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.
Table of Contents
Preface x
Chapter 1 Why Should We Reduce Medical Overuse? 1
Karen Born and Wendy Levinson
It Started with Quality Improvement 1
Then Came a Focus on Overuse 3
Overuse as a Global Healthcare Quality Concern 5
What Can Be Done to Address Overuse? 6
Choosing Wisely 7
What Can you Expect in the Following Chapters? 9
References 10
Chapter 2 Why Does Overuse Exist? 13
Tijn Kool, Simone van Dulmen, Andrea M. Patey, and Jeremy M. Grimshaw
A Multifactorial Challenge on Different Levels 13
Healthcare Professional Factors 14
Patient Factors 15
Preference for Acquiring Something 16
Clinical Care Context Factors 16
Absence of an Open Culture 17
Absence of Clear Leadership 17
Healthcare Organisation Factors 18
Insufficient Time 18
Lack of Coordination Amongst Healthcare Providers 19
Healthcare System Factors 19
Payment System that Rewards Volume 19
Influence of the Pharmaceutical and Medical Device Industry 20
Healthcare Insurance Policy 20
Key Points 20
References 21
Chapter 3 Why Is It So Hard to Change Behaviour and How Can We Influence It? 23
Jill J. Francis, Sanne Peters, Andrea M. Patey, Nicola McCleary, Leti van Bodegom- Vos, and Harriet Hiscock
The Challenge of Behaviour Change 24
Is The Behaviour a Routine? 24
Is The Behaviour Rewarding? 24
Do Habits or Routines Play a Role in Sustaining the Behaviour? 26
Four Crucial Questions to Address Before Working to Support Behaviour Change 28
Why Is It So Difficult to Change the Behaviour of Healthcare Professionals? 30
Designing Interventions to Change Behaviour 35
Summary 36
Sources of Information for Supporting Practice Change Among Healthcare Professionals 36
References 36
Chapter 4 How Can We Reduce Overuse: The Choosing Wisely De- Implementation Framework 41
Jeremy M. Grimshaw and Andrea M. Patey
Introduction 41
The Choosing Wisely De- Implementation Framework 44
Phase 0: Identification of Potential Areas of Low- Value Healthcare 44
Phase 1: Identification of Local Prioritiesfor the Implementation of Recommendations 45
Phase 2: Identification of Barriers and Enablers to Implementing Recommendations and Potential Interventions to Overcome These 46
Phase 3: Evaluation of the Implementation 48
Phase 4: Spread of Effective Implementation Programs 49
Key Points 50
References 51
Chapter 5 How Can You Engage Patients in De- Implementation Activities? 54
Stuart G. Nicholls, Brian Johnston, Barbara Sklar, and Holly Etchegary
What Is Patient Engagement and Why is it Relevant to De- Implementation? 54
Making a Patient Engagement Plan 56
The Level of Engagement 57
Area 1 - Patient Engagement in Agenda Setting and Prioritisation 61
Area 2 - Patient Engagement in the Design and Conduct of De- Implementation Activities 64
Area 3 - Patient Engagement in Spread 65
Important Considerations when Engaging Patients 66
Key Points 68
Sources of Information 69
General Resources 69
Planning Tools 69
Patient Engagement Methods 70
Evaluation Tools 70
References 70
Chapter 6 Identifying Potential Areas of Low- Value Healthcare- Phase 0 73
Moriah E. Ellen, Saritte M. Perlman, and Jeremy M. Grimshaw
How to Identify Low- Value Care? 73
Resources to Identify Low- Value Care 75
Recommendation Lists 76
Clinical Practice Guidelines 77
Health Technology Assessments 77
Evidence Syntheses and Systematic Reviews 78
From Identification to Measurement 78
Key Points 84
Sources of Further Information 84
References 84
Chapter 7 Measuring Low- Value Care and Choosing Your Local Priority (Phase 1) 88
Carole E. Aubert, Karen Born, Eve A. Kerr, Sacha Bhatia, and Eva W. Verkerk
Choosing Your Local Priority 89
Measuring Low- Value Care 89
Baseline Measurements 90
Estimating Improvement Potential 91
Evaluating De- Implementation Effects 91
Measuring Unintended Consequences 94
Measurement Methods and Data Source 95
Setting Specific, Measurable, Achievable, Relevant, and Time- Bound (SMART) Targets 98
Providing Data and Feedback to Stakeholders 98
Key Points 100
References 100
Chapter 8 Identifying Target Behaviours and Potential Barriers to Change (Phase 2a) 103
Andrea M. Patey, Nicola McCleary, Justin Presseau, Tijn Kool, Simone van Dulmen, and Jeremy M. Grimshaw
The Importance of Fully Understanding the Problem 104
Getting Started 104
Identifying Who Needs to do What Differently 105
Using the Action, Actor, Context, Target, Time (Aactt) Framework 106
Identifying Drivers of Current Behaviour and Barriers and Enablers to Changing Behaviour 109
Collecting Data 112
Interviews 112
Focus Groups 114
Surveys 116
Analysing the Data 118
Narrowing Down the Drivers or Barriers Identified 118
Key Points 119
Useful Resources 120
References 120
Appendix: Sample Interview Guide for Healthcare Providers Using the Tdf 122
Introduction Script 122
Background 123
Chapter 9 Selecting De-Implementation Strategies and Designing Interventions: Phase 2b 131
Justin Presseau, Nicola McCleary, Andrea M. Patey, Sheena McHugh, and Fabiana Lorencatto
What Do You Need To Do Before Selecting De- Implementation Strategies? 132
Ten General Principles to Consideras you Develop a de- Implementation Intervention 132
1. There Are No Magic Bullets: Design Your De- Implementation Intervention to Address Specific Barriers and Enablers 132
2. De- Implementation Interventions Are Often Also Implementation Interventions when Substituting One Practice with Another 133
3. Routinised, Habitually Performed Care May Be Operating Semi- Automatically 134
4. Follow the Evidence Wherever Possible when Designing Your De- Implementation Intervention 135
5. Avoid the Tower of Babel: Leverage Existing Listsof Change Strategies and Use Them to Help Match Specific Strategies to Identified Barriers/Enablers 136
6. Avoid Conflating Intervention Content with Its Method of Delivery 139
7. Decide on Tailoring and Adaptation 140
8. Co- Development, User- Centred Design to Enhance Feasibility, Acceptability, and Implementability 140
9. Prioritise Equity 141
10. Describe How the Strategy Works by Developing a De- Implementation Logic Model of Change 142
Key Points 143
Sources 144
References 144
Chapter 10 Evaluating De- Implementation Interventions: Phase 3 149
Beatriz Goulao, Eva W. Verkerk, Kednapa Thavorn, Justin Presseau, and Monica Taljaard
Why Should We Evaluate? 150
Outcomes 150
Types of Evaluations 151
Randomised Evaluations 152
Non- Randomised Evaluations 154
Selecting the Most Appropriate Evaluation Method 156
How and Why Does the Intervention Work? 158
Does the Intervention Offer Good Value for Money? 160
Key Points 161
References 162
Chapter 11 Preserving Results and Spreading Interventions: Phase 4 166
Simone van Dulmen, Daniëlle Kroon, and Tijn Kool
Why Are Sustainability and Spread So Important? 166
What Is Sustainability? 167
Factors Influencing Sustained Change 168
Factors Related to the Process 168
Factors Related to Staff 170
Factors Related to the Organisation 170
How Can You Facilitate Sustainability? 171
Assessing Sustainability 172
Sustainability and Culture 173
Spreading Successful De- Implementation Interventions 174
Scaling Strategy 175
De- Implementation Intervention 176
Adopters or Adopting Organisation 177
External Context 177
Key Points 178
References 178
Chapter 12 Training the Next Generation of Healthcare Providers to Address Overuse and Avoid Low- Value Care 181
Brian M. Wong, Christopher Moriates, Lorette Stammen, and Karen Born
Introduction 182
High- Value Care Competencies 182
Teaching Students and Trainees To Provide High- Value Care 183
Educational Changes to the Formal Curriculum 183
Faculty Role Modellingand Supportive Learning Environments 186
Assessing High- Value Care Learning Outcomes 190
Enablers of Educational Change 191
Aligning Continuing Professional Development and Quality Improvement 192
Key Points 193
Sources 196
References 196
Chapter 13 Examples from Clinical Practice 199
Simone van Dulmen, Daniëlle Kroon, Tijn Kool, Kyle Kirkham, and Johanna Caro Mendivelso
Introduction 199
References 215
Chapter 14 Starting Tomorrow 217
Tijn Kool, Andrea M. Patey, Jeremy M. Grimshaw, and Simone van Dulmen
Index 221
