Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review

Abstract

The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.

Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial

“…Thus it will be important in future research to measure longer term effects using other study designs. We tested a multicomponent intervention9 and our study was not designed to disentangle the effects of each of the precommitment intervention components, although our survey and interview results provide insight into clinicians’ perceptions of these components. As with any surveys or interviews, our findings about clinicians’ views of the intervention could have been subject to recall or social desirability biases.…”

“…Other studies have tested interventions to improve clinicians’ decisions about low-value care9 and guideline adherence,61 yet we are aware of only two trials that have tested behavioural economic strategies to discourage ordering of low-value services. The first trial tested poster-sized letters from clinicians that were placed in clinic examination rooms for 12 weeks.…”

Mapping the drivers of overdiagnosis to potential solutions

“…Multicomponent interventions tackling patient and provider roles (eg, clinician education with decision support or feedback) to reduce overuse and low value care 10 Using minimally invasive techniques to eventually replace surgery for low risk tumours (eg, low staged lung tumours) 39 Clinical decision support and performance feedback 10 13 Compare practices with peers (eg, prescribing, referrals, tests) More time with patient to order less tests 30 46 Tools to promote discussion with patients on why test might not be needed 13 Don't use diagnostic labels unless needed 33 Consider stepped or slower diagnosis 17 33 Overusing or over-reliance on tests Lack of knowledge or confidence about limits and harms of medicine 8 23 Research and promote doing nothing, watchful waiting, or active surveillance as legitimate options, where appropriate Expectation that clinicians will "do something" …”

“…Hard to do nothing rather than something [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Overemphasis on diagnosis 20 Problem based learning approach leads to shotgun approach to diagnosis, rewards unusual or rare diagnoses, and contributes to overtesting and overdiagnosis, with an emphasis on avoiding omission errors Poor knowledge of patient preference and shared decision making 23 Improper weighting of absolute v relative risk Lack of professional self confidence or knowledge of harms Interventions to reduce overuse and overdiagnosis:…”

“…Biased reporting by media-eg, reporting lack of care more than underdiagnosis and overdiagnosis [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Health system…”