Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands?

Abstract

BackgroundReducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects.MethodsWe performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated.ResultsFive out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy.ConclusionsSuccessfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.

Development and usability testing of a multifaceted intervention to reduce low-value injury care

“…(46) However, in order to overcome the powerful underlying drivers associated with low-value care, it was recognized that problem analysis and context assessment were fundamental to tailoring de-implementation strategies. (45,46) This exercise was made possible in our study through usability testing, which enabled us to re ne the intervention with interested parties to strengthen the ability of trauma teams to de-implement the targeted practices.…”

“…Previous systematic reviews have showed favorable outcomes associated with de-implementation interventions (45,46,(49)(50)(51) including a recent review of RCTs that found a signi cant median relative reduction of 17% in low-value care. (46) However, a greater number of interventions tailored to contextual factors, as in our study, were recognized as a potential strategy for further increasing their impact on lowvalue care.…”

“…(46) However, a greater number of interventions tailored to contextual factors, as in our study, were recognized as a potential strategy for further increasing their impact on lowvalue care. (45,46) In addition, most of the de-implementation interventions whose effectiveness has been evaluated to date have focused on medication in a primary care setting(46), and there is still limited evidence on emergency care, including trauma-speci c de-implantation interventions. The eld of trauma differs from many other healthcare areas due to the complexity of clinical practice resulting from the speed of decision-making, heterogeneous populations, the multiplicity of specialists involved, the wide range of diagnostic and therapeutic options, and the need to transfer many patients to specialized centers for de nitive care.…”

“…(26) These drivers include healthcare professionals' fear of the consequences of withholding a test or treatment, their desire to meet patients' expectations and the time needed to explain the non-necessity of a treatment, their willingness to adopt new treatments rather than abandon existing ones, and nancial incentive. (26, 45) Hence, interventions that address barriers and facilitators need to be designed diligently to facilitate the reduction of low-value care (45,. 46) A variety of strategies have been incorporated into interventions aimed at reducing low-value practices, such as those selected in our study (45)…”

What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies

“…This study was performed as part of a national program aimed at reducing LVC. 18 Within the scope of this overarching program, a systematic review of the literature on deimplementation was performed, which is used as a basis for this manuscript. The review protocol has not been registered or published.…”