Low-value health care, de-implementation, and implications for nursing research: A discussion paper

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.

A micro-costing analysis of post-fracture care pathways: results from the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)

This study identified the costs and health-related quality of life impacts of several post-fracture multidisciplinary care pathways specific to individual skeletal site (hip, distal forearm, vertebrae, humerus). These care pathways may assist healthcare providers in allocating resources for osteoporotic fractures in more effective and cost-efficient ways.

INTRODUCTION

This micro-costing study was undertaken to provide the estimated healthcare costs of several fracture site-specific health service use pathways associated with different trajectories of health-related quality of life (HRQoL) 12-months post-fracture.

METHODS

The study included 4126 adults aged ≥ 50 years with a fragility fracture (1657 hip, 681 vertebrae, 1354 distal forearm, 434 humerus) from the International Costs & Utilities Related to Osteoporotic fractures Study (ICUROS). ICUROS participants were asked to recall the frequency and duration (where applicable) of their health and community care service use at 4- and 12-month follow-up visits. Patient-level costs were identified and aggregated to determine the average cost of healthcare use related to the fracture in each care pathway (presented in Australian 2021 dollars). Mean cost differences were calculated and analysed using a one-way analysis of variance (ANOVA) and post hoc Bonferroni correction to determine any statistically significant differences.

RESULTS

The total direct cost of fractures was estimated at $89564, $38926, $18333, and $38461AUD per patient for hip, vertebral, wrist, and humeral participants, respectively. A Kruskal-Wallis test yielded a statistically significant difference in cost values between most care pathways (p < 0.001). Of the 20 care pathways, those associated with recovery of HRQoL had lower mean costs per patient across each fracture site.

CONCLUSIONS

This study identified the costs and HRQoL impacts of several multidisciplinary care pathways for individual fracture sites based on the health service utilization of an international cohort of older adults. These care pathways may assist healthcare providers in allocating resources for fragility fractures in more effective and cost-efficient ways.

Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia

BACKGROUND

Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic.

METHODS

A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews.

RESULTS

All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data.

CONCLUSION

Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

Sex differences in recovery of quality of life 12 months post-fracture in community-dwelling older adults: analyses of the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS)

In this study of 695 Australian older adults (aged ≥50 years), we found that men and women had a similar trajectory of health-related quality of life (HRQoL) recovery following fragility fracture at any skeletal site. These results provide us with critical knowledge that improves our understanding of health outcomes post-fracture.

INTRODUCTION

Mortality is higher in men than that in women following a fragility fracture, but it is unclear whether recovery of patient-reported outcomes such as health-related quality of life (HRQoL) differs between sexes. This study aimed to identify sex differences in HRQoL recovery 12 months post-fracture.

METHODS

Data were from the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS). Participants recruited to AusICUROS were adults aged ≥50 years who sustained a fragility fracture. HRQoL was measured using the EQ-5D-3L at three time-points post-fracture: within 2 weeks (including pre-fracture recall) and at 4 and 12 months. Multivariate logistic regression analyses were undertaken, adjusting for confounders including age, education, income, and healthcare utilization post-fracture.

RESULTS

Overall, 695 AusICUROS participants (536 women, 77.1%) were eligible for analysis with fractures at the hip (n = 150), distal forearm (n = 261), vertebrae (n = 61), humerus (n = 52), and other skeletal sites (n = 171). At the time of fracture, men were younger, reported a higher income, and were more likely to be employed, compared with women. For all fracture sites combined, there were no differences between men and women in recovery to pre-fracture HRQoL at 12-month follow-up (adjusted OR = 1.09; 95% CI: 0.75-1.61). When stratified by fracture site, no significant sex differences were seen for hip (OR = 1.02; 95% CI: 0.42-2.52), distal forearm (OR = 1.60; 95% CI: 0.68-3.78), vertebral (OR = 2.28; 95% CI: 0.61-8.48), humeral (OR = 1.62; 95% CI: 0.16-9.99), and other fractures (OR = 1.00; 95% CI: 0.44-2.26).

CONCLUSION

Community-dwelling men and women who survived the 12 months following fragility fracture had a similar trajectory of HRQoL recovery at any skeletal site.

Impact of COVID-19 on emergency department attendance in an Australia hospital: a parallel convergent mixed methods study

OBJECTIVES

The COVID-19 pandemic has changed the way people are accessing healthcare. The aim of this study was to examine the impact of COVID-19 on emergency department (ED) attendance for frequent attenders and to explore potential reasons for changes in attendance.

DESIGN

This convergent parallel mixed methods study comprised two parts.

SETTING

An interrupted time-series analysis evaluated changes in ED presentation rates; interviews investigated reasons for changes for frequent ED users in a culturally and linguistically diverse setting.

PARTICIPANTS

A total of 4868 patients were included in the time series. A subgroup of 200 patients were interviewed, mean age 66 years (range 23-99).

RESULTS

Interrupted time-series analysis from 4868 eligible participants showed an instantaneous decrease in weekly ED presentations by 36% (p<0.001), with reduction between 45% and 67% across emergency triage categories. 32% did not know they could leave home to seek care with differences seen in English versus non-English speakers (p<0.001). 35% reported postponing medical care. There was a high fear about the health system becoming overloaded (mean 4.2 (±2) on 6-point scale). Four key themes emerged influencing health-seeking behaviour: fear and/or avoidance of hospital care; use of telehealth for remote assessment; no fear or avoidance of hospital care; not leaving the house for any reason.

CONCLUSIONS

This study demonstrated reduced ED use by a vulnerable population of previously frequent attenders. COVID-19 has resulted in some fear and avoidance of hospitals, but has also offered new opportunity for alternative care through telehealth.

Can Pharmacists Fill the Primary Care Provider Gap in Recommending Breast Screening?

Background and context: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+, targeting women aged 50-74. The program reduces breast cancer deaths by up to 28%. Primary care is important in improving uptake of breast screening. In particular, a recommendation from a health professional is a strong influencer. Many general practitioners (GPs) recommend screening, however, it is important to expand recruitment to other health professionals given many women do not visit a GP regularly. Community pharmacists and pharmacy staff may be a trusted source of health information, and are potentially an underutilized opportunity to promote breast screening to women. Based on this gap, BSV developed a three month pharmacy-based screening awareness campaign that was trialed in community pharmacies throughout 2017/18. The campaign is based on a UK community pharmacy model that was shown to successfully increase public awareness about cancer screening. Aim: BSV aims to diversify the types of health professionals that recommend screening to reach women who do not visit a GP regularly. The aim of the pharmacy-based breast screening awareness campaign is to: • build capacity of pharmacy staff to deliver breast screening messages to their communities • increase awareness of breast screening in women aged 50-74 • increase awareness of breast screening among family and friends of women Strategy/Tactics: BSV's pharmacy-based breast screening awareness campaign was trialed in 4 community pharmacies in 2017. Each pharmacy received a grant of up to $1550 which enabled them to: • allow pharmacy staff to attend training to increase their knowledge of breast screening and the campaign • display BreastScreen collateral throughout the store to provide information and prompt queries • initiate conversations and answer questions about breast screening • monitor campaign activity via a number of methods Outcomes: • Posttraining, 100% of staff were confident in promoting breast screening to customers • Staff across 4 pharmacies had 638 conversations about breast screening with customers (average 160/pharmacy). The majority were with women in the target age group • Most pharmacies suggested shortening the campaign to 2 months • All pharmacies said the funding was a critical motivator to participation • All pharmacies stated that the campaign was worthwhile, and allowed them to participate in health promotion Two additional trials are scheduled to test a reduced campaign duration and funding model. Results will be available later in 2018 What was learned: • Many women do not visit their GP regularly • Community pharmacists and pharmacy staff are an underutilized opportunity to promote breast screening • Delivering cancer screening messages through community pharmacies is an effective way to reach women aged 50-74 • Pharmacy funding and training are critical in enabling pharmacies to deliver a breast screening awareness campaign

A Breast Screening Shawl to Help Aboriginal Women Feel More Comfortable and Culturally Safe

Background: It is recommended that Australian women aged 50-74 have a breast screen every two years. Aboriginal women have lower breast screening participation than the general population, and face barriers at a system, service and individual level including: • Cultural: lack of cultural awareness/safety at screening services • Fear: historical apprehension about health services due to the after effects of colonization and intergenerational trauma • Shame: feeling embarrassment/shame at being undressed in front of a stranger • Past experience: having a past unpleasant breast screen, or hearing about someone else' • Knowledge: lack of knowledge about screening • Logistics: not knowing service provider locations or limited access to transport During a 2016 project between BreastScreen Victoria (BSV) and Women's Health West, Aboriginal women discussed the need for a shawl to cover them during screening. This idea is based on a successful New Zealand model. Based on this, the Victorian Aboriginal Health Service (VAHS), Victorian Aboriginal Community Controlled Health Organization (VACCHO) and BSV formed a partnership to trial a breast screening shawl with Aboriginal women. A key principle underpinning the project is that success will reflect the degree to which this is an Aboriginal-led initiative, driven by the needs of Aboriginal women, and steered by community-based Aboriginal health organizations. Project aims: • Assess whether a cultural, strength based screening process increases engagement of Aboriginal women • Determine whether a screening shawl enhances comfort and culturally safety • Encourage breast screening services to develop culturally safe screening practices • Develop a flexible model that can be easily adapted by other Aboriginal health services to reproduce the shawl, in recognition of the diversity of Aboriginal communities Methods: This project adopted the following strategies: • A project steering group was established • The shawl will be trialled via a group booking at one BSV clinic • Before the group booking, BSV clinic staff will attend culturally safety training • On the trial day, women will attend an information session at VAHS about breast screening and receive their shawl, travel to the BSV clinic together for screening, and return to VAHS to discuss their experiences Results: The trial will be fully evaluated in 2018 to determine whether project aims were achieved. Conclusion: Key learnings to date are: • Breast screening interventions for Aboriginal women must be community-led to ensure they are culturally appropriate, safe and acceptable • Aboriginal women face a number of barriers to breast screening at a system, service and individual level • Health services play a critical role in adopting culturally safe screening practices • Developing a flexible model that can be easily adapted by other Aboriginal health services is critical in ensuring the sustainability and acceptability of the shawl.

Breast Screening Reminder Letters and Phone Calls to Women in Their Language

Background: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+; targeting women aged 50-74. The program reduces breast cancer-related deaths by up to 28%. BSV aims to ensure equitable participation by all women in the target population. However, women from Arabic and Italian speaking backgrounds have lower breast screening participation compared with English-speaking women. A needs analysis involving consultation with Arabic and Italian speaking women found that invitation letters and calls are important enablers to breast screening, however language is a barrier. Women suggested sending reminder letters and making outbound reminder calls in their language. Aim: The aim of this study was to determine whether, and to what extent, reminder letters and phone calls in language resulted in increased screening rates in Arabic and Italian women. Methods: Two randomized control trials ran in 2017. TRIAL 1: Women due for a routine breast screen who speak Italian or Arabic at home were randomized into one of two trial arms: women in the intervention arm received a reminder letter in language (with the English version enclosed also), and women in the control arm received a reminder letter in English only. 1032 women were included in the study; comprising 322 Arabic and 710 Italian women. TRIAL 2: Lapsed women (had not had a breast screen within 27 months) who speak Italian or Arabic at home were randomized into one of two trial arms: women in the intervention arm received an outbound call in language inviting them to book an appointment; women in the control arm did not receive a call. 219 lapsed screeners were included; comprising 93 Arabic and 126 Italian women Results: TRIAL 1: • Women in the intervention arm more frequently booked (61.2%) compared with the control group (59.8%). However, this difference was not statistically significant. • For Italian women, 64.5% in the intervention group and 66.2% in the control group booked a screening appointment within 30 days of the mail out. Among Arabic women, the rates were 53.1% and 47.5% respectively. TRIAL 2: • Women in the intervention group were 10.7 times more likely to make a booking (42.9%) compared with the control group (4%). The effect was larger for Arabic than for Italian women. Conclusion: Sending reminder letters to Italian and Arabic women in their own language did not result in a statistically significant increase in bookings. Making reminder phone calls to Italian and Arabic women in their own language did result in a large, statistically significant increase in bookings and attendance.

A systematic review of the effectiveness of whole-of-community interventions by socioeconomic position

Whole-of-community (WOC) interventions have led to modest reductions in population weight gain. Whether they exhibit differential effectiveness by socioeconomic position (SEP) remains unknown. We aimed to summarize evidence of differential effectiveness of WOC interventions by SEP. Electronic databases and grey literature were searched to identify studies that evaluated the effectiveness of a WOC intervention on behavioural change measures, energy balance behaviours and/or anthropometric outcomes according to any measure of SEP. Interventions were assessed for the following characteristics: structural changes to the environment, number of settings the intervention acted in, presence of community engagement and whether equity was considered in its design. Ten studies were included. Nine reported a greater or equal effect among low SEP groups compared with high SEP groups. These studies commonly featured interventions that incorporated structural changes to the environment, acted across more than three settings and/or employed community engagement. Conclusions did not change when excluding low-quality studies (n = 4). WOC interventions represent an effective and equitable approach for the reduction of population weight. Structural components, a larger number of settings and community engagement were common in equitable WOC interventions and should be considered in the design of future WOC interventions.

An open-source genetic algorithm for determining optimal seed distributions for low-dose-rate prostate brachytherapy

PURPOSE

An open source optimizer that generates seed distributions for low-dose-rate prostate brachytherapy was designed, tested, and validated.

METHODS

The optimizer was a simple genetic algorithm (SGA) that, given a set of prostate and urethra contours, determines the optimal seed distribution in terms of coverage of the prostate with the prescribed dose while avoiding hotspots within the urethra. The algorithm was validated in a retrospective study on 45 previously contoured low-dose-rate prostate brachytherapy patients. Dosimetric indices were evaluated to ensure solutions adhered to clinical standards. The SGA performance was further benchmarked by comparing solutions obtained from a commercial optimizer (inverse planning simulated annealing [IPSA]) with the same cohort of 45 patients.

RESULTS

Clinically acceptable target coverage by the prescribed dose (V100) was obtained for both SGA and IPSA, with a mean ± standard deviation of 98 ± 2% and 99.5 ± 0.5%, respectively. For the prostate D90, SGA and IPSA yielded 177 ± 8 Gy and 186 ± 7 Gy, respectively, which were both clinically acceptable. Both algorithms yielded reasonable dose to the rectum, with V100 < 0.3 cc. A reduction in dose to the urethra was seen using SGA. SGA solutions showed a slight prostate volume dependence, with smaller prostates (<25 cc) yielding less desirable, although still clinically viable, dosimetric outcomes. SGA plans used, on average, fewer needles than IPSA (21 vs. 24, respectively), which may lead to a reduction in urinary toxicity and edema that alters post-implant dosimetry.

CONCLUSIONS

An open source SGA was validated that provides a research tool for the brachytherapy community.

The effect of obesity prevention interventions according to socioeconomic position: a systematic review

Obesity prevention is a major public health priority. It is important that all groups benefit from measures to prevent obesity, but we know little about the differential effectiveness of such interventions within particular population subgroups. This review aimed to identify interventions for obesity prevention that evaluated a change in adiposity according to socioeconomic position (SEP) and to determine the effectiveness of these interventions across different socioeconomic groups. A systematic search of published and grey literature was conducted. Studies that described an obesity prevention intervention and reported anthropometric outcomes according to a measure of SEP were included. Evidence was synthesized using narrative analysis. A total of 14 studies were analysed, representing a range of study designs and settings. All studies were from developed countries, with eight conducted among children. Three studies were shown to have no effect on anthropometric outcomes and were not further analysed. Interventions shown to be ineffective in lower SEP participants were primarily based on information provision directed at individual behaviour change. Studies that were shown to be effective in lower SEP participants primarily included community-based strategies or policies aimed at structural changes to the environment. Interventions targeting individual-level behaviour change may be less successful in lower SEP populations. It is essential that our efforts to prevent obesity do not leave behind the most disadvantaged members of society.

Phase i/ii trial of 5-Fluorouracil, leucovorin, Zidovudine and dipyridamole for patients with metastatic colorectal-cancer, renal-cell carcinoma and malignant-melanoma

We conducted a phase I/II trial of 5-fluorouracil (5-FU), calcium leucovorin (LV), zidovudine (AZT) and dipyridamole (DP), (FLAP) in patients with metastatic colorectal cancer, renal cell carcinoma and malignant melanoma. AZT and DP were given to enhance the biochemical modulation and antitumor activity of 5-FU and LV. All patients received 5-FU (370 mg/m(2) i.v. bolus day 0-4), LV (50 mg/m(2) p.o. every 4 h day 0-4) and DP (50 mg/m(2) p.o. every 6 h days 0-27). In the phase I portion of the study, AZT was dose escalated in cohorts of 5 patients each, from 50 mg p.o. every 6 h days 0-27 to the MTD of 200 mg p.o. every 6 h days 0-27. Thirty-three patients received 200 mg of AZT in the phase II portion of the trial. Eleven patients developed grade III and 5 patients developed grade IV leukopenia. Four patients developed grade III and 21 patients developed grade IV neutropenia, with six febrile neutropenic episodes. Six patients experienced grade III anemia and four grade III thrombocytopenia. Diarrhea or stomatitis of greater than or equal to grade III occurred in six and four patients, respectively. Fifty-eight percent (19 of 33) of patients required dose reductions of AZT for hematologic toxicity (13 of 19 in the first treatment cycle). At the 200 mg AZT dose level, there were two partial responses in nine colorectal cancer patients (22%), no objective responses in 14 patients with renal cell carcinoma or in 14 patients with melanoma. FLAP does not have significant activity in melanoma, renal cell carcinoma or 5-FU-treated colorectal cancer patients, although it may have activity in untreated colon cancer.

Suboptimal management of cardiovascular risk factors in coronary heart disease patients in primary care occurs particularly in women

BACKGROUND

Patients with established coronary heart disease (CHD) are at the highest risk of further events. Despite proven therapies, secondary prevention is often suboptimal. General practitioners (GPs) are in an ideal position to improve secondary prevention.

AIM

To contrast management of cardiovascular risk factors in patients with established CHD in primary care to those in clinical guidelines and according to gender.

METHODS

GPs throughout Australia were approached to participate in a programme incorporating a disease management software (mdCare) program. Participating practitioners (1258 GPs) recruited individual patients whose cardiovascular risk factor levels were measured.

RESULTS

The mdCare programme included 12,509 patients (58% male) diagnosed with CHD. Their mean age was 71.7years (intra-quartile range 66-78) for men and 74years (intra-quartile range 68-80) for women. Low-density-lipoprotein cholesterol was above target levels in 69% (2032) of women compared with 58% (2487) in men (P < 0.0001). There was also a higher proportion of women with total cholesterol above target levels (76%, 3592) compared with men (57%, 3787) (P < 0.0001). In patients who were prescribed lipid-lowering medication, 53% (2504) of men and 72% (2285) of women continued to have a total cholesterol higher than recommended target levels (P < 0.0001). Overall, over half (52%, 6538) had at least five cardiovascular risk factors (55% (2914) in women and 50% (3624) in men, P < 0.0001).

CONCLUSION

This study found less intensive management of cardiovascular risk factors in CHD patients, particularly among women, despite equivalent cardiovascular risk. This study has shown that these patients have multiple risk factors where gender also plays a role.

CHÉLATES DU GERMANIUM (IV) AVEC LA TROPOLONE, LE MALTOL, LA LAWSONE ET LA TRICHLOROHYDROXY p-BENZOQUINON E: I. PROPRIÉTÉS ACIDES-BASES DES α-HYDROXYCÉTONES

The acidity constants k1 of the following α-hydroxyketones HL tropolone, maltol, lawsone, and trichlorohydroxy p-benzoquinone have been determined at ionic strength 0.50 (HCl, NaCl)• The values of pk1 are respectively: 6.67 ± 0.04; 8.36 ± 0.03; 4.00 ± 0.04; 1.05 ± 0.04. The formation of conjugated acids H2L+ in strongly acidic media has also been studied. The values of pk2 defined in terms of the acidity function H0 are: −0.53 ± 0.10; −0.71 ± 0.10; −5.6 ± 0.2; −8.8 ± 1.0.

CHÉLATES DU GERMANIUM (IV) AVEC LA TROPOLONE, LE MALTOL, LA LAWSONE ET LA TRICHLOROHYDROXY p-BENZOQUINONE: II. NATURE ET STABILITÉ DES CHÉLATES

The formation of chelates between germanium (IV) and a series of α-hydroxyketones (HL) has been examined spectrophotometrically. Tropolone and maltol have been shown to give the species Ge(OH)2L2 and GeL3+; the corresponding equilibrium constants β2 and β3 have been determined. The following solid compounds have been isolated: Ge(OH)2(tropolonate)2•2H2O, Ge(tropolonate)3ClO4, and Ge(maltolate)3ClO4. There was no evidence of complex formation with lawsone and trichlorohydroxy p-benzoquinone. Relations are discussed between the chelate stability, the state of germanium (IV) in solution, and the acid–base properties of the α-hydroxyketones.

COMPLEXES DU GERMANIUM (IV) AVEC LA DICHLORO-2,5 DIHYDROXY-3,6 p-BENZOQUINONE

not available