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Skolarus TA, Hawley ST, Forman J, Sales AE, Sparks JB, Metreger T, Burns J, Caram MV, Radhakrishnan A, Dossett LA, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Dunsmore J, Maclennan S, Saini S, Hollenbeck BK, Shahinian V, Wittmann DA, Deolankar V, Sriram S. Unpacking overuse of androgen deprivation therapy for prostate cancer to inform de-implementation strategies. Implement Sci Commun 2024; 5:37. [PMID: 38594740 PMCID: PMC11005280 DOI: 10.1186/s43058-024-00576-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/04/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Many men with prostate cancer will be exposed to androgen deprivation therapy (ADT). While evidence-based ADT use is common, ADT is also used in cases with no or limited evidence resulting in more harm than benefit, i.e., overuse. Since there are risks of ADT (e.g., diabetes, osteoporosis), it is important to understand the behaviors facilitating overuse to inform de-implementation strategies. For these reasons, we conducted a theory-informed survey study, including a discrete choice experiment (DCE), to better understand ADT overuse and provider preferences for mitigating overuse. METHODS Our survey used the Action, Actor, Context, Target, Time (AACTT) framework, the Theoretical Domains Framework (TDF), the Capability, Opportunity, Motivation-Behavior (COM-B) Model, and a DCE to elicit provider de-implementation strategy preferences. We surveyed the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on the likelihood of stopping overuse as ADT monotherapy for localized prostate cancer ("yes"/"probably yes," "probably no"/"no"), and characterized corresponding Likert scale responses to seven COM-B statements. We used multivariable regression to identify associations between stopping ADT overuse and COM-B responses. RESULTS Our survey was completed by 84 respondents (13% response rate), with 27% indicating "probably no"/"no" to stopping ADT overuse. We found differences across respondents who said they would and would not stop ADT overuse in demographics and COM-B statements. Our model identified 2 COM-B domains (Opportunity-Social, Motivation-Reflective) significantly associated with a lower likelihood of stopping ADT overuse. Our DCE demonstrated in-person communication, multidisciplinary review, and medical record documentation may be effective in reducing ADT overuse. CONCLUSIONS Our study used a behavioral theory-informed survey, including a DCE, to identify behaviors and context underpinning ADT overuse. Specifying behaviors supporting and gathering provider preferences in addressing ADT overuse requires a stepwise, stakeholder-engaged approach to support evidence-based cancer care. From this work, we are pursuing targeted improvement strategies. TRIAL REGISTRATION ClinicalTrials.gov, NCT03579680.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Surgery, Urology Section, University of Chicago, Chicago, USA.
| | - Sarah T Hawley
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Anne E Sales
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Burns
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Megan V Caram
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Archana Radhakrishnan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Jeremy B Shelton
- VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
- Department of Urology, University of California, Los Angeles, USA
| | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Dunsmore
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Steven Maclennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sameer Saini
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Varad Deolankar
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
| | - S Sriram
- Ross School of Business, University of Michigan, Ann Arbor, MI, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Parchman ML, Perloff J, Ritter G. Can clinician champions reduce potentially inappropriate medications in people living with dementia? Study protocol for a cluster randomized trial. Implement Sci 2022; 17:63. [PMID: 36163181 PMCID: PMC9513870 DOI: 10.1186/s13012-022-01237-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background For people living with dementia (PLWD) the overuse of potentially inappropriate medications (PIMs) remains a persistent problem. De-prescribing trials in the elderly have mixed results. Clinician champions may be uniquely suited to lead efforts to address this challenge. Here we describe the study protocol for a 24-month embedded pragmatic cluster-randomized clinical trial within two accountable care organizations (ACOs) of such a clinician champion intervention. The specific aims are to (1) assess the effectiveness of a clinician champion on de-implementing PIMs in PLWD, (2) determine if the intervention is associated with a reduction in emergency department (ED) visits and hospitalizations attributed to a fall, and (3) examine five implementation outcomes: appropriateness, feasibility, fidelity, penetration, and equity. Methods/design Two ACOs agreed to participate: United States Medical Management (USMM) and Oschner Health System. The unit of randomization will be the primary care clinic. A clinician champion will be recruited from each of the intervention clinics to participate in a 6-month training program and then work with clinicians and staff in their clinic for 12 months to reduce the use of PIMs in their PLWD population. For aims 1 and 2, Medicare claims data will be used to assess outcomes. The outcome for aim #1 will be medication possession rates per quarter, for the three therapeutic classes of PIMs among patients with dementia in intervention clinics versus control clinics. For aim #2, we will assess the incidence of falls using a previously validated algorithm. For both aims 1 and 2, we will construct hierarchical models with time period observations nested within patient using generalized estimating equations (GEE) with robust standard errors. The key variable of interest will be the treatment indicator assigned based on practice. For aim #3, we will conduct qualitative thematic analysis of documentation by the clinician champions in their project workbooks to evaluate the five implementation outcomes. Discussion This embedded pragmatic trial will add to our existing knowledge regarding the effectiveness of a clinician champion strategy to de-prescribe potentially inappropriate medication among patients with dementia as well as its appropriateness, feasibility, fidelity, penetration, and equity. Trial registration Clinicaltrials.govNCT05359679, Registered May 4, 2022
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Affiliation(s)
- Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
| | - Jennifer Perloff
- Brandeis University, Waltham, MA, USA.,Institute for Accountable Care, Washington, DC, USA
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Walsh-Bailey C, Tsai E, Tabak RG, Morshed AB, Norton WE, McKay VR, Brownson RC, Gifford S. A scoping review of de-implementation frameworks and models. Implement Sci 2021; 16:100. [PMID: 34819122 PMCID: PMC8611904 DOI: 10.1186/s13012-021-01173-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/09/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reduction or elimination of inappropriate, ineffective, or potentially harmful healthcare services and public health programs can help to ensure limited resources are used effectively. Frameworks and models (FM) are valuable tools in conceptualizing and guiding the study of de-implementation. This scoping review sought to identify and characterize FM that can be used to study de-implementation as a phenomenon and identify gaps in the literature to inform future model development and application for research. METHODS We searched nine databases and eleven journals from a broad array of disciplines (e.g., healthcare, public health, public policy) for de-implementation studies published between 1990 and June 2020. Two raters independently screened titles and abstracts, and then a pair of raters screened all full text records. We extracted information related to setting, discipline, study design, methodology, and FM characteristics from included studies. RESULTS The final search yielded 1860 records, from which we screened 126 full text records. We extracted data from 27 articles containing 27 unique FM. Most FM (n = 21) were applicable to two or more levels of the Socio-Ecological Framework, and most commonly assessed constructs were at the organization level (n = 18). Most FM (n = 18) depicted a linear relationship between constructs, few depicted a more complex structure, such as a nested or cyclical relationship. Thirteen studies applied FM in empirical investigations of de-implementation, while 14 articles were commentary or review papers that included FM. CONCLUSION De-implementation is a process studied in a broad array of disciplines, yet implementation science has thus far been limited in the integration of learnings from other fields. This review offers an overview of visual representations of FM that implementation researchers and practitioners can use to inform their work. Additional work is needed to test and refine existing FM and to determine the extent to which FM developed in one setting or for a particular topic can be applied to other contexts. Given the extensive availability of FM in implementation science, we suggest researchers build from existing FM rather than recreating novel FM. REGISTRATION Not registered.
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Affiliation(s)
- Callie Walsh-Bailey
- Prevention Research Center, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA.
| | - Edward Tsai
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Rachel G Tabak
- Prevention Research Center, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA
| | - Alexandra B Morshed
- Prevention Research Center, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Wynne E Norton
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20850, USA
| | - Virginia R McKay
- Prevention Research Center, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA
| | - Ross C Brownson
- Prevention Research Center, Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA
- Department of Surgery (Division of Public Health Sciences) and Alvin J. Siteman Cancer Center, Washington University School of Medicine, 4921 Parkview Place, Saint Louis, MO, 63110, USA
| | - Sheyna Gifford
- Department of Physical Medicine and Rehabilitation, Washington University in St. Louis, 4444 Forest Park Ave, Campus Box 8518, St. Louis, MO, 63108, USA
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Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett L, Paniagua-Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Sales AE, Wittmann DA. Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer. Implement Sci Commun 2021; 2:124. [PMID: 34711274 PMCID: PMC8555144 DOI: 10.1186/s43058-021-00224-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel's Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development. METHODS We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices. RESULTS Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT. CONCLUSIONS Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer. TRIAL REGISTRATION ClinicalTrials.gov , NCT03579680.
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Affiliation(s)
- Ted A Skolarus
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jordan B Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Megan V Caram
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly Dossett
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan Paniagua-Cruz
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Danil V Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY, USA
| | - John T Leppert
- Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Kristian D Stensland
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniela A Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI, USA
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, Alberta T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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Abstract
De-implementing inappropriate health interventions is essential for minimizing patient harm, maximizing efficient use of resources, and improving population health. Research on de-implementation has expanded in recent years as it cuts across types of interventions, patient populations, health conditions, and delivery settings. This commentary explores unique aspects of de-implementing inappropriate interventions that differentiate it from implementing evidence-based interventions, including multi-level factors, types of action, strategies for de-implementation, outcomes, and unintended negative consequences. We highlight opportunities to continue to advance research on the de-implementation of inappropriate interventions in health care and public health.
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Affiliation(s)
- Wynne E Norton
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, #3E424, Bethesda, MD, 20850, USA.
| | - David A Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, #3E424, Bethesda, MD, 20850, USA
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Bouck Z, Pendrith C, Chen XK, Frood J, Reason B, Khan T, Costante A, Kirkham K, Born K, Levinson W, Bhatia RS. Measuring the frequency and variation of unnecessary care across Canada. BMC Health Serv Res 2019; 19:446. [PMID: 31269933 PMCID: PMC6610789 DOI: 10.1186/s12913-019-4277-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 06/18/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions. METHODS Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years. RESULTS Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. CONCLUSIONS The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.
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Affiliation(s)
- Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville Street, 6th Floor, Toronto, Ontario M5S 1B2 Canada
| | - Ciara Pendrith
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
| | - Xi-Kuan Chen
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Jennifer Frood
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Ben Reason
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Tanya Khan
- Canadian Institute for Health Information, 1010 Sherbrooke Street West, Suite 602, Montreal, Quebec H3A 2R7 Canada
| | - Alicia Costante
- Canadian Institute for Health Information, 4110 Yonge Street, Suite 300, Toronto, Ontario M2P 2B7 Canada
| | - Kyle Kirkham
- Department of Anesthesia, Women’s College Hospital, 76 Grenville Street, Toronto, Ontario M5S 1B2 Canada
| | - Karen Born
- Choosing Wisely Canada, 250 Yonge Street, Room 648, Toronto, Ontario M5G 1B1 Canada
| | - Wendy Levinson
- Department of Medicine, University of Toronto – St Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada
| | - R. Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville Street, 6th Floor, Toronto, Ontario M5S 1B2 Canada
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Osorio D, Ribera A, Solans-Domènech M, Arroyo-Moliner L, Ballesteros M, Romea-Lecumberri S. Healthcare professionals' opinions, barriers and facilitators towards low-value clinical practices in the hospital setting. Gac Sanit 2019; 34:459-467. [PMID: 30745093 DOI: 10.1016/j.gaceta.2018.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore healthcare professionals' opinions about low-value practices, identify practices of this kind possibly present in the hospital and barriers and facilitators to reduce them. Low-value practices include those with little or no clinical benefit that may harm patients or lead to a waste of resources. METHOD Using a mixed methodology, we carried out a survey and two focus groups in a tertiary hospital. In the survey, we assessed doctors' agreement, subjective adherence and perception of usefulness of 134 recommendations to reduce low-value practices from local and international initiatives. We also identified low-value practices possibly present in the hospital. In the focus groups with professionals from surgical and medical fields, using a phenomenological approach, we identified additional low-value practices, barriers and facilitators to reduce them. RESULTS 169 doctors of 25 specialties participated (response rate: 7%-100%). Overall agreement with recommendations, subjective adherence and usefulness were 83%, 90% and 70%, respectively. Low-value practices form 22 recommendations (16%) were considered as possibly present in the hospital. In the focus groups, the professionals identified seven more. Defensive medicine and scepticism due to contradictory evidence were the main barriers. Facilitators included good leadership and coordination between professionals. CONCLUSIONS High agreement with recommendations to reduce low-value practices and high perception of usefulness reflect great awareness of low-value care in the hospital. However, there are several barriers to reduce them. Interventions to reduce low-value practices should foster confidence in decision-making processes between professionals and patients and provide trusted evidence.
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Affiliation(s)
- Dimelza Osorio
- Vall d'Hebron University Hospital, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Spain; Health Services Research Group, Institut de Recerca Vall d'Hebron, Barcelona, Spain.
| | - Aida Ribera
- CIBER de Epidemiología y Salud Pública (CIBERESP), Spain; Cardiovascular Epidemiology Unit, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Maite Solans-Domènech
- CIBER de Epidemiología y Salud Pública (CIBERESP), Spain; Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain
| | - Liliana Arroyo-Moliner
- Instituto de Innovación Social, Dpto. Ciencias Sociales, ESADE Business & Law School, Barcelona, Spain
| | - Mónica Ballesteros
- Vall d'Hebron University Hospital, Barcelona, Spain; Health Services Research Group, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Soledad Romea-Lecumberri
- Vall d'Hebron University Hospital, Barcelona, Spain; Health Services Research Group, Institut de Recerca Vall d'Hebron, Barcelona, Spain
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Calabrò GE, La Torre G, de Waure C, Villari P, Federici A, Ricciardi W, Specchia ML. Disinvestment in healthcare: an overview of HTA agencies and organizations activities at European level. BMC Health Serv Res 2018; 18:148. [PMID: 29490647 PMCID: PMC5831213 DOI: 10.1186/s12913-018-2941-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 02/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background In an era of a growing economic pressure for all health systems, the interest for “disinvestment” in healthcare increased. In this context, evidence based approaches such as Health Technology Assessment (HTA) are needed both to invest and to disinvest in health technologies. In order to investigate the extent of application of HTA in this field, methodological projects/frameworks, case studies, dissemination initiatives on disinvestment released by HTA agencies and organizations located in Europe were searched. Methods In July 2015, the websites of HTA agencies and organizations belonging to the European network for HTA (EUnetHTA) and the International Network of Agencies for HTA (INAHTA) were accessed and searched through the use of the term “disinvestment”. Retrieved deliverables were considered eligible if they reported methodological projects/frameworks, case studies and dissemination initiatives focused on disinvestment in healthcare. Results 62 HTA agencies/organizations were accessed and eight methodological projects/frameworks, one case study and one dissemination initiative were found starting from 2007. With respect to methodological projects/frameworks, two were delivered in Austria, one in Italy, two in Spain and three in U.K. As for the case study and the dissemination initiative, both came from U.K. The majority of deliverables were aimed at making an overview of existing disinvestment approaches and at identifying challenges in their introduction. Conclusions Today, in a healthcare context characterized by resource scarcity and increasing service demand, “disinvestment” from low-value services and reinvestment in high-value ones is a key strategy that may be supported by HTA. The lack of evaluation of technologies in use, in particular at the end of their lifecycle, may be due to the scant availability of frameworks and guidelines for identification and assessment of obsolete technologies that was shown by our work. Although several projects were carried out in different countries, most remain constrained to the field of research. Disinvestment is a relatively new concept in HTA that could pose challenges also from a methodological point of view. To tackle these challenges, it is necessary to construct experiences at international level with the aim to develop new methodological approaches to produce and grow evidence on disinvestment policies and practices. Electronic supplementary material The online version of this article (10.1186/s12913-018-2941-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G E Calabrò
- Institute of Public Health, Section of Hygiene, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168, Rome, Roma, Italy
| | - G La Torre
- Department of Public Health and Infectious Diseases, Sapienza Università di Roma, Rome, Italy
| | - C de Waure
- Institute of Public Health, Section of Hygiene, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168, Rome, Roma, Italy. .,Department of Experimental Medicine, University of Perugia, via Gambuli 1, 06132, Perugia, Italy.
| | - P Villari
- Department of Public Health and Infectious Diseases, Sapienza Università di Roma, Rome, Italy
| | | | - W Ricciardi
- Institute of Public Health, Section of Hygiene, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168, Rome, Roma, Italy
| | - M L Specchia
- Institute of Public Health, Section of Hygiene, Catholic University of the Sacred Heart, L.go F. Vito 1, 00168, Rome, Roma, Italy
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Wammes JJG, van den Akker-van Marle ME, Verkerk EW, van Dulmen SA, Westert GP, van Asselt ADI, Kool RB. Identifying and prioritizing lower value services from Dutch specialist guidelines and a comparison with the UK do-not-do list. BMC Med 2016; 14:196. [PMID: 27884150 PMCID: PMC5123317 DOI: 10.1186/s12916-016-0747-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 11/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The term 'lower value services' concerns healthcare that is of little or no value to the patient and consequently should not be provided routinely, or not be provided at all. De-adoption of lower value care may occur through explicit recommendations in clinical guidelines. The present study aimed to generate a comprehensive list of lower value services for the Netherlands that assesses the type of care and associated medical conditions. The list was compared with the NICE do-not-do list (United Kingdom). Finally, the feasibility of prioritizing the list was studied to identify conditions where de-adoption is warranted. METHODS Dutch clinical guidelines (published from 2010 to 2015) were searched for lower value services. The lower value services identified were categorized by type of care (diagnostics, treatment with and without medication), type of lower value service (not routinely provided or not provided at all), and ICD10 codes (international classification of diseases). The list was prioritized per ICD10 code, based on the number of lower value services per ICD10 code, prevalence, and burden of disease. RESULTS A total of 1366 lower value services were found in the 193 Dutch guidelines included in our study. Of the lower value services, 30% covered diagnostics, 29% related to surgical and medical treatment without drugs primarily, and 39% related to drug treatment. The majority (77%) of all lower value services was on care that should not be offered at all, whereas the other 23% recommended on care that should not be offered routinely. ICD10 chapters that included most lower value services were neoplasms and diseases of the nervous system. Dutch guidelines appear to contain more lower value services than UK guidelines. The prioritization processes revealed several conditions, including back pain, chronic obstructive pulmonary disease, and ischemic heart diseases, where lower value services most likely occur and de-adoption is warranted. CONCLUSIONS In this study, a comprehensive list of lower value services for Dutch hospital care was developed. A feasible method for prioritizing lower value services was established. Identifying and prioritizing lower value services is the first of several necessary steps in reducing them.
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Affiliation(s)
- Joost Johan Godert Wammes
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands.
| | - M Elske van den Akker-van Marle
- Department of Medical Decision Making, Leiden University Medical Centre, Albinusdreef 2, Postbus 9600, Leiden, 2300, RC, The Netherlands
| | - Eva W Verkerk
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
| | - Antoinette D I van Asselt
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, Groningen, 9713, AV, The Netherlands
| | - R B Kool
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, 114 IQ Healthcare, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
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