How to Reduce Overuse in Healthcare E-Book
45,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
HOW TO REDUCE OVERUSE IN HEALTHCARE Reduce low-value care with this practical guide Low-value care harms patients, overburdens healthcare professionals, threatens healthcare systems and damages the climate. How to Reduce Overuse in Healthcare: a practical guide is designed to provide practical guidance and tools for healthcare providers, their professional societies and policy makers developing programs to de-implement low-value or unnecessary care. This guide provides a five-step evidence and theory-based framework for developing and evaluating programs such as Choosing Wisely to reduce low-value care and improve patient outcomes. How to Reduce Overuse in Healthcare: a practical guide readers will also find: * An author team involved in the leading Choosing Wisely international network * Detailed analysis of how to identify potential low-value care areas, select interventions and more * Practical, real-world examples at the end of each chapter illustrating examples of overuse and de-implementation How to Reduce Overuse in Healthcare: a practical guide describes the state of the art in de-implementation for healthcare professionals, healthcare administrators and policy makers looking to reduce low-value care in a more effective and evidence-based way.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 306
Veröffentlichungsjahr: 2023
Ähnliche
Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Preface
CHAPTER 1: Why Should We Reduce Medical Overuse?
IT STARTED WITH QUALITY IMPROVEMENT
THEN CAME A FOCUS ON OVERUSE
OVERUSE AS A GLOBAL HEALTHCARE QUALITY CONCERN
WHAT CAN BE DONE TO ADDRESS OVERUSE?
WHAT CAN YOU EXPECT IN THE FOLLOWINGCHAPTERS?
REFERENCES
CHAPTER 2: Why Does Overuse Exist?
A MULTIFACTORIAL CHALLENGE ON DIFFERENT LEVELS
HEALTHCARE SYSTEM FACTORS
KEY POINTS
REFERENCES
CHAPTER 3: Why Is It So Hard to Change Behaviour and How Can We Influence It?
THE CHALLENGE OF BEHAVIOUR CHANGE
FOUR CRUCIAL QUESTIONS TO ADDRESS BEFORE WORKING TO SUPPORT BEHAVIOUR CHANGE
WHY IS IT SO DIFFICULT TO CHANGE THE BEHAVIOUR OF HEALTHCARE PROFESSIONALS?
DESIGNING INTERVENTIONS TO CHANGE BEHAVIOUR
SUMMARY
SOURCES OF INFORMATION FOR SUPPORTING PRACTICE CHANGE AMONG HEALTHCARE PROFESSIONALS
REFERENCES
CHAPTER 4: How Can We Reduce Overuse: The Choosing Wisely De‐Implementation Framework
INTRODUCTION
THE CHOOSING WISELY DE‐IMPLEMENTATION FRAMEWORK
PHASE 0: IDENTIFICATION OF POTENTIAL AREAS OF LOW‐VALUE HEALTHCARE
PHASE 1: IDENTIFICATION OF LOCAL PRIORITIES FOR THE IMPLEMENTATION OF RECOMMENDATIONS
PHASE 2: IDENTIFICATION OF BARRIERS AND ENABLERS TO IMPLEMENTING RECOMMENDATIONS AND POTENTIAL INTERVENTIONS TO OVERCOME THESE
PHASE 3: EVALUATION OF THE IMPLEMENTATION
PHASE 4: SPREAD OF EFFECTIVE IMPLEMENTATION PROGRAMS
KEY POINTS
REFERENCES
CHAPTER 5: How Can You Engage Patients in De‐Implementation Activities?
WHAT IS PATIENT ENGAGEMENT AND WHY IS IT RELEVANT TO DE‐IMPLEMENTATION?
MAKING A PATIENT ENGAGEMENT PLAN
KEY POINTS
SOURCES OF INFORMATION
REFERENCES
CHAPTER 6: Identifying Potential Areas of Low‐Value Healthcare‐Phase 0
HOW TO IDENTIFY LOW‐VALUE CARE?
KEY POINTS
SOURCES OF FURTHER INFORMATION
FURTHER READING
CHAPTER 7: Measuring Low‐Value Care and Choosing Your Local Priority (Phase 1)
CHOOSING YOUR LOCAL PRIORITY
MEASURING LOW‐VALUE CARE
ESTIMATING IMPROVEMENT POTENTIAL
EVALUATING DE‐IMPLEMENTATION EFFECTS
MEASURING UNINTENDED CONSEQUENCES
MEASUREMENT METHODS AND DATA SOURCE
SETTING SPECIFIC, MEASURABLE, ACHIEVABLE, RELEVANT, AND TIME‐BOUND (SMART) TARGETS
PROVIDING DATA AND FEEDBACK TO STAKEHOLDERS
KEY POINTS
REFERENCES
CHAPTER 8: Identifying Target Behaviours and Potential Barriers to Change (Phase 2a)
THE IMPORTANCE OF FULLY UNDERSTANDING THE PROBLEM
GETTING STARTED
IDENTIFYING WHO NEEDS TO DO WHAT DIFFERENTLY
USING THE ACTION, ACTOR, CONTEXT, TARGET, TIME (AACTT) FRAMEWORK
IDENTIFYING DRIVERS OF CURRENT BEHAVIOUR AND BARRIERS AND ENABLERS TO CHANGING BEHAVIOUR
COLLECTING DATA
ANALYSING THE DATA
NARROWING DOWN THE DRIVERS OR BARRIERS IDENTIFIED
KEY POINTS
USEFUL RESOURCES
REFERENCES
APPENDIX: SAMPLE INTERVIEW GUIDE FOR HEALTHCARE PROVIDERS USING THE TDF
CHAPTER 9: Selecting De‐Implementation Strategies and Designing Interventions: Phase 2b
WHAT DO YOU NEED TO DO BEFORE SELECTING DE‐IMPLEMENTATION STRATEGIES?
TEN GENERAL PRINCIPLES TO CONSIDER AS YOU DEVELOP A DE‐IMPLEMENTATION INTERVENTION
KEY POINTS
SOURCES
REFERENCES
CHAPTER 10: Evaluating De‐Implementation Interventions: Phase 3
WHY SHOULD WE EVALUATE?
OUTCOMES
TYPES OF EVALUATIONS
SELECTING THE MOST APPROPRIATE EVALUATION METHOD
HOW AND WHY DOES THE INTERVENTION WORK?
DOES THE INTERVENTION OFFER GOOD VALUE FOR MONEY?
KEY POINTS
REFERENCES
CHAPTER 11: Preserving Results and Spreading Interventions: Phase 4
WHY ARE SUSTAINABILITY AND SPREAD SO IMPORTANT?
WHAT IS SUSTAINABILITY?
FACTORS INFLUENCING SUSTAINED CHANGE
HOW CAN YOU FACILITATE SUSTAINABILITY?
ASSESSING SUSTAINABILITY
SUSTAINABILITY AND CULTURE
SPREADING SUCCESSFUL DE‐IMPLEMENTATION INTERVENTIONS
KEY POINTS
REFERENCES
CHAPTER 12: Training the Next Generation of Healthcare Providers to Address Overuse and Avoid Low‐Value Care
INTRODUCTION
HIGH‐VALUE CARE COMPETENCIES
TEACHING STUDENTS AND TRAINEES TO PROVIDE HIGH‐VALUE CARE
EDUCATIONAL CHANGES TO THE FORMAL CURRICULUM
FACULTY ROLE MODELLING AND SUPPORTIVE LEARNING ENVIRONMENTS
ASSESSING HIGH‐VALUE CARE LEARNING OUTCOMES
ENABLERS OF EDUCATIONAL CHANGE
ALIGNING CONTINUING PROFESSIONAL DEVELOPMENT AND QUALITY IMPROVEMENT
KEY POINTS
SOURCES
REFERENCES
CHAPTER 13: Examples from Clinical Practice
INTRODUCTION
REFERENCES
CHAPTER 14: Starting Tomorrow
Index
End User License Agreement
List of Tables
Chapter 1
TABLE 1.1 Overuse language and meanings.
Chapter 6
TABLE 6.1 Processes and approaches to identify low‐value care
Chapter 7
TABLE 7.1 De‐implementation measures.
TABLE 7.2 Measures of unintended consequences.
TABLE 7.3 Advantages and disadvantages of measurement tools according to me...
TABLE 7.4 Examples of non‐SMART and SMART targets.
Chapter 8
TABLE 8.1 Theoretical Domains Framework domains and their explanations.
Chapter 9
TABLE 9.1 Effectiveness of a selection of trialled implementation strategie...
Chapter 12
TABLE 12.1 Examples for incorporating high‐value care principles into forma...
List of Illustrations
Chapter 4
FIGURE 4.1 The Choosing Wisely De‐Implementation Framework.
Chapter 5
FIGURE 5.1 Link between the Choosing Wisely De‐Implementation Framework to a...
FIGURE 5.2 Stakeholder engagement primer: 4. Options for engagement.
Chapter 10
FIGURE 10.1 Selecting the most appropriate evaluation method.
FIGURE 10.2 The MRC process evaluation framework.
Chapter 11
FIGURE 11.1 Factors on the process, staff, and organisation related to susta...
Chapter 13
FIGURE 13.1 De‐implementation framework.
Guide
Cover Page
Title Page
Copyright Page
Preface
Table of Contents
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
Pages
iii
iv
x
xi
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
How to Reduce Overuse in Healthcare
A Practical Guide
Edited by
Tijn Kool
Andrea M. Patey
Simone van Dulmen
Jeremy M. Grimshaw
This edition first published 2024© 2024 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Tijn Kool, Andrea M. Patey, Simone van Dulmen, and Jeremy M. Grimshaw, to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
Registered OfficesJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.
Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/or its affiliates in the United States and other countries and may not be used without written permission. All other trademarks are the property of their respective owners. John Wiley & Sons, Inc. is not associated with any product or vendor mentioned in this book.
Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication DataNames: Kool, Tijn, editor. | Patey, Andrea (Andrea M.), editor. | Dulmen, Simone van, 1975– editor.| Grimshaw, Jeremy (Jeremy M.), editor.Title: How to reduce overuse in healthcare : a practical guide / edited by Tijn Kool, Andrea M. Patey, Simone van Dulmen, Jeremy M. Grimshaw.Description: First edition. | Chichester, West Sussex, UK ; Hoboken : Wiley‐Blackwell, 2024. | Includes bibliographical references and index.Identifiers: LCCN 2023008464 (print) | LCCN 2023008465 (ebook) | ISBN 9781119862727 (paperback) | ISBN 9781119862734 (adobe pdf) | ISBN 9781119862741 (epub)Subjects: MESH: Low‐Value Care | Medical Overuse | Patient PreferenceClassification: LCC RA418 (print) | LCC RA418 (ebook) | NLM W 74.1 | DDC 362.1–dc23/eng/20230614LC record available at https://lccn.loc.gov/2023008464LC ebook record available at https://lccn.loc.gov/2023008465
Cover Design: WileyCover Image: © ArtHead/Shutterstock
Preface
Low‐value care refers to care that is not proven to provide benefits to patients or where benefits are small in relation to its harms and costs compared to alternatives (including doing nothing) and do not address patients' preferences. Over the last two decades, we have seen increasing global recognition of the existence of low‐value care and its negative consequences. These include (direct and indirect) patient harms, unnecessary workload for hard‐pressed healthcare professionals, wasted healthcare resources, and negative impacts on the climate. Low‐value care may relate to both overdiagnosis and overtreatment. We are faced with major challenges such as demographic changes in societies globally with an increase in the elderly who often require healthcare, advances in biomedical discoveries that offer new therapeutic opportunities (but nearly always at increased costs), and human health resources challenges. There is an urgent need to address these challenges to protect patients, healthcare professionals and systems, and the planet.
In many countries around the world, healthcare professional societies have risen to this challenge by establishing Choosing Wisely and comparable programmes. These bottom‐up professionally led campaigns have been highly successful in raising awareness about low‐value care among healthcare professionals and patients and are increasingly feeding into professional training and quality initiatives. However, as we have observed in many other quality areas in healthcare, identifying a problem does not automatically lead to addressing this. The next urgent issue that we face is how to de‐implement low‐value care. This will be challenging because there are many drivers of low‐value care at different levels of the system. Successful implementation will need careful diagnosis of the problem matched by targeted interventions that address important barriers and enablers. Successful de‐implementation will require key actors, whether they are healthcare professionals, managers, policy makers, or patients, to change their decisions and behaviours, even whilst they are working, planning, or receiving care in time‐poor, high‐pressured, and somewhat chaotic settings. It can feel insurmountable to know how to start and what to do.
In this book, we hope to provide practical insights and tools to help those interested in de‐implementing low‐value care to systematically plan de‐implementation programs. These build upon the insights and expertise of our multidisciplinary group of authors who have decades of experience in behavioural and social sciences and implementation and improvement research. We have tried to make this guide as practical as possible. We hope that this book will inspire and support healthcare professionals to take a first step in reducing medical overuse in their own environment and to continually learn from their efforts.
Tijn Kool
Andrea M. Patey
Simone van Dulmen
Jeremy M. Grimshaw
CHAPTER 1Why Should We Reduce Medical Overuse?
Karen Born1 and Wendy Levinson2
1 Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
IT STARTED WITH QUALITY IMPROVEMENT
The idea that poor quality and patient safety harms are unacceptable and can be measured and improved was introduced into mainstream medical and public culture in the United States nearly 25 years ago and subsequently spread around the globe. This can be traced to the release of a ground‐breaking report, To Err is Human, published by the Institute of Medicine (Donaldson et al. 2000). This report was part of a multi‐year effort led by the Institute of Medicine to change the discourse around patient safety and quality in the United States. To Err is Human focused on the issue of medical errors and safety issues. It highlighted systemic drivers that lead to errors and established a patient safety agenda with a focus on enhancing leadership, measurement, and systems to identify and decrease medical errors. It also highlighted that harm to patients from healthcare is a chronic threat to public health and is pervasive and preventable. This publication was followed shortly thereafter by the report, Crossing the Quality Chasm, which laid out an ambitious agenda for improving healthcare quality in the United States (Institute of Medicine 2002). This included establishing a six‐dimensional framework to measure health system performance: safety, effectiveness, patient‐centredness, timeliness, efficiency, and equity. In addition, Crossing the Quality Chasm offered three major categories for healthcare quality problems: overuse, underuse, and misuse. Overuse relates to healthcare services that have no benefits or for which harms outweigh benefits, underuse to healthcare services that offer benefits to patients but are not provided to relevant patients, and misuse to healthcare services that offer benefits in certain contexts but not others.
Subsequently, quality improvement collaboratives, campaigns, and efforts swept across the United States and other countries with wide variations in results and outcomes. About 14 years after the publication of To Err is Human, experts in quality and patient safety expressed frustration at the slow pace of change. In particular, decreasing overuse was rarely addressed by quality improvement efforts. The Institute of Medicine's report, The Healthcare Imperative, highlighted the shocking figure that nearly 30% of all healthcare costs in the United States were wasted or unnecessary (Yong et al. 2010). The report estimated that this unnecessary care, or overuse, costed upwards of $750 billion in 2009. The problem of overuse began to achieve more prominence as a quality problem, which necessitated further efforts to change. This figure of 30% of all healthcare being low‐value has been reported in other high‐income countries, including Canada (Canadian Institute for Health Information 2017). One commentary bemoaning the lack of change since the publication of the landmark reports over a decade earlier stated, in 2013, that, ‘alongside important efforts to eliminate preventable complications of care, there must also be an effort to seriously address the widespread overuse of health services. That overuse, which places patients at risk of harm and wastes resources at the same time, has been almost entirely left out of recent quality improvement endeavours’ (Chassin 2013).
This sentiment was supported by evidence that overuse is difficult to change. A United States study compared the quality indicators of overuse, misuse, and underuse in outpatient visits in 1999 and 2009 (Kale et al. 2013). The study found that during this period, 6 of the 9 underuse indicators improved, 1 of the 2 misuse indicators improved but only 2 of the 11 overuse indicators improved, with one getting significantly worse.
Chapters 2 and 3 will delve into why overuse is such a stubborn and challenging problem. And why strategies to reduce overuse need to be multi‐pronged to be effective and supported by efforts to change the culture driving overuse, as well as systems that can drive overuse.
THEN CAME A FOCUS ON OVERUSE
Overuse was originally defined in the Institute of Medicine reports, and since that time, there has been a proliferation of terminology to define and describe waste and overuse in healthcare. Common terminology includes low‐value care, unnecessary care, appropriateness, overdiagnosis, de‐adoption, and de‐implementation. Table 1.1 offers four categories to classify key descriptions for overuse. Note that positive language, such as appropriate care, high‐value care or right care, has been used to contrast with overuse and to emphasis quality problems associated with underuse and misuse, as well as overuse, and as such are not included in the table.
This book will use the terms overuse and low‐value care as they are consistent with the broader language used in the quality and patient safety literature. However, clarity regarding terminology can help to communicate the complex topic of overuse to various audiences.
TABLE 1.1 Overuse language and meanings.
Category
Common terms
Application
Example
Processes of care which are not effective or cost effective
Unnecessary care Low‐value care Waste Inappropriate care
Processes of care that are not effective or cost‐effective, delivery marginal clinical value or benefit to patients, and where harms outweigh benefits clinically
Annual or routine blood screening tests in asymptomatic patients
Overuse of a test, treatment of procedure
Overuse Overprescribing Overdiagnosis Overtreatment
Variation in a practice across settings with additional use not delivering benefit
Overprescribing of antibiotics for respiratory tract infection in some settings or regions with similar case mix and population characteristics
Treatments which are no longer beneficial
Obsolete Outdated technologies/care
A treatment which was once perceived to be beneficial but has been replaced with a better process of care, or now has strong evidence showing it does not work
Transfusing more than one red cell unit at a time when transfusion is required in stable, non‐bleeding patients
OVERUSE AS A GLOBAL HEALTHCARE QUALITY CONCERN
In the chapter thus far, we have covered key American reports and data associated with the quality and patient safety movement. This movement spread globally, and with increased awareness of overuse came several key publications, which sought to describe and measure overuse in a global context. In 2017, The Lancet published a landmark special series of the journal with a focus on Right Care (Berwick 2017). The series emphasised the importance of the coexistence of overuse and underuse globally, offering evidence for overuse not just from high‐income countries such as the United States, but also evidence of overuse in low‐ and middle‐income countries. Also, the Organisation for Economic Cooperation and Development (OECD) released a report on overuse Tackling Wasteful Spending on Health in 2017. It began with a powerful statement contrasting spending pressures on healthcare systems globally with evidence that one‐fifth of healthcare expenditures have no or minimal contribution to good health outcomes (OECD 2017). The OECD report linked the imperative to reduce overuse with the interconnected goals of spending less on healthcare while improving health. The OECD now includes overuse indicators, for example, antibiotic volumes, benzodiazepine prescriptions in older adults, and imaging tests in their annual Health at a Glance report (OECD 2021). The accumulation of evidence of overuse and presence of measures at the system level helped to articulate a case globally for the harms of overuse as a quality problem moving beyond costs. Importantly, these measures helped to emphasise a broad range of the harms of overuse to individuals to health systems.
It is important to frame and shape a narrative about overuse as going beyond wasteful healthcare spending to engage and motivate various stakeholders to take action. These include patients, clinicians, and the general public who may not be motivated to change due to government or payor concerns, but instead are concerned with individual safety and quality care (Born et al. 2017; Levinson et al. 2018).
Harms to individual patients from overuse include side effects from and medication interactions with unnecessary treatments, and incidental findings and testing cascades from unnecessary tests that can expose patients to risk. Overuse can also harm patients by wasting time or financial resources through delays in access to care, needless stress or worry, and wasted time and money pursuing follow‐up appointments.
Harms to providers and organisations can be associated with wasted time, resources, and broader inefficiencies driving up wait times for patients and increasing inefficiencies for organisations. Inefficiencies in care, like pursing unnecessary test results, take up clinician time and can lead to excess workload and provider stress.
Overuse can harm healthcare systems at the regional, provincial, national, and indeed global level. Overuse wastes scarce healthcare resources. Public health crises, such as the opioid epidemic and antimicrobial resistance, are associated with and accelerated by the overuse and overprescribing of these medications. These can drive social and socioeconomic harms.
Finally, healthcare overuse is increasingly seen as harmful to human health and the environment (Barratt et al. 2022). There is a growing recognition of healthcare's climate footprint, the majority of which is driven by the complex supply chain of the manufacturing and distribution of healthcare goods such as pharmaceuticals, as well as service delivery in hospital and community settings (MacNeill et al. 2021). Recent reports suggest that healthcare sector emissions are responsible for nearly 5% of global net emissions (HCHW 2019). A key strategy to reduce healthcare emissions is to avoid overuse. The sustainability of any healthcare system depends on using resources to maximise benefit and avoiding wasteful spending that does not add value to patients or the public.
WHAT CAN BE DONE TO ADDRESS OVERUSE?
With the accumulating evidence of overuse, as well as clear demonstration of the harms of overuse, increasingly efforts are being directed towards interventions to reduce overuse. Systematic reviews have highlighted that given the complexity of overuse, multi‐component interventions that target both clinician and patient drivers of overuse are most likely to be effective (Colla et al. 2017). Components at the individual clinician and patient level, which draw from quality improvement approaches, include clinical decision support, performance measurement, and feedback, in addition to patient and provider education that is necessary but not sufficient to drive change. While health systems have explored policy initiatives to reduce overuse, including pay for performance, payment restriction, and risk sharing, there is limited evidence of effectiveness. Top‐down approaches of payers to reduce overuse are often limited in scope and can meet resistance from both clinicians and patients if they are perceived as rationing healthcare.
Choosing Wisely
National approaches to reduce overuse have been driven by various actors and groups, including payers and healthcare systems. However, the most well‐known movement in the past decade has been a clinician‐led approach to reduce overuse in nearly 30 countries globally (Born et al. 2019). Choosing Wisely® was initially launched as a campaign in the United States led by the American Board of Internal Medicine Foundation in 2012 (Cassel and Guest 2012). The campaign was aimed at galvanising physician leadership around ballooning domestic healthcare costs in the United States and lagging efforts to address overuse as an important quality problem. Choosing Wisely campaigns bring together national clinician specialty societies, which develop lists of recommendations identifying overused tests, treatments, and procedures within a clinical specialty.
Choosing Wisely campaigns share a core set of principles to ensure that clinician‐led efforts to address overuse are not co‐opted by government or other stakeholders. The campaigns should stay firmly associated with efforts to reduce harms to patients and improve quality at the individual, organisational, and health system levels. First, campaigns must be clinician‐led (as opposed to payer‐ and/or government‐led). This is important to building and sustaining the trust of clinicians and patients. It emphasises that campaigns are focused on the quality of care and harm reduction, rather than cost reduction. Second, campaigns must be patient‐focused and involve efforts to engage patients in the development and implementation process. Communication between clinicians and patients is central to Choosing Wisely. Third, campaigns should be multi‐professional, where possible, including physicians, nurses, pharmacists, and other healthcare professionals. Fourth, campaigns should be evidence‐based wherein recommendations issued by campaigns are based on strong and high‐quality evidence and reviewed on an ongoing basis to ensure credibility. Finally, campaigns must be transparent, so processes used to create the recommendations must be public and any conflicts of interest should be be declared (Levinson et al. 2015).
Choosing Wisely campaigns have been present for nearly a decade in some jurisdictions and the key question is whether these campaigns have an impact on reducing overuse. A measurement framework for Choosing Wisely campaigns was established which we will discuss in more detail in Chapter 7 on measuring low‐value care. The framework suggests that campaign impact can be measured at three levels: first, awareness of overuse among relevant stakeholders; second, changes to processes in care; and third, changes to outcomes of care (Bhatia et al. 2015). These changes take time and involve changes to individual practice, as well as system drivers of overuse. A recent systematic review considering efforts to implement Choosing Wisely recommendations in the United States found that the publication and dissemination of recommendations through Choosing Wisely campaigns are necessary but not sufficient. Raising awareness and developing evidence‐based recommendations will not address the complex drivers and factors associated with overuse; however, interventions by health systems and providers to implement campaign recommendations into practice using multiple components that target clinicians specifically, such as audit and feedback, changing order sets and education can reduce overuse (Cliff et al. 2021).
Efforts to reduce overuse need multi‐component interventions due to the complex drivers of overuse. Overuse has been built into the culture of medicine for clinicians, and patients often believe that ‘more is better’ and underappreciate risks and harms of low‐value tests, treatments and procedures (Kerr et al. 2017). Providers have developed long‐standing practice patterns of the ways they typically investigate or treat particular conditions, often including exhaustive testing to rule out any potential but rare condition. Physicians learned to practice a particular way during their training, and changing these longstanding practice patterns is very challenging. Hospitals or clinics have systems that drive overuse, including order entry systems, routine order sets for hospital admissions or nursing directives for care, or routine annual visits and testing in primary care (Morgan et al. 2017). Healthcare systems create inefficiencies often due to the lack of integrated information systems, so redundant tests are done without providers knowing they had already been conducted. We will discuss all these mechanisms that operate on different levels in Chapter 2. Reducing overuse requires understanding the cause of the overuse in a particular situation and harnessing the appropriate mechanisms to drive change (Born et al. 2019). Changing the culture of overuse that pervades medicine is going to take years, and this journey is only in its early stages. This book gives readers a view of the present status of the problem, the opportunities and challenges of reducing overuse, and helps readers to start reducing overuse themselves.
WHAT CAN YOU EXPECT IN THE FOLLOWINGCHAPTERS?
This book consists of 14 chapters. In this first chapter, we have introduced ‘overuse’ and why it should be reduced. Chapter 2 describes why overuse exists. It is a multifactorial challenge with causes on several levels. Chapter 3 discusses the reasons why changing clinicians' and patients' behaviours, that is necessary for reducing overuse, is so hard.
In Chapter 4, we introduce a framework to reduce overuse that can help you to develop, evaluate, and scale up de‐implementation interventions. In Chapter 5, we emphasise the importance of engaging patients in all the phases of the framework: designing an intervention and realising, spreading, and preserving the change.
In Chapter 6, we describe how healthcare professionals can start with reducing overuse by identifying potential areas of low‐value healthcare and assessing the volume of low‐value care to be de‐implemented (see Chapter 7).
In Chapter 8, we describe how healthcare professionals can choose a specific strategy to reduce overuse by identifying the barriers for de‐implementation and choosing the appropriate intervention for their identified problem (see Chapter 9). It is also important to evaluate the effects of an intervention to determine whether it was successful (see Chapter 10).
Then, we discuss the sustainability and spread of de‐implementation interventions: how to increase the likelihood that interventions are sustainable and can be disseminated (see Chapter 11) and how to leverage professional education for sustainability and dissemination (see Chapter 12).
Finally, we present cases of de‐implementation strategies from different countries through all abovementioned phases (see Chapter 13) and summarise how you can take steps to reduce overuse in your own practice (see Chapter 14).
REFERENCES
Barratt, A.L., Bell, K.J., Charlesworth, K. et al. (2022). High value health care is low carbon health care.
Medical Journal of Australia
216: 67–68.
Berwick, D.M. (2017). Avoiding overuse – the next quality frontier.
The Lancet
390: 102–104.
Bhatia, R.S., Levinson, W., Shortt, S. et al. (2015). Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low‐value care.
BMJ Quality and Safety
24: 523–531.
Born, K.B., Coulter, A., Han, A. et al. (2017).
Engaging Patients and the Public in Choosing Wisely
. BMJ Publishing Group Ltd.
Born, K., Kool, T., and Levinson, W. (2019). Reducing overuse in healthcare: advancing Choosing Wisely.
BMJ
367.
Canadian Institute for Health Information (2017).
Unnecessary Care in Canada: Technical Report
. Ottawa, ON: Canadian Institute for Health Information.
Cassel, C.K. and Guest, J.A. (2012). Choosing Wisely: helping physicians and patients make smart decisions about their care.
JAMA
307: 1801–1802.
Chassin, M.R. (2013). Improving the quality of health care: what's taking so long?
Health Affairs
32: 1761–1765.
Cliff, B.Q., Avancena, A.L., Hirth, R.A. et al. (2021). The impact of Choosing Wisely interventions on low‐value medical services: a systematic review.
The Milbank Quarterly
99: 1024–1058.
Colla, C.H., Mainor, A.J., Hargreaves, C. et al. (2017). Interventions aimed at reducing use of low‐value health services: a systematic review.
Medical Care Research and Review
74: 507–550.
Donaldson, M.S., Corrigan, J.M., Kohn, L.T. et al. (2000).
To Err Is Human: Building a Safer Health System
. Washington DC: National Academies Press (US).
HCHW (2019). Health care's climate footprint. How the health sector contributes to the global climate crisis and opportunities for action. In:
Climate‐Smart Health Care Series
(ed. H.C.W. Harm). Healthcare Without Harm.
Institute of Medicine, C.O.Q.H.C.I.A (2002).
Crossing the Quality Chasm
. Washington, DC: National Academy Press.
Kale, M.S., Bishop, T.F., Federman, A.D. et al. (2013). Trends in the overuse of ambulatory health care services in the United States.
JAMA Internal Medicine
173: 142–148.
Kerr, E.A., Kullgren, J.T., and Saini, S.D. (2017). Choosing Wisely: how to fulfill the promise in the next 5 years.
Health Affairs
36: 2012–2018.
Levinson, W., Kallewaard, M., Bhatia, R.S. et al. (2015). ‘Choosing Wisely’: a growing international campaign.
BMJ Quality and Safety
24: 167–174.
Levinson, W., Born, K., and Wolfson, D. (2018). Choosing Wisely campaigns: a work in progress.
JAMA
319: 1975–1976.
Macneill, A.J., Mcgain, F., and Sherman, J.D. (2021). Planetary health care: a framework for sustainable health systems.
The Lancet Planetary Health
5: e66–e68.
Morgan, D.J., Leppin, A.L., Smith, C.D. et al. (2017). A practical framework for understanding and reducing medical overuse: conceptualizing overuse through the patient‐clinician interaction.
Journal of Hospital Medicine
12: 346–351.
OECD (2017).
Tackling Wasteful Spending on Health
. Paris: OECD Publishing.
OECD (2021).
Health at a Glance 2021: OECD Indicators
. Paris: OECD Publishing.
Yong, P.L., Olsen, L., and Saunders, R.S. (2010).
The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary
. National Academies Press (US).
CHAPTER 2Why Does Overuse Exist?
Tijn Kool1, Simone van Dulmen1, Andrea M. Patey2,4, and Jeremy M. Grimshaw2,3,4
1 Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
2 Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
3 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
4 School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
A MULTIFACTORIAL CHALLENGE ON DIFFERENT LEVELS
To understand why overuse exists, it is important to understand the mechanisms behind overuse. Why do healthcare professionals order inappropriate laboratory tests and perform invasive procedures such as arthroscopies without evidence of necessity? And why do patients ask for harmful interventions and laboratory testing? Overuse is a multifactorial challenge with causes at several levels: healthcare professionals, patients, the clinical care context, healthcare organisations, and the healthcare system.
Healthcare Professional Factors
Healthcare professionals play an important role in creating overuse. The lack of knowledge about current evidence of effective care may be a reason for providing low‐value care. Healthcare professionals need to be aware of the scientific research of the effectiveness of treatments and its costs, but also of alternative treatment options. The general principle of good practice is that the healthcare professional uses scientific evidence as a basis for her professional practice. However, it is a challenge to keep an overview on all these alternatives. Adherence to guidelines and protocols by healthcare professionals is often modest (Grol and Grimshaw 2003).
The clinical behaviour of healthcare professionals involves two different processes: reflective and automatic approaches. Reflective processes are often described as reasoned behaviours based on knowledge about facts and values, whereas automatic approaches are described as routines or habitual behaviours and rely on heuristic decision‐making (Strack and Deutsch 2004
