The problem with eliminating ‘low-value care’

Willson, Alan

doi:10.1136/bmjqs-2015-004518

Cited by 21 publications

(25 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We favour the term ‘de‐implementation’ because abandoning low‐value care seems to require managed action that addresses a variety of the factors that drive the use of low‐value care (van Bodegom‐Vos et al, ). In general, it is suggested that there are fundamental differences between implementation and de‐implementation as it is harder to give up low‐value care than to adopt new and promising innovations (Davidoff, ; Ubel & Asch, ; Willson, ; van Bodegom‐Vos et al, ). Therefore, the challenges related to de‐implementation may differ from the challenges of implementation (Elshaug et al, ; Willson, ; van Bodegom‐Vos et al, ).…”

Section: Implementation Vs De‐implementationmentioning

confidence: 99%

“…However, the number of experiences with de‐implementation efforts is growing. The success of these efforts varies as they do not always result in a reduction or abandonment of low‐value care (Garner & Littlejohns, ; Willson, ). We elaborate on this with three examples.…”

Section: Implementation Vs De‐implementationmentioning

confidence: 99%

“…In addition, theory on how to de-implement effectively is sparse (Doust & Mar, 2004;Elshaug et al, 2007;Polisena et al, 2013;Roman & Asch, 2014;Davidoff, 2015;Montini & Graham, 2015;Niven et al, 2015;Ubel & Asch, 2015;Willson, 2015). However, the number of experiences with de-implementation efforts is growing.…”

Section: Implementation Vs De-implementationmentioning

confidence: 99%

See 2 more Smart Citations

Towards a systematic approach for (de)implementation of patient blood management strategies

Voorn

Bodegom‐Vos

So‐Osman

2018

Transfusion Medicine

View full text Add to dashboard Cite

Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.

show abstract

Section: Implementation Vs De‐implementationmentioning

confidence: 99%

Section: Implementation Vs De‐implementationmentioning

confidence: 99%

See 1 more Smart Citation

Towards a systematic approach for (de)implementation of patient blood management strategies

Voorn

Bodegom‐Vos

So‐Osman

2018

Transfusion Medicine

View full text Add to dashboard Cite

show abstract

“…While overdiagnosis and overtreatment may be worthy problems to seek to address, robust evaluation of the impact of having done so is important. One reason for this is that the reward may turn out to be smaller than anticipated,26 with some studies of the likely gains to be made through targeting so-called ‘low value’ care raising questions about the magnitude of any likely impact 27 28. A second reason that robust evaluation is needed is that these issues may be trickier to gain traction on than might be anticipated.…”

Section: Insights From Healthcare Improvement Researchmentioning

confidence: 99%

Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research

Armstrong

2018

BMJ Qual Saf

View full text Add to dashboard Cite

“…It is suggested that there are fundamental differences between de-implementation and implementation, as it is harder to give up low-value care, particularly when not substituted with something else, than to adopt new and promising techniques. [13, 14] But theory or empirical evidence on how to effectively de-implement is sparse, and only limited knowledge is available about the specific agents involved in de-implementation, the relevant barriers and facilitators, and the effective interventions for successful de-implementation of low-value care [13–21]. …”

Section: Introductionmentioning

confidence: 99%

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

View full text Add to dashboard Cite

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.

show abstract

The problem with eliminating ‘low-value care’

Cited by 21 publications

References 11 publications

Towards a systematic approach for (de)implementation of patient blood management strategies

Towards a systematic approach for (de)implementation of patient blood management strategies

Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research

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

Contact Info

Product

Resources

About