Top-down and bottom-up approaches to low-value care

Patey, Andrea M.; Soong, Christine

doi:10.1136/bmjqs-2022-014977

Cited by 8 publications

(5 citation statements)

References 23 publications

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“…The selected pilot Implementation research study, EMBED, provides an opportunity to raise awareness of the role of implementation science in clinical practice and for capacity building. This study has the advantage of both top down organisational leadership support and bottom up clinician and consumer input [ 8 ]. It will be critical that we evaluate both the implementation and clinical impacts of undertaking this pilot Implementation research project.…”

Section: Discussionmentioning

confidence: 99%

“…Clearly organisational leadership and resource management are key for successful implementation, but empirical evidence from a wide range of reviews is also clear that these factors are often not enough on their own to achieve lasting practice change. ( https://epoc.cochrane.org/our-reviews ) Bottom-up approaches centre on frontline activity including factors such as staff beliefs about an intervention, consumer engagement and alignment with professional identity [ 8 ]. A robust understanding of both context and implementation research is required to effectively examine and tackle some of the implementation challenges faced in the health and care setting.…”

Section: Introductionmentioning

confidence: 99%

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Aligning organisational priorities and implementation science for cancer research

Best,

Thursky,

Buzza

et al. 2024

BMC Health Serv Res

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Background The challenge of implementing evidence into routine clinical practice is well recognised and implementation science offers theories, models and frameworks to promote investigation into delivery of evidence-based care. Embedding implementation researchers into health systems is a novel approach to ensuring research is situated in day-to-day practice dilemmas. To optimise the value of embedded implementation researchers and resources, the aim of this study was to investigate stakeholders’ views on opportunities for implementation science research in a cancer setting that holds potential to impact on care. The research objectives were to: 1) Establish stakeholder and theory informed organisation-level implementation science priorities and 2) Identify and prioritise a test case pilot implementation research project. Methods We undertook a qualitative study using semi-structured interviews. Participants held either a formal leadership role, were research active or a consumer advocate and affiliated with either a specialist cancer hospital or a cancer alliance of ten hospitals. Interview data were summarised and shared with participants prior to undertaking both thematic analysis, to identify priority areas for implementation research, and content analysis, to identify potential pilot implementation research projects. The selected pilot Implementation research project was prioritised using a synthesis of an organisational and implementation prioritisation framework – the organisational priority setting framework and APEASE framework. Results Thirty-one people participated between August 2022 and February 2023. Four themes were identified: 1) Integration of services to address organisational priorities e.g., tackling fragmented services; 2) Application of digital health interventions e.g., identifying the potential benefits of digital health interventions; 3) Identification of potential for implementation research, including deimplementation i.e., discontinuing ineffective or low value care and; 4) Focusing on direct patient engagement e.g., wider consumer awareness of the challenges in delivering cancer care. Six potential pilot implementation research projects were identified and the EMBED project, to support clinicians to refer appropriate patients with cancer for genetic testing, was selected using the synthesised prioritisation framework. Conclusions Using a theory informed and structured approach the alignment between strategic organisational priorities and implementation research priorities can be identified. As a result, the implementation research focus can be placed on activities with the highest potential impact.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Aligning organisational priorities and implementation science for cancer research

Best,

Thursky,

Buzza

et al. 2024

BMC Health Serv Res

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“… 48 - 50 Therefore, future “top-down” policy changes, such as an active disinvestment initiative, should always be combined with “bottom-up” (eg, physician-oriented) co-interventions in order to maximize its effectiveness and increase to possibility for success. 51 , 52 Additionally, future active disinvestment initiatives must be aligned with pre-existing theories, such as basic economic theory, and consider theoretical frameworks on eg, priority setting and/or de-implementation 35 , 53 as their implications largely overlap. Future research should further explore the effectiveness of active disinvestment initiatives, while taking into account these co-interventions, incorporate the perspectives of patients and develop more specific theoretical frameworks to facilitate understanding how active disinvestment influences (clinical) decision-making.…”

Section: Discussionmentioning

confidence: 99%

Impact of Active Disinvestment on Decision-Making for Surgery in Patients With Subacromial Pain Syndrome: A Qualitative Semi-structured Interview Study Among Hospital Sales Managers and Orthopedic Surgeons

Geurkink,

Marang-van de Mheen,

Nagels

et al. 2023

Int J Health Policy Manag

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Background: Withdrawal of reimbursement for low-value care through a policy change, i.e., active disinvestment, is considered a potentially effective de-implementation strategy. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may be effective is unclear. This study explored how the active disinvestment initiative regarding subacromial decompression surgery for subacromial pain syndrome(SAPS) in the Netherlands influenced clinical decision-making around surgery, including the perspectives of orthopedic surgeons and hospital sales managers. Methods: We performed 20 semi-structured interviews from November-2020 to October-2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals across the Netherlands as relevant stakeholders in the active disinvestment process. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion. Results: Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative for SAPS. The first theme was that the active disinvestment represented a "Too small piece of the pie" indicating little financial consequences for the hospital as it was merely used in negotiations with health care insurers to reduce costs, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in the overall healthcare insurer agreements. The second theme was "They[healthcare insurer] got it wrong", as the evidence and guidelines had been incorrectly interpreted, the active disinvestment was at odds with clinician experiences and beliefs and was perceived as a reduction in their professional autonomy. Conclusion: The two overarching themes and their underlying factors highlight the complexity for active disinvestment initiatives to be effective. Future de-implementation initiatives including active disinvestment should engage relevant stakeholders at an early stage to incorporate their different perspectives, gain support and increase the probability of success.

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“…It is of low value from a clinical perspective. It refers to care proven to have little to no benefit or the benefit of which fails to outweigh the harm 7,[16][17][18][19][20][21][22][23][24][25][26][27] . For example, prolonged preoperative fasting in elective surgical patients is a well-known example of low-value care in nursing, which has been proven to be more harmful than useful 28 .…”

Section: Attributes Of Low-value Carementioning

confidence: 99%

Low-value care: an evolutionary concept analysis

Guan,

Song,

et al. 2024

Interdisciplinary Nursing Research

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Background: Low-value care is a significant contributor to healthcare waste and a threat to the viability and sustainability of healthcare systems. Low-value care has attracted increasing international attention in the last decade, but its precise conception remains elusive. Objective: To clarify the concept of low-value care. Methods: A systematic search was conducted of the Medline, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, Health Technology Assessment, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from their inception to 22 July 2023 for articles written in English. Rodgers’ evolutionary method guided the narrative analysis. The attributes of low-value care, as well as its antecedents, consequences, and related terms were extracted and synthesized. Results: A total of 53 articles were included in this concept analysis. Defining attributes included: being of little to no benefit or potentially harmful, not being cost-effective, occurring along a continuum, being relative, ignoring or disregarding patient wishes in certain circumstances, and involving multiple types of care. Low-value care antecedents were classified into four categories: demand-side factors, supply-side factors, social factors, and healthcare system factors, while consequences of low-value care were categorized into patient harms and healthcare system-related consequences. Conclusions: This in-depth analysis of attributes, antecedents, and consequences of low-value care promotes a better understanding of low-value care among healthcare providers, thus contributing to the identification and de-implementation of low-value care in practice, and eventually contributing to reducing waste in healthcare spending and improving patient outcomes.

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Top-down and bottom-up approaches to low-value care

Cited by 8 publications

References 23 publications

Aligning organisational priorities and implementation science for cancer research

Aligning organisational priorities and implementation science for cancer research

Impact of Active Disinvestment on Decision-Making for Surgery in Patients With Subacromial Pain Syndrome: A Qualitative Semi-structured Interview Study Among Hospital Sales Managers and Orthopedic Surgeons

Low-value care: an evolutionary concept analysis

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