Perceived barriers among physicians for stopping non–cost‐effective blood‐saving measures in total hip and total knee arthroplasties

Voorn, Veronique M A; Mheen, Perla J Marang-van de; Wentink, Manon M.; Kaptein, Ad A.; Gemert, A.W.M.M. Koopman-van; So‐Osman, Cynthia; Vlieland, Thea Vliet; Nelissen, Rob G H H; Bodegom‐Vos, Leti van

doi:10.1111/trf.12672

Cited by 22 publications

(41 citation statements)

References 37 publications

(98 reference statements)

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“…Finally, reflective cognition cannot be used endlessly; an individual's ability to exert self‐control and engage in reflective cognition (eg, problem solving, self‐regulating behaviour, or processing new information) is a finite resource; the more they engage in reflective cognition to make a decision or guide behaviour, the greater the difficulty in exercising reflective cognition for a new task, a condition referred to as ego depletion . This is congruent with research that has highlighted the importance of providing alternatives to clinicians when taking away ineffective practices …”

Section: Introductionmentioning

confidence: 67%

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

Helfrich

Rose

Hartmann

et al. 2018

Evaluation Clinical Practice

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Rationale and objectivesOne way to understand medical overuse at the clinician level is in terms of clinical decision‐making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision‐making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De‐implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition.ResultsWe define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as “the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines.” We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience “reactance,” ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice.We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur.Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together.ConclusionsBy taking into account the dual process model of cognition, we may be able to design de‐implementation strategies matched to clinicians' decision‐making processes and avoid unintended consequence.

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Section: Introductionmentioning

confidence: 67%

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

Helfrich

Rose

Hartmann

et al. 2018

Evaluation Clinical Practice

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“…We use empirical data here from two previously published studies, which are performed at different moments in time: one involving implementation28 29 and one involving de-implementation30 31 among Dutch orthopaedic surgeons. The implementation study aimed to identify factors influencing the implementation of a step-wise strategy of non-surgical therapy for patients with hip and knee osteoarthritis (OA) (including medication and referral guidelines) before undertaking surgical therapy 14.…”

Section: Empirical Datamentioning

confidence: 99%

Implementation and de-implementation: two sides of the same coin?

2016

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Avoiding low value care received increasing attention in many countries, as with the Choosing Wisely campaign and other initiatives to abandon care that wastes resources or delivers no benefit to patients. While an extensive literature characterises approaches to implementing evidence-based care, we have limited understanding of the process of de-implementation, such as abandoning existing low value practices. To learn more about the differences between implementation and de-implementation, we explored the literature and analysed data from two published studies (one implementation and one de-implementation) by the same orthopaedic surgeons. We defined 'leaders' as those orthopaedic surgeons who implemented, or de-implemented, the target processes of care and laggards as those who did not. Our findings suggest that leaders in implementation share some characteristics with leaders in de-implementation when comparing them with laggards, such as more open to new evidence, younger and less time in clinical practice. However, leaders in de-implementation and implementation differed in some other characteristics and were not the same persons. Thus, leading in implementation or de-implementation may depend to some degree on the type of intervention rather than entirely reflecting personal characteristics. De-implementation seemed to be hampered by motivational factors such as department priorities, and economic and political factors such as cost-benefit considerations in care delivery, whereas organisational factors were associated only with implementation. The only barrier or facilitator common to both implementation and de-implementation consisted of outcome expectancy (ie, the perceived net benefit to patients). Future studies need to test the hypotheses generated from this study and improve our understanding of differences between the processes of implementation and de-implementation in the people who are most likely to lead (or resist) these efforts.

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“…A strength of this study is that it was preceded by a problem analysis study [37, 38, 54]. In this preceding study, we identified the extent of the problem (frequency of use of blood salvage and EPO) and which barriers play a role in this specific situation of low-value care.…”

Section: Discussionmentioning

confidence: 99%

“…The strategy was tailored to address barriers identified in our problem analysis study [38, 40]. The Theoretical Domains Framework (TDF) was used to identify relevant barriers.…”

Section: Methodsmentioning

confidence: 99%

“…Despite this evidence, both techniques are still used in clinical practice [27, 36, 37]. Additional effort is needed to reduce the use of this low-value care in patients in which the use of blood salvage and EPO is not cost-effective, taking into account the existing barriers and facilitators for de-implementation as recommended by Lorencatto et al who calls for more theoretically informed behavior change research in transfusion [38, 39]. …”

Section: Introductionmentioning

confidence: 99%

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The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial

et al. 2017

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BackgroundPerioperative autologous blood salvage and preoperative erythropoietin are not (cost) effective to reduce allogeneic transfusion in primary hip and knee arthroplasty, but are still used. This study aimed to evaluate the effectiveness of a theoretically informed multifaceted strategy to de-implement these low-value blood management techniques.MethodsTwenty-one Dutch hospitals participated in this pragmatic cluster-randomized trial. At baseline, data were gathered for 924 patients from 10 intervention and 1040 patients from 11 control hospitals undergoing hip or knee arthroplasty. The intervention included a multifaceted de-implementation strategy which consisted of interactive education, feedback on blood management performance, and a comparison with benchmark hospitals, aimed at orthopedic surgeons and anesthesiologists. After the intervention, data were gathered for 997 patients from the intervention and 1096 patients from the control hospitals. The randomization outcome was revealed after the baseline measurement. Primary outcomes were use of blood salvage and erythropoietin. Secondary outcomes included postoperative hemoglobin, length of stay, allogeneic transfusions, and use of local infiltration analgesia (LIA) and tranexamic acid (TXA).ResultsThe use of blood salvage (OR 0.08, 95% CI 0.02 to 0.30) and erythropoietin (OR 0.30, 95% CI 0.09 to 0.97) reduced significantly over time, but did not differ between intervention and control hospitals (blood salvage OR 1.74 95% CI 0.27 to 11.39, erythropoietin OR 1.33, 95% CI 0.26 to 6.84). Postoperative hemoglobin levels were significantly higher (β 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (β −0.36, 95% CI −0.64 to −0.09) in hospitals receiving the multifaceted strategy, compared with control hospitals and after adjustment for baseline. Transfusions did not differ between the intervention and control hospitals (OR 1.06, 95% CI 0.63 to 1.78). Both LIA (OR 0.0, 95% CI 0.0 to 0.0) and TXA (OR 0.3, 95% CI 0.2 to 0.5) were significantly associated with the reduction in blood salvage over time.ConclusionsBlood salvage and erythropoietin use reduced over time, but not differently between intervention and control hospitals. The reduction in blood salvage was associated with increased use of local infiltration analgesia and tranexamic acid, suggesting that de-implementation is assisted by the substitution of techniques. The reduction in blood salvage and erythropoietin did not lead to a deterioration in patient-related secondary outcomes.Trial registrationwww.trialregister.nl, NTR4044Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-017-0601-0) contains supplementary material, which is available to authorized users.

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Perceived barriers among physicians for stopping non–cost‐effective blood‐saving measures in total hip and total knee arthroplasties

Cited by 22 publications

References 37 publications

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

Implementation and de-implementation: two sides of the same coin?

The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial

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