Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

Abstract

for the Low-Value Practices in Trauma Care Expert Consensus Group IMPORTANCE The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. OBJECTIVE To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care.DESIGN, SETTING, AND PARTICIPANTS This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. MAIN OUTCOMES AND MEASURESPanelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. RESULTSOf 49 eligible experts approached, 46 (94%; 18 experts [39%] aged Ն50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), ( 4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and ( 9) routine blood work (minor orthopedic surgery). CONCLUSIONS AND RELEVANCEIn this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

Validation of Quality Indicators Targeting Low-Value Trauma Care

“…In addition to low frequency, repeated head CT had low construct validity and ICU admission for mild complicated TBI had low construct and predictive validity. Of note, repeated CT for mild complicated TBI was selected by the panel of international experts in our consensus study but not by local stakeholders, whereas ICU admission for the same diagnosis was selected by local stakeholders but not by international experts …”

“…Hospital admission in blunt abdominal trauma with a negative CT had an incidence above 10% and high interhospital variation but low case volume and low construct and predictive validity. This QI was selected by international experts but not by local stakeholders in our consensus study and is one of the few that is not targeted in any clinical practice guidelines we identified. Finally, the QI on orthosis in thoracolumbar burst fractures had low frequency and construct validity.…”

“…We recently developed a trauma-specific list of QIs targeting low-value clinical practices for trauma care using a scoping review of the literature, syntheses of evidence on benefits and harms, an evaluation of cost-effectiveness, and an expert consensus study . Two panels of international (76% participation [25 of 33]) and local stakeholders (94% participation [15 of 16]), and 3 patient partners identified 16 clinical practices whose use should be questioned and assessed with QIs.…”

Low Value Surgical Care: Are We Choosing Wisely?

“…In addition to unfamiliarity with this nascent science and complexities of the whole process, most frequently reported barriers are patient-related (lack of awareness, belief that more is better, demands, and preferences), provider-related (lack of awareness/conviction re: LVC, belief that their experience is better, lack of time for shared decision making, the number of tests recommended by specialists, malpractice concerns), health system-related (lack of leadership support, financial incentives to do more-irrespective of value, and resistance/restriction by insurance regulators), evidencerelated (heterogeneous studies with imprecise measures and high risk of bias, low quality systematic reviews, lack of credible strong evidence to support de-implementation), or society-related (cultural norms or health policy) [6,[22][23][24][25][26][27][28]. However, it must be conceded that it is an evolving science with heterogeneous metrics and such scientific exercises take time [23,28].…”

Potential Avoidable Costs of Low-Value Clinical Practices in Acute Injury Care in an Integrated Canadian Provincial Trauma System

“…Given the need to make rapid decisions between multiple diagnostic and therapeutic options, trauma care is a high-risk setting for low-value practices (LVPs), defined as tests or treatments not supported by evidence or that expose patients to unnecessary harm . A consensus-based list of 16 LVPs for trauma care was recently published . Studies have estimated spending associated with such services among individuals with fee-for-service Medicare at about US $50 000 per 1000 admissions .…”