De-implementing wisely: developing the evidence base to reduce low-value care

Grimshaw, Jeremy; Patey, Andrea M.; Kirkham, Kyle R.; Hall, Amanda; Dowling, Shawn; Rodondi, Nicolas; Ellen, Moriah; Kool, Rudolf B; Dulmen, Simone A. van; Kerr, Eve A.; Linklater, Stefanie; Levinson, Wendy; Bhatia, R. Sacha

doi:10.1136/bmjqs-2019-010060

Cited by 130 publications

(141 citation statements)

References 54 publications

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“…Overuse of medical services has been generally recognized worldwide [ 154 ] and a movement towards a wiser choice of diagnostic tests and therapies is spreading valuable suggestions [ 155 , 156 ]. Beyond the possible patients’ harm derived from these over-diagnostics and overtreatments [ 149 ], overuse contributes significantly to the total spending for healthcare worldwide.…”

Section: Flaws Of Patients Health Professionals Industries Andmentioning

confidence: 99%

Medicine and Phlebolymphology: Time to Change?

Cavezzi

2020

JCM

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Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients’ management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients’ lack of education, industry-influenced science, and physician’s improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.

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Section: Flaws Of Patients Health Professionals Industries Andmentioning

confidence: 99%

Medicine and Phlebolymphology: Time to Change?

Cavezzi

2020

JCM

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“…The goal of the campaign is to facilitate the communication between physicians and patients about unnecessary tests, treatments and procedures through the provision of evidence-based resources and clinical guidance 8 , and to help them to make informed decisions to ensure high-quality care 9 . The campaign has now spread internationally to at least 20 countries 10 including the development of recommendations to reduce unnecessary tests, treatment and procedures 11 .…”

Section: Introductionmentioning

confidence: 99%

An Idea Worth Sustaining: Evaluation of the sustainability potential of Choosing Wisely across Ontario Community Hospitals and Family Health Teams

Kastner¹,

Makarski²,

Mossman³

et al. 2020

Preprint

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BackgroundEvidence shows that 30% of healthcare services are unnecessary and unlikely to benefit patients and may even be harmful. Choosing Wisely (CW) is a physician-initiated, international campaign (with campaigns in at least 20 countries) aimed at addressing unnecessary medical care through the provision of evidence-based resources and clinical guidance. Our objectives were to evaluate the sustainability potential of CW across four Ontario community hospitals and affiliated family health teams (FHT). MethodsWe recruited CW implementation teams across Ontario hospitals and their affiliated primary care family health teams (FHTs) to participate in a mixed-methods study to identify and respond to their CW implementation and sustainability challenges. The study involved the administration of a validated sustainability Survey at baseline, 6- and 12-months follow-up, and participation in two focus groups (at baseline and 6 months) to discuss identified successes and opportunities for improvement, and to respond to implementation and sustainability challenges through a team exercise involving the co-creation and implementation of an action plan to directly address them.ResultsFifteen CW implementation teams across five Ontario community hospitals and affiliated FHTs participated in the study. Three CW de-adoption priority areas were investigated by teams: de-prescribing of proton pump inhibitors (PPIs), and reducing Pre-Op testing and BUN/Urea lab testing. All 15 teams achieved a baseline sustainability team score that was well above the threshold of what is considered a potentially sustainable innovation (i.e., >55%). We observed steady improvements in sustainability scores over three time points across all primary care teams, which is a strong indication that CW is sustainable in these settings. Regardless of site or priority area, facilitators that were common across all teams were fit with existing processes and workflows, leadership support, and optimized team communication. Common challenges were: lack of awareness and buy-in, lack of leadership engagement or a champion, and lack of fit with existing workflow and culture. All teams identified at least one challenge (during the baseline focus groups) for which they co-designed and implemented a plan to address them aimed at maximizing the sustainability potential of their CW priority areas. ConclusionsEvaluating the sustainability potential of an innovation such as Choosing Wisely is critical to ensuring that they have the best potential for impact. Our work highlights that implementation teams can be empowered to influence their implementation efforts, and to realize positive outcomes for their healthcare services and patients.

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“… 13 Evidence about reducing low-value care is increasing, and recently, a framework was developed to reduce low-value care, which includes rigorous evaluation of Choosing Wisely implementation programmes. 14 We found that 4 years after the start of the campaign, the implementation of the Choosing Wisely recommendation was already quite good in the EDs. The implementation was outstanding for the second recommendation, where only one patient received an abdominal X-rays for acute abdominal pain.…”

Section: Discussionmentioning

confidence: 77%

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

et al. 2021

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BackgroundChoosing Wisely aims to reduce low-value care to improve quality and lower costs. In the Netherlands, this campaign offers three recommendations for internal medicine applicable in emergency departments (EDs): (1) do not place an indwelling urinary catheter in non-critically ill patients who can void; (2) do not order plain abdominal radiographs in patients with acute abdominal pain; and (3) discuss whether treatment limitations are needed. This quality improvement project aims to increase the implementation of the recommendations by patient information leaflets.MethodsIn a prospective before–after study, we collected data every other week during baseline and intervention periods (both 7 months) in two university medical centres. The primary outcomes were the adherence rates to the recommendations.Results805 patients visited the EDs for internal medicine, of whom 391 (48.6%) were hospitalised. Only 153 (19%) patients received the information leaflet. We found no change in implementation rates of the recommendations after the introduction of the patient information leaflet. In the baseline period, 28 patients received a urinary catheter, of whom 5 (17.9%) had no appropriate indication, compared with 4 (25.0%) of 16 patients in the intervention period (p=0.572). Unnecessary abdominal X-ray occurred once in the baseline period and not in the intervention period. Treatment limitations were not reported in 13 (6.5%) of 200 hospitalised patients in the baseline period, and in 17 (8.9%) of 191 patients in the intervention period (p=0.373).ConclusionsPatient information leaflets did not increase the implementation of Choosing Wisely recommendations, which can be due to a high baseline rate and a poor dissemination of leaflets. Our ED seems not to be a practicable setting for dissemination of leaflets, since staff engagement was not possible due to high workload and shortage of qualified nursing staff in the Netherlands.

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De-implementing wisely: developing the evidence base to reduce low-value care

Cited by 130 publications

References 54 publications

Medicine and Phlebolymphology: Time to Change?

Medicine and Phlebolymphology: Time to Change?

An Idea Worth Sustaining: Evaluation of the sustainability potential of Choosing Wisely across Ontario Community Hospitals and Family Health Teams

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

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