Strategies to reduce the use of low-value medical tests in primary care: a systematic review

Enablers and barriers to a quaternary prevention approach: a qualitative study of field experts

OBJECTIVE

There is a growing concern about the sustainability of healthcare and the impacts of 'overuse' on patients and systems. Quaternary prevention (P4), a concept promoting the protection of patients from medical interventions in which harms outweigh benefits, is well positioned to stimulate reflection and inspire solutions, yet has not been widely adopted. We sought to identify enablers and barriers to a P4 approach, according to field experts and advocates in one health system.

DESIGN

Qualitative methodology, using semistructured interviews and a grounded theory approach facilitated thematic analysis and development of a conceptual model.

SETTING

Virtual interviews, conducted in British Columbia, Canada.

PARTICIPANTS

12 field experts, recruited based on their interest and work related to P4 and related concepts.

RESULTS

Four factors were seen as promoting or hindering P4 efforts depending on context: relationship between patient and clinician, education of clinicians and the public, health system design and influencers. We extracted four broad enablers of P4: evidence-based medicine, personal experiences and questioning attitude, public P4 campaigns and experience in resource-poor contexts. There were six barriers: peer pressure between clinicians, awareness and screening campaigns, cognitive biases, cultural factors, complexity of the problem and industry influence.

CONCLUSIONS

Elicited facilitators and impediments to the application of P4 were similar to those seen in existing literature but framed uniquely; our findings place increased emphasis on the clinician-patient relationship as central to decision-making and position other drivers as influencing this relationship. A transition to a model of care that explicitly integrates conscious protection of patients by reducing overtesting, overdiagnosis and overtreatment will require changes across health systems and society.

Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study

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.

Economic evaluations of audit and feedback interventions: a systematic review

BACKGROUND

The effectiveness of audit and feedback (A&F) interventions to improve compliance to healthcare guidelines is supported by randomised controlled trials (RCTs) and meta-analyses of RCTs. However, there is currently a knowledge gap on their cost-effectiveness.

OBJECTIVE

We aimed to assess whether A&F interventions targeting improvements in compliance to recommended care are economically favourable.

METHODS

We conducted a systematic review including experimental, observational and simulation-based economic evaluation studies of A&F interventions targeting healthcare providers. Comparators were a 'do nothing' strategy, or any other intervention not involving A&F or involving a subset of A&F intervention components. We searched MEDLINE, CINAHL, CENTRAL, Econlit, EMBASE, Health Technology Assessment Database, MEDLINE, NHS Economic Evaluation Database, ABI/INFORM, Web of Science, ProQuest and websites of healthcare quality associations to December 2021. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios, incremental net benefit and incremental cost-benefit ratios. Pairs of reviewers independently selected eligible studies and extracted relevant data. Reporting quality was evaluated using CHEERS (Consolidated Health Economic Evaluation Reporting Standards). Results were synthesised using permutation matrices for all studies and predefined subgroups.

RESULTS

Of 13 221 unique citations, 35 studies met our inclusion criteria. The A&F intervention was dominant (ie, at least as effective with lower cost) in 7 studies, potentially cost-effective in 26 and was dominated (ie, the same or less effectiveness and higher costs) in 2 studies. A&F interventions were more likely to be economically favourable in studies based on health outcomes rather than compliance to recommended practice, considering medical costs in addition to intervention costs, published since 2010, and with high reporting quality.

DISCUSSION

Results suggest that A&F interventions may have a high potential to be cost-effective. However, as is common in systematic reviews of economic evaluations, publication bias could have led to an overestimation of their economic value.

General practitioner gender and use of diagnostic procedures: a French cross-sectional study in training practices

OBJECTIVES

The acceleration in the number of female doctors has led to questions about differences in how men and women practice medicine. The aim of this study was to assess the influence of general practitioner (GP) gender on the use of the three main categories of diagnostic procedures-clinical examinations, laboratory tests and imaging investigations.

DESIGN

Cross-sectional nationwide multicentre study.

SETTING

French training general practices.

PARTICIPANTS

The patient sample included all the voluntary patients over a cumulative period of 5 days per office between November 2011 and April 2012. The GP sample included 85 males and 43 females.

METHODS

54 interns in general practice, observing their GP supervisors, collected data about the characteristics of GPs and consultations, as well as the health problems managed during the visit and the processes of care associated with them. Using hierarchical multilevel mixed-effect logistic regression models, we performed multivariable analyses to assess differences in each of the three main categories of diagnostic procedures, and two specific multivariable analyses for each category, distinguishing screening from diagnostic or follow-up procedures. We searched for interactions between GP gender and patient gender or type of health problem managed.

RESULTS

This analysis of 45 582 health problems managed in 20 613 consultations showed that female GPs performed more clinical examinations than male GPs, both for screening (OR 1.75; 95% CI 1.19 to 2.58) and for diagnostic or follow-up purposes (OR 1.41; 95% CI 1.08 to 1.84). Female GPs also ordered laboratory tests for diagnostic or follow-up purposes more frequently (OR 1.21; 95% CI 1.03 to 1.43). Female GPs performed even more clinical examinations than male GPs to diagnose or follow-up injuries (OR 1.69; 95% CI 1.19 to 2.40).

CONCLUSION

Further research on the appropriateness of diagnostic procedures is required to determine to what extent these differences are related to underuse or overuse.