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Limit, lean or listen? A typology of low-value care that gives direction in de-implementation

Limit, lean or listen? A typology of low-value care that gives direction in de-implementation Background: Overuse of unnecessary care is widespread around the world. This so-called low- value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, differ- ent strategies might be necessary to reduce it and awareness of this may help in designing a de- implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care. Results: The type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappro- priate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients’ preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typ- ology gives direction in choosing whether to limit, lean or listen. Conclusion: We developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for redu- cing low-value care. Key words: low-value care, overuse, de-implementation, disinvestment, de-adoption Introduction healthcare: improving the experience of care and the health of popu- Overuse of unnecessary care is widespread around the world and lations, and reducing its costs [6]. Hence, there is an increasing num- especially prevalent in high-income countries [1, 2]. Experts estimate ber of initiatives around the world to identify and reduce low-value that ~10–30% of all healthcare practices have little or no benefitto care [1, 7], the largest of them being Choosing Wisely [8]. the patient [3, 4]. Apart from wasting limited resources, these so- The concept of low-value care is broad and listed low-value ser- called low-value care practices may cause physical, psychological vices vary, ranging from routine transthoracic echocardiograms [9] and financial harm to patients [1]. For example, an unnecessary CT- to the chronic use of benzodiazepines [10] and curative treatment scan exposes the body to harmful radiation and overuse of antibio- for patients that prefer palliative care [11]. These cases of low-value tics contributes to antibiotic resistance at population level. Berwick care have different contexts and different reasons for being of low- and Hackbarth estimated that between $107 billion and $389 bil- value, enable different perspectives by diverse stakeholders and lion was wasted on low-value care in the USA in 2011 [5]. Reducing require different strategies for de-implementation. Just as in imple- low-value care is therefore a step towards the triple aim in mentation [4], one size does not fit all in de-implementation and © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. 736 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/intqhc/article/30/9/736/4993353 by DeepDyve user on 19 July 2022 Low-value care: a typology � Patient-centred care 737 tailoring your strategy to the context of the low-value care practice is important. We are convinced that being aware of the reason for care to be of low-value is important in selecting a strategy. To the best of our knowledge, there is no literature that reports taking this into account in developing a strategy for reducing low- value care. The aim of this paper is to introduce a typology of low- value care that creates awareness of the wide range of low-value care and provides direction in how to reduce it. What is low-value care? What low-value care entails depends on the definition of value. Literature shows different definitions for low-value care that contain several elements [12–18]; low-value care is care: that provides min- imal or no health benefit; which benefit does not weigh up to the harms; which benefit does not weigh up to the costs; that is less cost-effective than alternative care, and that does not fit the prefer- ences of the patient. There is no definition that encompasses all ele- ments. Therefore, we will use the following definition of low-value care: ‘care that is unlikely to benefit the patient given the harms, cost, available alternatives, or preferences of the patient’. This defin- ition includes care that is low-value from both the patients’ and soci- Figure 1 Flowchart literature scan. etal perspective. Low-value care is also being addressed in other terms, such as overuse, which is often mentioned next to underuse (failing to pro- typologies that did not provide insight into the reason for being vide care when it would have produced a favorable outcome) and low-value, such as type of care (diagnostics, treatment or preven- misuse (selecting high-value care but not delivering to its full poten- tion), costs and effects of care, and barriers and facilitators for redu- tial due to preventable complications) [12]. The related terms over- cing low-value care. Wennberg identified three types of unwarranted treatment and overtesting indicate the inappropriate delivery of variations in care; effective care, preference-sensitive care and particular types of services [1]. Another related term, overdiagnosis, supply-sensitive care [23]. However, these unwarranted variations occurs when people without symptoms are diagnosed with a disease include both overuse of low-value care and underuse of high-value that ultimately will not cause symptoms or early death [19]. care, while we focus on care that is proven of low-value. In this paper, we focus on care that is proven to be of low-value The found typologies describe several reasons for care to be of and of which the physician can predict it is of low-value at the time low-value, such as when care ‘occurs too frequently’ [13], ‘is not of deciding to deliver the specific care practice. We do not focus on clinically indicated for the patient’s symptom or diagnosis’ [13], ‘is care that has unknown effectiveness and care that appeared to be of delivered in the wrong doses or duration’ [21], ‘has a cheaper, no value after it had been used. However, determining if a care prac- equally effective alternative’ [21]or ‘has a close benefit-risk balance tice is unlikely to benefit the patient on beforehand can be hard. in mild cases’ [22]. Often there is a lack of sound scientific evidence, for example, The typologies all include categories focused on the value of a because studies lack an appropriate comparator or relevant and service from a medical perspective. However, none of the typologies long-term outcome measures [20]. Drugs and medical devices can be include the option of care being low-value due to the patients’ pre- authorized for the market based on this weak evidence. And even ferences. Since patient preferences are recognized in the definitions when there is sufficient evidence, using it to predict for an individual of low-value care and evidence based practice, and are recognized patient whether a practice is of low-value or not could also be hard. by Choosing wisely as being an important component of avoiding overuse [24], the current typologies do not represent the full spec- trum of low-value care. In addition, two typologies include categor- Current typologies ies that do not match our definition of low-value care [21, 22], We We reviewed scientific literature on low-value care of the past 10 would categorize ‘Not receiving a medicine that is clinically needed’ years and found three papers that describe a typology or framework as underuse, and ‘canceled procedures’ and ‘potentially cosmetic with different types of low-value care related to the reason for being interventions’ are not necessarily low-value according to our defin- low-value [13, 21, 22]. We searched PubMed on 28 March 2017 ition. Some categories within the typologies have the same under- with the following search strategy and included articles from 01 lying cause for being low-value. For example, the categories ‘services January 2007: (low-value care[tiab] OR lower-value care[tiab] OR that are not matched to the patient’s risk of disease’ and ‘when the unnecessary care[tiab] OR overuse[tiab] OR overdiagnosis[tiab] OR patient has contraindications that increase the risk of the service’ Medical Overuse[Mesh]) AND (framework[tiab] OR types[tiab] both represent care whose benefits do not outweigh the risks. Lastly, OR typology[tiab] OR classification[tiab]). E.W.V. and S.A.vD. screened the typologies do not facilitate the selection of a promising strategy all articles independently and discussed for final inclusion. See Fig. 1 for reducing low-value care. Each typology offers insight in low- for a flowchart of this process. We included articles that describe dif- value care, but they do not comprise the full spectrum of low-value ferent types of low-value care related to the reason for being low- care and they do not give direction to reducing low-value care. value. We excluded papers without typologies and papers with Therefore, we developed a new typology. Downloaded from https://academic.oup.com/intqhc/article/30/9/736/4993353 by DeepDyve user on 19 July 2022 738 Verkerk et al. certain care. This enables macro-level strategies enacted by the gov- Introduction of a new typology ernment or national institutes with consequences for the whole com- Based on our definition of low-value care and in collaboration with munity, such as market withdrawal or exclusion from the benefit five clinicians and researchers with expertize on low-value care or package, which make care inaccessible or unprofitable. These are implementation, we created three types of low-value care related to strong incentives and can be a successful and sustainable addition to their reason for being of low-value. Figure 2 shows our typology. a de-implementation process. However, policy changes could be dif- The category ineffective care is of low-value from a medical perspec- ficult to achieve. Other strategies for reducing ineffective care are tive. It includes care that is proven (cost)ineffective for a certain con- incorporation of do-not-do recommendations in clinical practice dition or which benefit does not weigh up to the harms according to guidelines and protocols or installing barriers or alerts in electronic scientific standards, for the majority of the population or a well- patient records when a low-value care practice is ordered. For defined subgroup. Examples are shaving before an operation, the example, a study installed soft- and hard-stop computer alerts when use of antibiotics in children with upper respiratory tract infections metformin was ordered inappropriately [25]. The key word for de- and routine echocardiography for asymptomatic patients. implementing this kind of low-value care is ‘limit’. The category inefficient care is of low-value from a societal per- ‘Inefficient care’ is caused by inefficient organization and lack of spective. It includes care that is in essence effective for the targeted cooperation. Market withdrawal or exclusion from the benefit pack- condition, but becomes of low-value through inefficient provision or age are not possible, since this care is in essence effective and still inappropriate high intensity or duration. Examples of inefficient needs to be delivered. A promising and sustainable strategy here lies provision are duplication of diagnostic tests and removing stitches in in hospitals or regional networks reorganizing care and facilitating hospital instead of general practice. Examples of inappropriate communication between healthcare providers. Duplication of intensity are routine use of ‘last-resort’ antibiotics, chronic benzodi- imaging for example might be solved by better information trans- azepine use and prolonged catheterization. mission between electronic patient files. Another example is a study The category unwanted care, lastly, is of low-value from the that reduced the high intensity of routine laboratory tests by imple- patients’ perspective. Like ‘inefficient care’ it is in essence effective menting a new ordering system in which each test needs to be for the targeted condition, but becomes low-value because it does ordered individually instead of in groups [26]. The key word for de- not solve the individual patients’ problem or does not fit the individ- implementing this kind of low-value care is ‘lean’. ual patient’s preferences. Examples are vaccines and blood transfu- Since ‘unwanted care’ depends on the preferences and values of sions for patients with certain religious beliefs, chemotherapy for a the patient, limiting or reorganizing care for all patients is not patient that prefers palliative care, or surgery while the patient pre- appropriate. A promising strategy for reducing unwanted care is fers conservative treatment. This category is probably the least well- facilitating shared-decision-making and sufficient communication known and least well-studied type of low-value care, because it can between patient and caregiver. It is important that patients are well- only be identified and measured by assessing the patient’s values. informed before making a decision and empowered to be more An example to illustrate this typology is the use of an magnetic involved in their healthcare, although this could be difficult because resonance imaging (MRI) scan in a patient with a lumbal hernia. An it requires time and skills from the caregiver. An example is a study MRI scan may have been low-value because the scan was not indi- that reduced unwanted prostate cancer screening by providing cated (ineffective); because the scan had been done before (ineffi- patients with a decision aid and educating physicians [27]. The key cient) or because the outcome of the scan would not alter treatment word for de-implementing this kind of low-value care is ‘listen’. anyway: the patient prefers conservative treatment over an oper- Incorporating the reason for care to be of low-value in develop- ation (unwanted). Logically, the strategy to reduce unnecessary MRI ing de-implementation strategies is important but not sufficient. scans in each of the three options differs. Other contextual factors (e.g. local organizational structure, culture, available time and money) play an important role and need to be taken into account in a full-grown strategy. This means that facilita- Using the typology in reducing low-value care tors and barriers that either stimulate or impede wise choices need We argue that these three types differ in their most promising strat- to be tackled [28, 29]. The driving factors can be different for every egy for de-implementation. For the category ‘Ineffective care’, it can low-value care practice and can include fear of litigation, financial be clearly determined which patients do and do not need to receive incentives, pressure from patients or lack of consultation time [30]. Ineffective care E.g. essentially (cost)ineffective care or Limit (cost)ineffective care for a well-defined subgroup Inefficient care Low-value care E.g. inefficient provision or Lean inappropriate intensity Unwanted care E.g. care doesn't solve problem patient Listen or doesn't meet preferences patient Figure 2 Typology of low-value care. Downloaded from https://academic.oup.com/intqhc/article/30/9/736/4993353 by DeepDyve user on 19 July 2022 Low-value care: a typology � Patient-centred care 739 10. van de Steeg-van Gompel CH, Wensing M, De Smet PA. Implementation Also, combining multiple strategies is generally more effective than a of a discontinuation letter to reduce long-term benzodiazepine use–a clus- single strategy [18]. Even when taking all these elements into ter randomized trial. Drug Alcohol Depend 2009;99:105–14. account, achieving sustainable change is hard and takes determin- 11. Fischberg D, Bull J, Casarett D et al. Five things physicians and patients ation, time and money. This is a challenge we need to face in order should question in hospice and palliative medicine. J Pain Symptom to reduce low-value care and improve healthcare. Manage 2013;45:595–605. 12. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. Conclusion JAMA 1998;280:1000–5. 13. Powell AA, Bloomfield HE, Burgess DJ et al. A conceptual framework for We have developed a typology with three types of low-value care understanding and reducing overuse by primary care providers. Med Care related to their reason for being of low-value that describe the full Res Rev 2013;70:451–72. spectrum of low-value care according to our definition. Care can be 14. Niven DJ, Mrklas KJ, Holodinsky JK et al. Towards understanding the of low-value because it is ineffective, inefficient and unwanted. de-adoption of low-value clinical practices: a scoping review. BMC Med Recognition of these reasons may help to stimulate the debate on 2015;13:255. how to reduce low-value care. Since for different types of low-value 15. Riggs KR, Knight SJ. The language of Stewardship: is the ‘low-value’ care, different types of action may be the most promising target for label overused? Mayo Clin Proc 2017;92:11–4. sustainable de-implementation, this typology may help in developing 16. Elshaug AG, Rosenthal MB, Lavis JN et al. Levers for addressing medical a tailor-made strategy. Low-value care is an increasing problem in underuse and overuse: achieving high-value health care. Lancet 2017; 390:191–202. western countries and there is an urge to take action. Reducing low- 17. Scott IA, Duckett SJ. In search of professional consensus in defining and value care increases the quality and safety of care and reduces costs, reducing low-value care. Med J Aust 2015;203:179–81. and should be on the agenda in every country on policy, organiza- 18. Colla CH, Mainor AJ, Hargreaves C et al. Interventions aimed at redu- tional and professional level. In addition, countries should focus on cing use of low-value health services: a systematic review. Med Care Res preventing low-value care by investing in proper research and stric- Rev 2017;74:507–50. ter market authorization. We are positive that this typology will give 19. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop insight in low-value care and guide healthcare providers, policy harming the healthy. BMJ 2012;344:e3502. makers and researchers in the challenge of de-implementing low- 20. Garner S, Docherty M, Somner J et al. Reducing ineffective practice: chal- value care in many countries. lenges in identifying low-value health care using Cochrane systematic reviews. J Health Serv Res Policy 2013;18:6–12. 21. Busfield J. Assessing the overuse of medicines. Soc Sci Med 2015;131: Funding 199–206. 22. Garcia-Armesto S, Campillo-Artero C, Bernal-Delgado E. Disinvestment This work was supported by ZonMw, the Netherlands Organization for in the age of cost-cutting sound and fury. Tools for the Spanish National Health Research and Development [grant number 80-83920-98-400]. Health System. Health Policy 2013;110:180–5. 23. Wennberg JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ 2002;325:961–4. References 24. Born KB, Coulter A, Han A et al. Engaging patients and the public in 1. Brownlee S, Chalkidou K, Doust J et al. Evidence for overuse of medical Choosing Wisely. BMJ Qual Saf 2017;26:687–91. services around the world. Lancet 2017;390:156–68. 25. Rossi AP, Wellins CA, Savic M et al. Use of computer alerts to prevent 2. Keyhani S, Falk R, Howell EA et al. Overuse and systems of care: a sys- the inappropriate use of metformin in an inpatient setting. Qual Manag tematic review. Med Care 2013;51:503–8. Health Care 2012;21:235–9. 3. Morgan DJ, Brownlee S, Leppin AL et al. Setting a research agenda for 26. Attali M, Barel Y, Somin M et al. A cost-effective method for reducing medical overuse. BMJ 2015;351:h4534. the volume of laboratory tests in a university-associated teaching hospital. 4. Grol R, Grimshaw J. From best evidence to best practice: effective imple- Mt Sinai J Med 2006;73:787–94. mentation of change in patients’ care. Lancet 2003;362:1225–30. 27. Sheridan SL, Golin C, Bunton A et al. Shared decision making for pros- 5. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA tate cancer screening: the results of a combined analysis of two practice- 2012;307:1513–6. based randomized controlled trials. BMC Med Inform Decis Mak 2012; 6. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and 12:130. cost. Health Aff (Millwood) 2008;27:759–69. 28. Bhatia RS, Levinson W, Shortt S et al. Measuring the effect of Choosing 7. Dianahealth: Dissemination of Initiatives to Analyse Appropriateness in Wisely: an integrated framework to assess campaign impact on low-value Healthcare. http://www.dianasalud.com/ care. BMJ Qual Saf 2015;24:523–31. 8. Levinson W, Kallewaard M, Bhatia RS et al. ‘Choosing Wisely’: a grow- 29. Fleuren MA, Paulussen TG, Van Dommelen P et al. Towards a measure- ing international campaign. BMJ Qual Saf 2015;24:167–74. ment instrument for determinants of innovations. Int J Qual Health Care 9. Bhatia RS, Dudzinski DM, Malhotra R et al. Educational intervention to 2014;26:501–10. reduce outpatient inappropriate echocardiograms: a randomized control 30. Saini V, Garcia-Armesto S, Klemperer D et al. Drivers of poor medical trial. JACC Cardiovasc Imaging 2014;7:857–66. care. Lancet 2017;390:178–90. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Limit, lean or listen? A typology of low-value care that gives direction in de-implementation

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Oxford University Press
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Copyright © 2022 International Society for Quality in Health Care and Oxford University Press
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Abstract

Background: Overuse of unnecessary care is widespread around the world. This so-called low- value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, differ- ent strategies might be necessary to reduce it and awareness of this may help in designing a de- implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care. Results: The type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappro- priate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients’ preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typ- ology gives direction in choosing whether to limit, lean or listen. Conclusion: We developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for redu- cing low-value care. Key words: low-value care, overuse, de-implementation, disinvestment, de-adoption Introduction healthcare: improving the experience of care and the health of popu- Overuse of unnecessary care is widespread around the world and lations, and reducing its costs [6]. Hence, there is an increasing num- especially prevalent in high-income countries [1, 2]. Experts estimate ber of initiatives around the world to identify and reduce low-value that ~10–30% of all healthcare practices have little or no benefitto care [1, 7], the largest of them being Choosing Wisely [8]. the patient [3, 4]. Apart from wasting limited resources, these so- The concept of low-value care is broad and listed low-value ser- called low-value care practices may cause physical, psychological vices vary, ranging from routine transthoracic echocardiograms [9] and financial harm to patients [1]. For example, an unnecessary CT- to the chronic use of benzodiazepines [10] and curative treatment scan exposes the body to harmful radiation and overuse of antibio- for patients that prefer palliative care [11]. These cases of low-value tics contributes to antibiotic resistance at population level. Berwick care have different contexts and different reasons for being of low- and Hackbarth estimated that between $107 billion and $389 bil- value, enable different perspectives by diverse stakeholders and lion was wasted on low-value care in the USA in 2011 [5]. Reducing require different strategies for de-implementation. Just as in imple- low-value care is therefore a step towards the triple aim in mentation [4], one size does not fit all in de-implementation and © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. 736 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/intqhc/article/30/9/736/4993353 by DeepDyve user on 19 July 2022 Low-value care: a typology � Patient-centred care 737 tailoring your strategy to the context of the low-value care practice is important. We are convinced that being aware of the reason for care to be of low-value is important in selecting a strategy. To the best of our knowledge, there is no literature that reports taking this into account in developing a strategy for reducing low- value care. The aim of this paper is to introduce a typology of low- value care that creates awareness of the wide range of low-value care and provides direction in how to reduce it. What is low-value care? What low-value care entails depends on the definition of value. Literature shows different definitions for low-value care that contain several elements [12–18]; low-value care is care: that provides min- imal or no health benefit; which benefit does not weigh up to the harms; which benefit does not weigh up to the costs; that is less cost-effective than alternative care, and that does not fit the prefer- ences of the patient. There is no definition that encompasses all ele- ments. Therefore, we will use the following definition of low-value care: ‘care that is unlikely to benefit the patient given the harms, cost, available alternatives, or preferences of the patient’. This defin- ition includes care that is low-value from both the patients’ and soci- Figure 1 Flowchart literature scan. etal perspective. Low-value care is also being addressed in other terms, such as overuse, which is often mentioned next to underuse (failing to pro- typologies that did not provide insight into the reason for being vide care when it would have produced a favorable outcome) and low-value, such as type of care (diagnostics, treatment or preven- misuse (selecting high-value care but not delivering to its full poten- tion), costs and effects of care, and barriers and facilitators for redu- tial due to preventable complications) [12]. The related terms over- cing low-value care. Wennberg identified three types of unwarranted treatment and overtesting indicate the inappropriate delivery of variations in care; effective care, preference-sensitive care and particular types of services [1]. Another related term, overdiagnosis, supply-sensitive care [23]. However, these unwarranted variations occurs when people without symptoms are diagnosed with a disease include both overuse of low-value care and underuse of high-value that ultimately will not cause symptoms or early death [19]. care, while we focus on care that is proven of low-value. In this paper, we focus on care that is proven to be of low-value The found typologies describe several reasons for care to be of and of which the physician can predict it is of low-value at the time low-value, such as when care ‘occurs too frequently’ [13], ‘is not of deciding to deliver the specific care practice. We do not focus on clinically indicated for the patient’s symptom or diagnosis’ [13], ‘is care that has unknown effectiveness and care that appeared to be of delivered in the wrong doses or duration’ [21], ‘has a cheaper, no value after it had been used. However, determining if a care prac- equally effective alternative’ [21]or ‘has a close benefit-risk balance tice is unlikely to benefit the patient on beforehand can be hard. in mild cases’ [22]. Often there is a lack of sound scientific evidence, for example, The typologies all include categories focused on the value of a because studies lack an appropriate comparator or relevant and service from a medical perspective. However, none of the typologies long-term outcome measures [20]. Drugs and medical devices can be include the option of care being low-value due to the patients’ pre- authorized for the market based on this weak evidence. And even ferences. Since patient preferences are recognized in the definitions when there is sufficient evidence, using it to predict for an individual of low-value care and evidence based practice, and are recognized patient whether a practice is of low-value or not could also be hard. by Choosing wisely as being an important component of avoiding overuse [24], the current typologies do not represent the full spec- trum of low-value care. In addition, two typologies include categor- Current typologies ies that do not match our definition of low-value care [21, 22], We We reviewed scientific literature on low-value care of the past 10 would categorize ‘Not receiving a medicine that is clinically needed’ years and found three papers that describe a typology or framework as underuse, and ‘canceled procedures’ and ‘potentially cosmetic with different types of low-value care related to the reason for being interventions’ are not necessarily low-value according to our defin- low-value [13, 21, 22]. We searched PubMed on 28 March 2017 ition. Some categories within the typologies have the same under- with the following search strategy and included articles from 01 lying cause for being low-value. For example, the categories ‘services January 2007: (low-value care[tiab] OR lower-value care[tiab] OR that are not matched to the patient’s risk of disease’ and ‘when the unnecessary care[tiab] OR overuse[tiab] OR overdiagnosis[tiab] OR patient has contraindications that increase the risk of the service’ Medical Overuse[Mesh]) AND (framework[tiab] OR types[tiab] both represent care whose benefits do not outweigh the risks. Lastly, OR typology[tiab] OR classification[tiab]). E.W.V. and S.A.vD. screened the typologies do not facilitate the selection of a promising strategy all articles independently and discussed for final inclusion. See Fig. 1 for reducing low-value care. Each typology offers insight in low- for a flowchart of this process. We included articles that describe dif- value care, but they do not comprise the full spectrum of low-value ferent types of low-value care related to the reason for being low- care and they do not give direction to reducing low-value care. value. We excluded papers without typologies and papers with Therefore, we developed a new typology. Downloaded from https://academic.oup.com/intqhc/article/30/9/736/4993353 by DeepDyve user on 19 July 2022 738 Verkerk et al. certain care. This enables macro-level strategies enacted by the gov- Introduction of a new typology ernment or national institutes with consequences for the whole com- Based on our definition of low-value care and in collaboration with munity, such as market withdrawal or exclusion from the benefit five clinicians and researchers with expertize on low-value care or package, which make care inaccessible or unprofitable. These are implementation, we created three types of low-value care related to strong incentives and can be a successful and sustainable addition to their reason for being of low-value. Figure 2 shows our typology. a de-implementation process. However, policy changes could be dif- The category ineffective care is of low-value from a medical perspec- ficult to achieve. Other strategies for reducing ineffective care are tive. It includes care that is proven (cost)ineffective for a certain con- incorporation of do-not-do recommendations in clinical practice dition or which benefit does not weigh up to the harms according to guidelines and protocols or installing barriers or alerts in electronic scientific standards, for the majority of the population or a well- patient records when a low-value care practice is ordered. For defined subgroup. Examples are shaving before an operation, the example, a study installed soft- and hard-stop computer alerts when use of antibiotics in children with upper respiratory tract infections metformin was ordered inappropriately [25]. The key word for de- and routine echocardiography for asymptomatic patients. implementing this kind of low-value care is ‘limit’. The category inefficient care is of low-value from a societal per- ‘Inefficient care’ is caused by inefficient organization and lack of spective. It includes care that is in essence effective for the targeted cooperation. Market withdrawal or exclusion from the benefit pack- condition, but becomes of low-value through inefficient provision or age are not possible, since this care is in essence effective and still inappropriate high intensity or duration. Examples of inefficient needs to be delivered. A promising and sustainable strategy here lies provision are duplication of diagnostic tests and removing stitches in in hospitals or regional networks reorganizing care and facilitating hospital instead of general practice. Examples of inappropriate communication between healthcare providers. Duplication of intensity are routine use of ‘last-resort’ antibiotics, chronic benzodi- imaging for example might be solved by better information trans- azepine use and prolonged catheterization. mission between electronic patient files. Another example is a study The category unwanted care, lastly, is of low-value from the that reduced the high intensity of routine laboratory tests by imple- patients’ perspective. Like ‘inefficient care’ it is in essence effective menting a new ordering system in which each test needs to be for the targeted condition, but becomes low-value because it does ordered individually instead of in groups [26]. The key word for de- not solve the individual patients’ problem or does not fit the individ- implementing this kind of low-value care is ‘lean’. ual patient’s preferences. Examples are vaccines and blood transfu- Since ‘unwanted care’ depends on the preferences and values of sions for patients with certain religious beliefs, chemotherapy for a the patient, limiting or reorganizing care for all patients is not patient that prefers palliative care, or surgery while the patient pre- appropriate. A promising strategy for reducing unwanted care is fers conservative treatment. This category is probably the least well- facilitating shared-decision-making and sufficient communication known and least well-studied type of low-value care, because it can between patient and caregiver. It is important that patients are well- only be identified and measured by assessing the patient’s values. informed before making a decision and empowered to be more An example to illustrate this typology is the use of an magnetic involved in their healthcare, although this could be difficult because resonance imaging (MRI) scan in a patient with a lumbal hernia. An it requires time and skills from the caregiver. An example is a study MRI scan may have been low-value because the scan was not indi- that reduced unwanted prostate cancer screening by providing cated (ineffective); because the scan had been done before (ineffi- patients with a decision aid and educating physicians [27]. The key cient) or because the outcome of the scan would not alter treatment word for de-implementing this kind of low-value care is ‘listen’. anyway: the patient prefers conservative treatment over an oper- Incorporating the reason for care to be of low-value in develop- ation (unwanted). Logically, the strategy to reduce unnecessary MRI ing de-implementation strategies is important but not sufficient. scans in each of the three options differs. Other contextual factors (e.g. local organizational structure, culture, available time and money) play an important role and need to be taken into account in a full-grown strategy. This means that facilita- Using the typology in reducing low-value care tors and barriers that either stimulate or impede wise choices need We argue that these three types differ in their most promising strat- to be tackled [28, 29]. The driving factors can be different for every egy for de-implementation. For the category ‘Ineffective care’, it can low-value care practice and can include fear of litigation, financial be clearly determined which patients do and do not need to receive incentives, pressure from patients or lack of consultation time [30]. Ineffective care E.g. essentially (cost)ineffective care or Limit (cost)ineffective care for a well-defined subgroup Inefficient care Low-value care E.g. inefficient provision or Lean inappropriate intensity Unwanted care E.g. care doesn't solve problem patient Listen or doesn't meet preferences patient Figure 2 Typology of low-value care. Downloaded from https://academic.oup.com/intqhc/article/30/9/736/4993353 by DeepDyve user on 19 July 2022 Low-value care: a typology � Patient-centred care 739 10. van de Steeg-van Gompel CH, Wensing M, De Smet PA. Implementation Also, combining multiple strategies is generally more effective than a of a discontinuation letter to reduce long-term benzodiazepine use–a clus- single strategy [18]. Even when taking all these elements into ter randomized trial. Drug Alcohol Depend 2009;99:105–14. account, achieving sustainable change is hard and takes determin- 11. Fischberg D, Bull J, Casarett D et al. Five things physicians and patients ation, time and money. This is a challenge we need to face in order should question in hospice and palliative medicine. J Pain Symptom to reduce low-value care and improve healthcare. Manage 2013;45:595–605. 12. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. Conclusion JAMA 1998;280:1000–5. 13. Powell AA, Bloomfield HE, Burgess DJ et al. A conceptual framework for We have developed a typology with three types of low-value care understanding and reducing overuse by primary care providers. Med Care related to their reason for being of low-value that describe the full Res Rev 2013;70:451–72. spectrum of low-value care according to our definition. Care can be 14. Niven DJ, Mrklas KJ, Holodinsky JK et al. Towards understanding the of low-value because it is ineffective, inefficient and unwanted. de-adoption of low-value clinical practices: a scoping review. 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Journal

International Journal for Quality in Health Care – Oxford University Press

Published: Nov 1, 2018

Keywords: low-value care; deimplementation

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