one-third (33/109, 30.3%) were neutral on this question. Multiple challenges were identified for trough-based TDM, including sub- or supra-therapeutic concentrations and collection of specimens at inappropriate times. Overall, 40.5% (47/116) of respondents agreed that AUC-based TDM was likely safer than trough-based TDM, whereas 23.3% (27/116) agreed that AUC-based TDM was likely more effective. Conclusions This survey represents a first step in developing evidence-based, standardized best practices for vancomycin TDM that are uniquely suited to the Canadian health care system.
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Affiliation(s)
- Sarah C J Jorgensen
- , PharmD, MPH, is with the Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Mark McIntyre
- , PharmD, is with the Antimicrobial Stewardship Program, Sinai Health/University Health Network, and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Jennifer Curran
- , PharmD, is with the Antimicrobial Stewardship Program, Sinai Health/University Health Network, and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Miranda So
- , PharmD, MPH, is with the Antimicrobial Stewardship Program, Sinai Health/University Health Network; the Leslie Dan Faculty of Pharmacy, University of Toronto; and the Toronto General Hospital Research Institute, Toronto, Ontario
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22
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White MJ, Kolbow M, Prathibha S, Praska C, Ankeny JS, LaRocca CJ, Jensen EH, Tuttle TM, Hui JYC, Marmor S. Chemotherapy refusal and subsequent survival in healthy older women with high genomic risk estrogen receptor-positive breast cancer. Breast Cancer Res Treat 2023; 198:309-319. [PMID: 36692668 DOI: 10.1007/s10549-023-06862-x] [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: 07/18/2022] [Accepted: 01/08/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with estrogen receptor (ER)-positive, HER2-negative breast cancer (BC), and high-risk 21-gene recurrence score (RS) results benefit from chemotherapy. We evaluated chemotherapy refusal and survival in healthy older women with high-RS, ER-positive BC. METHODS Retrospective review of the National Cancer Database (2010-2017) identified women ≥ 65 years of age, with ER-positive, HER2-negative, high-RS (≥ 26) BC. Patients with Charlson Comorbidity Index ≥ 1, stage III/IV disease, or incomplete data were excluded. Women were compared by chemotherapy receipt or refusal using the Cochrane-Armitage test, multivariable logistical regression modeling, the Kaplan-Meier method, and Cox's proportional hazards modeling. RESULTS 6827 women met study criteria: 5449 (80%) received chemotherapy and 1378 (20%) refused. Compared to women who received chemotherapy, women who refused were older (71 vs 69 years), were diagnosed more recently (2014-2017, 67% vs 61%), and received radiation less frequently (67% vs 71%) (p ≤ 0.05). Refusal was associated with decreased 5-year OS for women 65-74 (92% vs 95%) and 75-79 (85% vs 92%) (p ≤ 0.05), but not for women ≥ 80 years old (84% vs 91%; p = 0.07). On multivariable analysis, hazard of death increased with refusal overall (HR 1.12, 95% CI 1.04-1.2); but, when stratified by age, was not increased for women ≥ 80 years (HR 1.10, 95% CI 0.80-1.51). CONCLUSIONS Among healthy women with high-RS, ER-positive BC, chemotherapy refusal was associated with decreased OS for women ages 65-79, but did not impact the OS of women ≥ 80 years old. Genomic testing may have limited utility in this population, warranting prudent shared decision-making and further study.
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Affiliation(s)
- McKenzie J White
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
| | - Madison Kolbow
- University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Saranya Prathibha
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
| | - Corinne Praska
- University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- School of Medicine and Public Health, Department of Surgery, Clinical Science Center, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | - Jacob S Ankeny
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
- Masonic Cancer Center, University of Minnesota, 420 Delaware St SE, MMC 806, Minneapolis, MN, 55455, USA
| | - Christopher J LaRocca
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
- Masonic Cancer Center, University of Minnesota, 420 Delaware St SE, MMC 806, Minneapolis, MN, 55455, USA
| | - Eric H Jensen
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
- Masonic Cancer Center, University of Minnesota, 420 Delaware St SE, MMC 806, Minneapolis, MN, 55455, USA
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
- Masonic Cancer Center, University of Minnesota, 420 Delaware St SE, MMC 806, Minneapolis, MN, 55455, USA
| | - Jane Y C Hui
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA
- Masonic Cancer Center, University of Minnesota, 420 Delaware St SE, MMC 806, Minneapolis, MN, 55455, USA
| | - Schelomo Marmor
- Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
- Masonic Cancer Center, University of Minnesota, 420 Delaware St SE, MMC 806, Minneapolis, MN, 55455, USA.
- Center for Clinical Quality & Outcomes Discovery & Evaluation (C-QODE), University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
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23
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Van Dulmen SA, Verkerk EW, Born K, Gupta R, Westert GP, Kool RB. Challenges and Opportunities for Reducing Low-Value Care; A Response to Recent Commentaries. Int J Health Policy Manag 2023; 12:7954. [PMID: 37579421 PMCID: PMC10461886 DOI: 10.34172/ijhpm.2023.7954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Simone A. Van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva W. Verkerk
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karen Born
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Reshma Gupta
- University of California Health, Los Angeles, CA, USA
| | - Gert P. Westert
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rudolf B. Kool
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
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24
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Leonard LD, Beaty L, Thomas M, Quinn C, Colborn KL, de Araujo TB, Torphy RJ, Assumpção LR, Olino K, Studts CR, Rodriguez Franco S, McCarter M, Stewart C, Gleisner AL. Unmeasured factors are associated with the use of completion lymph node dissection (CLND) in melanoma. J Surg Oncol 2023; 127:716-726. [PMID: 36453464 DOI: 10.1002/jso.27153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/28/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Completion lymph node dissection (CLND) was the standard treatment for patients with melanoma with positive sentinel lymph nodes (SLN) until 2017 when data from the DeCOG-SLT and MLST-2 randomized trials challenged the survival benefit of this procedure. We assessed the contribution of patient, tumor and facility factors on the use of CLND in patients with surgically resected Stage III melanoma. METHODS Using the National Cancer Database, patients who underwent surgical excision and were found to have a positive SLN from 2012 to 2017 were included. A multivariable mixed-effects logistic regression model with a random intercept for the facility was used to determine the effect of patient, tumor, and facility variables on the risk of CLND. Reference effect measures (REMs) were used to compare the contribution of contextual effects (unknown facility variables) versus measured variables on the variation in CLND use. RESULTS From 2012 to 2017, the overall use of CLND decreased from 59.9% to 26.5% (p < 0.0001). Overall, older patients and patients with government-based insurance were less likely to undergo CLND. Tumor factors associated with a decreased rate of CLND included primary tumor location on the lower limb, decreasing depth, and mitotic rate <1. However, the contribution of contextual effects to the variation in CLND use exceeded that of the measured facility, tumor, time, and patient variables. CONCLUSIONS There was a decrease in CLND use during the study period. However, there is still high variability in CLND use, mainly driven by unmeasured contextual effects.
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Affiliation(s)
- Laura D Leonard
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laurel Beaty
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Madeline Thomas
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher Quinn
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Thiago B de Araujo
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Robert J Torphy
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lia R Assumpção
- Department of Surgery, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Kelly Olino
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christina R Studts
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Salvador Rodriguez Franco
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,The Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Martin McCarter
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Camille Stewart
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ana L Gleisner
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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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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F John J, B S Etges AP, A Z Marcolino M, D Urman R, Marques-Gomes J, A Polanczyk C. Definition of low-value care in a low-risk preoperative population: A scoping review. J Eval Clin Pract 2023; 29:639-646. [PMID: 36779241 DOI: 10.1111/jep.13812] [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: 09/19/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/14/2023]
Abstract
RATIONALE Preoperative care is one of the main areas in which to address low-value care. A detailed definition of what low-value care is in this period of the surgical care journey paves the way for new scientific research, clinical improvements, and reduction of unnecessary costs in this field. AIMS AND OBJECTIVE To identify how low-value care in low-risk preoperative population has been defined in the scientific literature and propose a low-value care framework with potential consequences in this setting. METHODS Scoping review of theoretical studies and peer-reviewed papers, including reviews, commentaries, or expert opinions, were considered eligible for inclusion. The following databases were consulted: MEDLINE (via PubMed), EMBASE, and SCOPUS (from inception to July 24, 2021), using a structured search with the keywords "low value care", "clinical waste", "preoperative", and "elective procedures." Two independent reviewers performed study selection and data extraction. The definition of low-value care in the preoperative period and their consequences were described after extracting previous low-value care concepts and summarising the contents. Also, a visual framework was built with this information. RESULTS From 1519 publications identified in the initial searches, 22 underwent full-text assessment, and 11 conceptual studies were included in the review. A total of four studies (36%) presented a general low-value care definition, and all studies report some situations considered low-value care in the preoperative field of low-risk surgeries. The most common example of preoperative low-value care, listed in nine studies (81%), was having asymptomatic patients undergo screening tests before surgery. The main clinical and nonclinical consequences of low-value care in the preoperative phase included false-positive results from exams as well as psychological distress, increased costs, and delay in surgery. CONCLUSIONS Revisiting and integrating previous definitions of low-value care in low-risk surgery into a scoping review is a starting point for de-implementing unnecessary care and promoting improvements in surgical pathways.
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Affiliation(s)
- Josiane F John
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,Graduate Program in Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Paula B S Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,School of Technology, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Miriam A Z Marcolino
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Richard D Urman
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - João Marques-Gomes
- Nova School of Business and Economics, Carcavelos, Portugal.,Nova Medical School, Nova University Lisbon, Lisbon, Portugal
| | - Carisi A Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Brazil.,Graduate Program in Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Fournier KA, Dwyer PA, Vessey JA. De-adopting low-value care: The missing step in evidence-based practice? J Pediatr Nurs 2023; 69:71-76. [PMID: 36669294 DOI: 10.1016/j.pedn.2022.12.020] [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: 09/23/2022] [Accepted: 12/20/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Low-value care provides little or no benefit to pediatric patients, has the potential to cause harm, waste healthcare resources, and increase healthcare costs. Nursing has a responsibility to identify and de-adopt low-value practices to help promote quality care. PURPOSE 1) Describe the process of identifying and de-adopting low-value clinical practices guided by a conceptual model using a case study approach. 2) Identify facilitators and barriers to de-adoption practices, including levels of stakeholder engagement, organizational structures, and the quality of available scientific and non-scientific evidence. METHODOLOGY An evidence-based practice (EBP) project investigating the efficacy of antihistamines in decreasing infusion reactions to infliximab identified a low-value practice within a pediatric infusion center. The Synthesis Model for the Process of De-adoption was then applied to guide the de-adoption of this low-value practice. Case study analysis highlighted facilitators and barriers to de-adoption efforts. CONCLUSIONS The process for de-adopting care is an essential component of EBP and, as such, should be explicated through robust, standardized EBP processes and education. PRACTICE IMPLICATIONS Nurses are best positioned to identify, assess and prioritize low-value practices and facilitate the de-adoption of low-value practice that impact pediatric patients and families. Models to support de-adoption and a focus on site-specific practices including a prepared nursing workforce, continuous evaluation of care processes and the use of resources to assess for contextual determinants facilitates success and sustainability of this essential EBP approach.
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Affiliation(s)
| | - Patricia A Dwyer
- Satellite Services, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Judith A Vessey
- Medical, Surgical, & Behavioral Health Programs, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Selvam R, Jarrar A, Meghaizel C, Mamazza J, Neville A, Walsh C, Kolozsvari N. Redefining the role of routine postoperative bloodwork following uncomplicated bariatric surgery. Surg Endosc 2023; 37:364-370. [PMID: 35951121 DOI: 10.1007/s00464-022-09518-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/26/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND A quality improvement opportunity was identified to de-adopt the low-value care practice of routinely performing bloodwork for all patients undergoing elective bariatric surgery. While these patients are typically discharged on postoperative day 1 (POD1) after bloodwork is performed, it is uncommon for the discharge plan to change due to unexpected laboratory abnormalities alone. METHODS Patients undergoing bariatric surgery between September 2020 and April 2021 only had POD1 bloodwork if there were perioperative clinical concerns, they had insulin-dependent diabetes, or they were therapeutically anticoagulated. Thirty-day Emergency Department (ED) visits and readmissions were monitored as balancing measures. Outcomes were compared to a control group that underwent bariatric surgery prior to September 2020 when POD1 laboratory testing was routinely performed. Financial and environmental costs were estimated based our institutional standards. RESULTS The intervention group consisted of 303 patients: 248 (82%) Roux-en-Y gastric bypasses and 55 (18%) sleeve gastrectomies. Most patients (n = 256, 84.5%) did not have POD1 bloodwork. Twelve (3.9%) had bloodwork performed in violation of our protocol, of which none had a change in management based on the results. Of the 35 (12%) who had appropriately ordered bloodwork, 6 (2%) required a transfusion and 2 (0.7%) required a second surgery on the same admission for hemorrhage. Forty-four (14.5%) had 30-day ED visits of which 17 (5.6%) were within 7 days. Sixteen (5.3%) were readmitted. There were no significant differences between intervention and control groups in the rate of transfusion, second surgery, or 30-day ED visits. The avoidance of POD1 bloodwork saved approximately $6602.24 in lab processing fees alone and 512 test tubes. CONCLUSION POD1 bloodwork can be safely avoided in the absence of clinical concerns. In addition to not significantly increasing postoperative complications, there were benefits from a financial cost, environmental impact, and patient discomfort perspective.
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Affiliation(s)
- Rajajee Selvam
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Civic Campus, Loeb Research Building, 725 Parkdale Avenue - Office WM150B, Ottawa, ON, K1Y 4E9, Canada.
| | - Amer Jarrar
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Civic Campus, Loeb Research Building, 725 Parkdale Avenue - Office WM150B, Ottawa, ON, K1Y 4E9, Canada
| | - Cynthia Meghaizel
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Civic Campus, Loeb Research Building, 725 Parkdale Avenue - Office WM150B, Ottawa, ON, K1Y 4E9, Canada
| | - Joseph Mamazza
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Civic Campus, Loeb Research Building, 725 Parkdale Avenue - Office WM150B, Ottawa, ON, K1Y 4E9, Canada
| | - Amy Neville
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Civic Campus, Loeb Research Building, 725 Parkdale Avenue - Office WM150B, Ottawa, ON, K1Y 4E9, Canada
| | - Caolan Walsh
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Civic Campus, Loeb Research Building, 725 Parkdale Avenue - Office WM150B, Ottawa, ON, K1Y 4E9, Canada
| | - Nicole Kolozsvari
- Division of General Surgery, Department of Surgery, The Ottawa Hospital, Civic Campus, Loeb Research Building, 725 Parkdale Avenue - Office WM150B, Ottawa, ON, K1Y 4E9, Canada
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Advani SD, McKay V. Beyond implementation: Uncovering the parallels between de-implementation and antimicrobial stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e73. [PMID: 37113202 PMCID: PMC10127237 DOI: 10.1017/ash.2023.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 04/29/2023]
Abstract
De-implementation is defined as the process of discontinuing, removing, reducing, or replacing a harmful, ineffective, or low-value clinical practice or intervention. The goal of de-implementation strategies is to minimize patient harm, maximize use of resources, and reduce healthcare costs and inequities. Both antibiotic and diagnostic stewardship programs focus on reducing low-value interventions (tests or antimicrobials). Stewardship interventions commonly involve de-implementation and deprescribing strategies. This commentary explores unique aspects of deimplementing low-value testing and unnecessary antimicrobial use, similarities between de-implementation and stewardship approaches, multilevel factors that impact de-implementation, and opportunities for future research.
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Affiliation(s)
- Sonali D. Advani
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
- Author for correspondence: Sonali D. Advani, MBBS, MPH, FIDSA, Duke University School of Medicine, 315 Trent Drive, Hanes House, Room 154, Durham, NC27710. E-mail:
| | - Virginia McKay
- Brown School, Washington University in St. Louis, St. Louis, Missouri
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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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Carpenter CR, Southerland LT, Lucey BP, Prusaczyk B. Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities. J Am Geriatr Soc 2022; 70:3620-3630. [PMID: 36005482 PMCID: PMC10538952 DOI: 10.1111/jgs.17993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.
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Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University in St Louis School of Medicine, St. Louis, Missouri, USA
| | - Beth Prusaczyk
- Department of Medicine Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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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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Gangathimmaiah V, Evans R, Moodley N, Sen Gupta T, Drever N, Cardona M, Carlisle K. Identification of barriers, enablers and interventions to inform deimplementation of low-value care in emergency medicine practice: A protocol for a mixed methods scoping review informed by the Theoretical Domains Framework. BMJ Open 2022; 12:e062755. [PMID: 36368755 PMCID: PMC9660707 DOI: 10.1136/bmjopen-2022-062755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Low-value care can lead to patient harm, misdirected clinician time and wastage of finite healthcare resources. Despite worldwide endeavours, deimplementing low-value care has proved challenging. Multifaceted, context and barrier-specific interventions are essential for successful deimplementation. The aim of this literature review is to summarise the evidence about barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. METHODS AND ANALYSIS A mixed methods scoping review using the Arksey and O'Malley framework will be conducted. MEDLINE, CINAHL, EMBASE, EMCare, Scopus and grey literature will be searched from inception. Primary studies will be included. Barriers, enablers and interventions will be mapped to the domains of the Theoretical Domains Framework. Study selection, data collection and quality assessment will be performed by two independent reviewers. NVivo software will be used for qualitative data analysis. Mixed Methods Appraisal Tool will be used for quality assessment. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework will be used to present results. ETHICS AND DISSEMINATION Ethics approval is not required for this scoping review. This review will generate an evidence summary regarding barriers to, enablers of and interventions for deimplementation of low-value care in emergency medicine practice. This review will facilitate discussions about deimplementation with relevant stakeholders including healthcare providers, consumers and managers. These discussions are expected to inform the design and conduct of planned future projects to identify context-specific barriers and enablers then codesign, implement and evaluate barrier-specific interventions.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Douglas, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry and Anton Breinl Research Centre for Health Systems Strengthening, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Townsville Public Health Unit, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
- EBP Professorial Unit, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Farmer RL, Zaheer I, Schulte M. Disentangling low-value practices from pseudoscience in health service psychology. PHILOSOPHICAL PSYCHOLOGY 2022. [DOI: 10.1080/09515089.2022.2144193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ryan L. Farmer
- Psychology Department, The University of Memphis, Memphis, Tennessee, USA
| | - Imad Zaheer
- Psychology Department, St.John’s University, New York, USA
| | - Megan Schulte
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma, USA
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Kroon D, van Dulmen SA, Westert GP, Jeurissen PPT, Kool RB. Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study. BMJ Open 2022; 12:e062902. [PMID: 36343997 PMCID: PMC9644331 DOI: 10.1136/bmjopen-2022-062902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.
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Affiliation(s)
| | | | | | | | - Rudolf B Kool
- IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
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Halm MA. On Low-Value Nursing Care: Part 2, De-implementing Practices in Your Unit. Am J Crit Care 2022; 31:508-513. [PMID: 36316169 DOI: 10.4037/ajcc2022835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Margo A Halm
- Margo A. Halm is associate chief nurse executive, nursing research and evidence-based practice, VA Portland HealthCare System, Portland, Oregon
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Ingvarsson S, Hasson H, von Thiele Schwarz U, Nilsen P, Powell BJ, Lindberg C, Augustsson H. Strategies for de-implementation of low-value care-a scoping review. Implement Sci 2022; 17:73. [PMID: 36303219 PMCID: PMC9615304 DOI: 10.1186/s13012-022-01247-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. Method A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies. Results The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC. Conclusions Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01247-y.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Clara Lindberg
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Karolinska, Sweden.,Unit for implementation and evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, Stockholm, Sweden
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Raudasoja AJ, Falkenbach P, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Komulainen J, Sipilä R, Tikkinen KAO. Randomized controlled trials in de-implementation research: a systematic scoping review. Implement Sci 2022; 17:65. [PMID: 36183140 PMCID: PMC9526943 DOI: 10.1186/s13012-022-01238-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare costs are rising, and a substantial proportion of medical care is of little value. De-implementation of low-value practices is important for improving overall health outcomes and reducing costs. We aimed to identify and synthesize randomized controlled trials (RCTs) on de-implementation interventions and to provide guidance to improve future research. METHODS MEDLINE and Scopus up to May 24, 2021, for individual and cluster RCTs comparing de-implementation interventions to usual care, another intervention, or placebo. We applied independent duplicate assessment of eligibility, study characteristics, outcomes, intervention categories, implementation theories, and risk of bias. RESULTS Of the 227 eligible trials, 145 (64%) were cluster randomized trials (median 24 clusters; median follow-up time 305 days), and 82 (36%) were individually randomized trials (median follow-up time 274 days). Of the trials, 118 (52%) were published after 2010, 149 (66%) were conducted in a primary care setting, 163 (72%) aimed to reduce the use of drug treatment, 194 (85%) measured the total volume of care, and 64 (28%) low-value care use as outcomes. Of the trials, 48 (21%) described a theoretical basis for the intervention, and 40 (18%) had the study tailored by context-specific factors. Of the de-implementation interventions, 193 (85%) were targeted at physicians, 115 (51%) tested educational sessions, and 152 (67%) multicomponent interventions. Missing data led to high risk of bias in 137 (60%) trials, followed by baseline imbalances in 99 (44%), and deficiencies in allocation concealment in 56 (25%). CONCLUSIONS De-implementation trials were mainly conducted in primary care and typically aimed to reduce low-value drug treatments. Limitations of current de-implementation research may have led to unreliable effect estimates and decreased clinical applicability of studied de-implementation strategies. We identified potential research gaps, including de-implementation in secondary and tertiary care settings, and interventions targeted at other than physicians. Future trials could be improved by favoring simpler intervention designs, better control of potential confounders, larger number of clusters in cluster trials, considering context-specific factors when planning the intervention (tailoring), and using a theoretical basis in intervention design. REGISTRATION OSF Open Science Framework hk4b2.
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Affiliation(s)
- Aleksi J Raudasoja
- Faculty of Medicine, University of Helsinki, Helsinki, Finland. .,Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, Oulu, Finland.,University of Oulu, Oulu, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea & Westminster NHS Foundation Trust, London, UK.,Department of Epidemiology & Biostatistics, Imperial College London, London, UK
| | - Herney A Garcia-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Tampere University Hospital and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Hatanpää Health Center, City of Tampere, Finland.,Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Eero Raittio
- Oral Health Care, Tampere, Finland.,Institute of Dentistry, University of Eastern Finland, Kuopio, Finland.,Nordic Healthcare Group Ltd., Helsinki, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Burnham JP, Kwon JH, Newland JG, McKay VR. Dissemination and implementation science and antimicrobial stewardship in solid organ transplantation: A perspective. Transpl Infect Dis 2022; 24:e13903. [DOI: 10.1111/tid.13903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/08/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Jason P. Burnham
- Division of Infectious Diseases Washington University in St. Louis School of Medicine St. Louis Missouri USA
| | - Jennie H. Kwon
- Division of Infectious Diseases Washington University in St. Louis School of Medicine St. Louis Missouri USA
| | - Jason G. Newland
- Department of Pediatrics Washington University in St. Louis School of Medicine St. Louis Missouri USA
| | - Virginia R. McKay
- Brown School at Washington University in St. Louis St. Louis Missouri USA
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Childers S, Houchens N, Gupta A. Quality and safety in the literature: October 2022. BMJ Qual Saf 2022; 31:768-772. [PMID: 36122926 DOI: 10.1136/bmjqs-2022-015316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, whereas others will highlight unique publications from high-impact medical journals.
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Affiliation(s)
- Scott Childers
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Verkerk EW, van Dulmen SA, Westert GP, Hooft L, Heus P, Kool RB. Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands? BMJ Open Qual 2022. [PMCID: PMC9454034 DOI: 10.1136/bmjoq-2021-001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects. Methods We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated. Results Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy. Conclusions Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.
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Affiliation(s)
- Eva W Verkerk
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Gert P Westert
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rudolf B Kool
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Kherad O, Carneiro AV. Ten year anniversary of choosing wisely campaigns. Eur J Intern Med 2022; 103:118-119. [PMID: 35654675 DOI: 10.1016/j.ejim.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Omar Kherad
- Internal medicine division, Hôpital de la Tour and University of Geneva, Switzerland; Choosing Wisely working group of the European Federation of Internal Medicine, Switzerland
| | - Antonio Vaz Carneiro
- Institute for Evidence Based Healthcare, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Choosing Wisely working group of the European Federation of Internal Medicine, Switzerland.
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Verkerk EW, Van Dulmen SA, Born K, Gupta R, Westert GP, Kool RB. Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands. Int J Health Policy Manag 2022; 11:1514-1521. [PMID: 34273925 PMCID: PMC9808325 DOI: 10.34172/ijhpm.2021.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 04/30/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. METHODS We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. RESULTS The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy. CONCLUSION Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.
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Affiliation(s)
- Eva W. Verkerk
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simone A. Van Dulmen
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karen Born
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Reshma Gupta
- University of California Health, Sacramento, CA, USA
| | - Gert P. Westert
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rudolf B. Kool
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Ambasta A. Ten Years Since the Choosing Wisely Campaign: Are We Ordering Laboratory Tests More Wisely in Our Hospitalized Patients? Jt Comm J Qual Patient Saf 2022; 48:500-502. [DOI: 10.1016/j.jcjq.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Guan Y, Haardörfer R, McBride CM, Lipscomb J, Escoffery C. Factors Associated with Mammography Screening Choices by Women Aged 40-49 at Average Risk. J Womens Health (Larchmt) 2022; 31:1120-1126. [PMID: 35171027 DOI: 10.1089/jwh.2021.0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The U.S. Preventive Services Task Force (USPSTF) does not recommend routine mammogram screening for women aged 40-49 years at average risk for breast cancer. We aimed to assess the extent to which women were following guideline recommendations and to examine whether guideline awareness and other individual-level factors were associated with adherence. Materials and Methods: We surveyed a nationally representative panel of 383 U.S. women aged 40-49 years at low risk for hereditary breast cancer in October 2019. Results: Only 29% of women reported not having initiated screening mammography. Most women (80%) were unaware of the USPSTF screening guideline related to age of initiation and frequency of mammography. Being aware of the recommendation to initiate screening at age 50 increased the odds of not initiating screening (odds ratio [OR] = 6.70, p < 0.001), whereas being older than 45 years (OR = 0.22, p < 0.001) and having a primary care doctor decreased the odds of not initiating screening (OR = 0.25, p < 0.001). Conclusions: Mammogram screening in excess of USPSTF recommendations is prevalent among U.S. women aged 40-49 years. Efforts are needed to increase women's awareness of the rationale for guidelines and the opportunities to discuss with providers whether delaying mammograms is appropriate.
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Affiliation(s)
- Yue Guan
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Regine Haardörfer
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Colleen M McBride
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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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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Swindle T, Rutledge JM, Zhang D, Martin J, Johnson SL, Selig JP, Yates AM, Gaulden DT, Curran GM. De-Implementation of Detrimental Feeding Practices in Childcare: Mixed Methods Evaluation of Community Partner Selected Strategies. Nutrients 2022; 14:nu14142861. [PMID: 35889818 PMCID: PMC9319894 DOI: 10.3390/nu14142861] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023] Open
Abstract
This pilot evaluated strategies to decrease detrimental feeding practices in early care and education, which are hypothesized to compete with evidence-based feeding and obesity prevention practices. This study made two key comparisons: (1) a between-site comparison of sites receiving (a) no implementation or de-implementation strategies (i.e., Basic Support; B), (b) implementation strategies only (i.e., Enhanced Support; E), and (c) implementation and de-implementation strategies (i.e., De-implementation + Enhanced Support; D + E) and (2) a within-site pre-post comparison among sites with D + E. At nutrition lessons, the D + E group had more Positive Comments (Hedege’s g = 0.60) and higher Role Model fidelity (Hedege’s g = 1.34) compared to the E group. At meals, assistant teachers in the D + E group had higher Positive Comments than in the B group (g = 0.72). For within-group comparisons, the D + E group decreased Negative Comments (t(19) = 2.842, p = 0.01), increased Positive Comments (t(20) = 2.314, p = 0.031), and improved use of the program mascot at nutrition lessons (t(21) = 3.899, p = 0.001). At meals, lead teachers’ Negative Comments decreased (t(22) = 2.73, p = 0.01). Qualitative data identified strengths and opportunities for iteration. Despite a COVID interruption, mid-point comparisons and qualitative feedback suggest promise of the de-implementation strategy package.
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Affiliation(s)
- Taren Swindle
- Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (D.Z.); (J.M.); (D.T.G.)
- Correspondence:
| | - Julie M. Rutledge
- College of Applied and Natural Sciences, School of Human Ecology, Louisiana Tech University, Ruston, LA 71272, USA; (J.M.R.); (A.M.Y.)
| | - Dong Zhang
- Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (D.Z.); (J.M.); (D.T.G.)
| | - Janna Martin
- Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (D.Z.); (J.M.); (D.T.G.)
| | - Susan L. Johnson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - James P. Selig
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Amy M. Yates
- College of Applied and Natural Sciences, School of Human Ecology, Louisiana Tech University, Ruston, LA 71272, USA; (J.M.R.); (A.M.Y.)
| | - Daphne T. Gaulden
- Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (D.Z.); (J.M.); (D.T.G.)
| | - Geoffrey M. Curran
- Department of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
- Central Arkansas Veterans Healthcare System, Little Rock, AR 72205, USA
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Ingvarsson S, Hasson H, Augustsson H, Nilsen P, von Thiele Schwarz U, Sandaker I. Management strategies to de-implement low-value care-an applied behavior analysis. Implement Sci Commun 2022; 3:69. [PMID: 35752858 PMCID: PMC9233807 DOI: 10.1186/s43058-022-00320-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a lack of knowledge about management strategies being used to de-implement low-value care (LVC). Furthermore, it is not clear from the current literature what mechanisms are involved in such strategies and how they can change physicians' behaviors. Understanding the mechanisms is important for determining a strategy's potential impact. Applied behavior analysis focuses on processes involved in increasing and decreasing behaviors. Therefore, the aim of this study is to understand what management strategies are being used to de-implement LVC and the possible mechanisms involved in those strategies, using concepts from applied behavior analysis. METHOD We applied a qualitative study design using an inductive approach to understand what management strategies are in use and then employed applied behavior analysis concepts to deductively analyze the mechanisms involved in them. RESULTS We identified eight different management strategies intended to influence LVC. Five of the strategies were developed at a regional level and had the potential to influence physicians' LVC-related behaviors either by functioning as rules on which LVC to de-implement or by initiating local strategies in each health care center that in turn could influence LVC practices. The local strategies had a stronger potential for influencing de-implementation. CONCLUSION Both strategies at a systemic level (regional) and on a local level (health care centers) must be considered to influence LVC-related behaviors. Strategies at the center level have a specific opportunity to impact LVC-related behaviors because they can be tailored to specific circumstances, even though some of them probably were initiated as an effect of strategies on a regional level. Using applied behavior analysis to understand these circumstances can be helpful for tailoring strategies to reduce LVC use.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, SE, Sweden.
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, SE, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, 171 29, Stockholm, SE, Sweden
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, SE, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Stockholm Region, 171 29, Stockholm, SE, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Division of Public Health, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, SE, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
| | - Ingunn Sandaker
- SCBE Research Group, Department of Behavioral Science, Faculty of Health Sciences, Oslo Metropolitan University, St. Olavs plass, P.O. Box 4, NO-0130, Oslo, Norway
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An Analysis of 5 Years of Randomized Trials in Gastroenterology and Hepatology Reveals 52 Medical Reversals. Dig Dis Sci 2022; 67:2011-2018. [PMID: 34463882 DOI: 10.1007/s10620-021-07199-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/26/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS One manifestation of low-value medical practice is the medical reversal, a practice in widespread use that, once subjected to a randomized controlled trial (RCT), is found to be no better-or worse-than a prior established standard of care. We aimed to determine the prevalence of medical reversals in gastroenterology (GI) journals and characterize these reversals. METHODS We searched the American Journal of Gastroenterology, Clinical Gastroenterology and Hepatology, Gastroenterology, Gut, Hepatology, and the Journal of Hepatology, reviewing studies published in 2015-2019. We identified RCTs that tested an established clinical practice and produced negative results, considered tentative reversals. Any systematic review or meta-analysis that included the article was categorized as confirming the reversal, refuting the reversal, or providing insufficient data. RESULTS During the 5-year period, we identified 5,898 original articles, of which 212 tested an established practice and 52 were categorized as unrefuted medical reversals (25% of articles testing standard of care). Of the reversals, 21 (40%) tested procedures and devices, 15 (29%) tested medications, and 8 (15%) tested vitamins/supplements/diet. Twenty-three (44%) considered the alimentary tract, 12 (23%) considered the liver, pancreas, or biliary tract, and 17 (33%) considered endoscopy. Thirty-eight (73%) were funded exclusively by non-industry sources. CONCLUSION This review reveals a total of 52 reversals across all subfields of GI and medical, procedural, screening, and diagnostic interventions, occurring in 25% of randomized trials testing an established practice. More research is needed to determine the optimal way to engage stakeholders and remove reversed practices from medical care.
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Kherad O, Bottequin E, Steiner D, Alibert A, Eurin R, Bothorel H. Implementing a Multifaceted Intervention among Internal Medicine Residents with Audit and Educative Data Feedback Significantly Reduces Low-Value Care in Hospitalized Patients. J Clin Med 2022; 11:jcm11092435. [PMID: 35566562 PMCID: PMC9104072 DOI: 10.3390/jcm11092435] [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] [Received: 03/11/2022] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: The dissemination of recommendations on low-value care alone may not lead to physicians’ behavioral changes. The aim of this study was to evaluate whether a multifaceted behavioral intervention among internal medicine residents could reduce low-value care in hospitalized patients. Methods: A pre–post quality improvement intervention was conducted at the Internal Medicine Division of La Tour hospital (Geneva, Switzerland) from May 2020 to October 2021. The intervention period (3 months) consisted of a multifaceted informational intervention with audits and educative feedback about low-value care. The pre- and post-intervention periods including the same six calendar months were compared in terms of number of blood samples per patient day, prescription rates of benzodiazepines (BZDs) and proton pump inhibitors (PPIs), as well as safety indicators including potentially avoidable readmissions, premature deaths and complications. results: A total of 3400 patients were included in this study; 1095 (32.2%) and 1155 (34.0%) were, respectively, hospitalized during the pre- and post-intervention periods. Patient characteristics were comparable between the two periods. Only the number of blood tests per patient day and the BZD prescription rate at discharge were significantly reduced in the post-intervention phase (pre: 0.54 ± 0.43 vs. post: 0.49 ± 0.60, p ≤ 0.001; pre: 4.2% vs. post: 1.7%, p = 0.003, respectively). PPI prescription rates remained comparable. Safety indicators analyses revealed no significant differences between the two periods of interest. Conclusions: Our results demonstrate a modest but statistically significant effect of a multifaceted educative intervention in reducing the number of blood tests and the BZD prescription rate at discharge in hospitalized patients. Limiting low-value services is very challenging and additional long-term interventions are necessary for wider implementation.
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Affiliation(s)
- Omar Kherad
- Internal Medicine Division, Hôpital de la Tour and University of Geneva, 1217 Geneva, Switzerland
- Business Intelligence Unit, Hôpital de la Tour, 1217 Geneva, Switzerland;
- Correspondence: ; Tel.: +41-227196099
| | - Ezra Bottequin
- Business Intelligence Unit, Hôpital de la Tour, 1217 Geneva, Switzerland;
| | - Dorsaf Steiner
- Quality Department, Hôpital de la Tour, 1217 Geneva, Switzerland; (D.S.); (A.A.)
| | - Axelle Alibert
- Quality Department, Hôpital de la Tour, 1217 Geneva, Switzerland; (D.S.); (A.A.)
- General Management Department, Hôpital de la Tour, 1217 Geneva, Switzerland;
| | - Rodolphe Eurin
- General Management Department, Hôpital de la Tour, 1217 Geneva, Switzerland;
| | - Hugo Bothorel
- Research Department, Hôpital de la Tour, 1217 Geneva, Switzerland;
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