Since the launch of Choosing Wisely in the United States,1 efforts to raise awareness about avoiding low-value care have spread internationally,2 prompting numerous commentaries,3–7 descriptive studies and improvement interventions,8–10 as well as inspiring new hospital job descriptions (eg, Chief Value Officer), journal sections11 and conferences devoted to the ‘Less is More’ paradigm. Low-value clinical care refers to services or interventions that provide little to no benefit to patients in specific clinical scenarios, may cause harm and/or incur unnecessary cost.6 12 13
One example of a commonly encountered low-value practice is the continuation of proton pump inhibitors (PPIs) in patients without indication for ongoing use. Following completion of a defined period of therapy for appropriate indications (eg, peptic ulcer disease), continued use...
Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.1 Though it is generally accepted that properly conducted randomised trials (and subsequent meta-analyses) provide the best evidence to answer a clinical question, these are not always possible and they have been less frequently performed in surgery. If there are randomised trials, and good evidence is thus available, this should guide therapeutic and diagnostic choices but also still requires clinical judgement to translate the results from these trials to an individual patient in daily practice, for instance because some subgroups of patients may have been excluded from these trials.2
In this issue of BMJ Quality & Safety, an interesting and informative article by Reeves et al entitled ‘Implementation of research evidence in orthopaedics: a tale of three trials’3 seeks to examine the...
In this issue of BMJ Quality & Safety, Meddings et al1 report the evaluation of a national effort to reduce two well-known safety targets, central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). The paper’s introduction helpfully informs readers of the context. Prior projects funded by the US Agency for Healthcare Research and Quality (AHRQ) have reported well-known successes for both these targets.2 3 One national collaborative reported a greater than 40% reduction in CLABSI in intensive care units (ICUs).2 And, a comparably large project reported a 32% reduction in CAUTI in clinical units other than ICUs, but with no reduction occurring in ICUs.3
This lack of improvement for CAUTI in ICUs might perplex those familiar with the history of these interventions. The AHRQ On the CUSP: Stop CAUTI project3 included the Comprehensive Unit-based Safety...
Proton pump inhibitor (PPI) use is widespread. There have been increasing concerns about overuse of high-dose PPIs for durations longer than clinically necessary.Objective
To evaluate the impact of national education initiatives on reducing PPI use in Australia.Design
Population-based, controlled interrupted time series analysis of PPI dispensing claims data for Australian adults from July 2012 to June 2018; we used statin dispensing as a control.Interventions
A year-long educational initiative led by NPS MedicineWise (previously the National Prescribing Service) from April 2015. Simultaneously, Choosing Wisely released recommendations in April 2015 and May 2016. Both promoted review of prolonged PPI use and encouraged stepping down or ceasing treatment, where appropriate.Measurements
We examined monthly changes in PPI (and statin) dispensing (stratified by high, standard and low tablet strength), rates of switching from higher to lower strength PPIs and rates of PPI (and statin) discontinuation.Results
We observed 12 040 021 PPI dispensings to 579 594 people. We observed a sustained –1.7% (95% CI: –2.7 to –0.7%) decline in monthly dispensing of standard strength PPIs following the initiatives until the end of the study period. There were no significant changes in high or low strength PPI (or statin) dispensings, switching to lower strength PPIs, or PPI (and statin) treatment discontinuation.Conclusion
Our findings suggest that these educational initiatives alone were insufficient in curbing overuse of PPIs on a national level. Concerted efforts with policy levers such as imposing tighter restrictions on subsidised use of PPIs may be more effective. Noting low strength esomeprazole is not publicly subsidised in Australia, availability of these preparations may also facilitate more appropriate practice
To examine implementation of evidence in orthopaedic practice following publication of the results of three pivotal clinical trials.Design
Case studies based on three orthopaedic trials funded in sequence by the National Institute for Health Research Health Technology Assessment (HTA) programme. These trials dealt with treatment of fractures of the humerus, radius and ankle, respectively. For each case study, we conducted time-series analyses to examine the relationship between publication of findings and the implementation (or not) of the findings.Results
The results of all three trials favoured the less expensive and less invasive option. In two cases, a change of practice, in line with the evidence that eventually emerged, preceded publication. Furthermore, the upturn in use of the intervention most supported by each of these two trials corresponded to the start of recruitment to the respective trial. The remaining trial failed to influence practice despite yielding clear-cut evidence.Conclusions
Implementation of results of all three HTA orthopaedic trials favoured the less expensive and less invasive option. In two of the three studies, a change in practice, in line with the evidence that eventually emerged, preceded publication of that evidence. A trend or a change in practice, at around the start of the trial, indicates that the direction of causation opposes our hypothesis that publication of trial findings would lead to changes in practice. Our results provide provocative insight into the nuanced topic of research and practice, but further qualitative work is needed to fully explain what led to the pre-emptive change in practice we observed and why there was no change in the third case.
Over the past decade, acute kidney injury (AKI) has become a global priority for improving patient safety and health outcomes. In the UK, a confidential inquiry into AKI led to the publication of clinical guidance and a range of policy initiatives. National patient safety directives have focused on the mandatory establishment of clinical decision support systems (CDSSs) within all acute National Health Service (NHS) trusts to improve the detection, alerting and response to AKI. We studied the organisational work of implementing AKI CDSSs within routine hospital care.Methods
An ethnographic study comprising non-participant observation and interviews was conducted in two NHS hospitals, delivering AKI quality improvement programmes, located in one region of England. Three researchers conducted a total of 49 interviews and 150 hours of observation over an 18-month period. Analysis was conducted collaboratively and iteratively around emergent themes, relating to the organisational work of technology adoption.Results
The two hospitals developed and implemented AKI CDSSs using very different approaches. Nevertheless, both resulted in adaptive work and trade-offs relating to the technology, the users, the organisation and the wider system of care. A common tension was associated with attempts to maximise benefit while minimise additional burden. In both hospitals, resource pressures exacerbated the tensions of translating AKI recommendations into routine practice.Conclusions
Our analysis highlights a conflicted relationship between external context (policy and resources), and organisational structure and culture (eg, digital capability, attitudes to quality improvement). Greater consideration is required to the long-term effectiveness of the approaches taken, particularly in light of the ongoing need for adaptation to incorporate new practices into routine work.
Patients and caregivers often face significant challenges when they are discharged home from hospital. We sought to understand what influenced patient and caregiver experience in the transition from hospital to home and which of these aspects they prioritised for health system improvement.Methods
We conducted group concept mapping over 11 months with patients—and their caregivers—who were admitted to a hospital overnight in the last 3 years in Ontario, Canada and discharged home. Home included supportive housing, shelters and long-term care. Participants responded to a single focal prompt about what affected their experience during the transition. We summarised responses in unique statements. We then recruited participants to rate each statement on a five-point scale on whether addressing this gap should be a priority for the health system. The provincial quality agency recruited participants in partnership with patient, community and healthcare organisations. Participation was online, in-person or virtual.Results
736 participants provided 2704 responses to the focal prompt. Unique concepts were summarised in 52 statements that were then rated by 271 participants. Participants rated the following three statements most highly as a gap that should be a priority for the health system to address (in rank order): ‘Not enough publicly funded home care services to meet the need’, ‘Home care support is not in place when arriving home from hospital’ and ‘Having to advocate to get enough home care’. The top priority was consistent across multiple subgroups.Conclusions
In a country with universal health insurance, patients and caregivers from diverse backgrounds consistently prioritised insufficient public coverage for home care services as a gap the health system should address to improve the transition from hospital to home.
A recent BMJ Quality & Safety article and accompanying editorial highlighted key challenges with quality measurement in US nursing homes, including the challenge of identifying the impact of measures on observable patient outcomes and determining what matters in terms of measurement.1 2 Both pieces offer important insights into the issue of measuring what is meaningful and both offer ideas for improvements.
Picking up a thread from the BMJ Quality & Safety editorial, this viewpoint advances the discussion of measuring what matters. However, this viewpoint shifts the focus to measuring what matters to patients. Considering the multiple types of care and people cared for in nursing homes, we can broaden our understanding of ‘patients’ to mean long-stay nursing home residents, short-stay postacute/rehabilitation patients, and families of residents and patients. While the focus of the editorial is on process and outcome measures of quality, the authors acknowledge...
The Tour de France is revered as one of sports’ most challenging events. Team Sky, a cycling team from the UK, recently captured its sixth Tour victory in 7 years, a feat that makes it one of sport’s greatest dynasties. Dave Brailsford, the coach and architect behind Team Sky, became the Billy Beane of the cycling world by using advanced analytics to identify areas where his team could make marginal gains in their performance producing substantial improvements in outcomes. Beane’s success using this approach with the Oakland Athletics was made famous by a book and movie Moneyball and has been followed by many major success stories in the sporting world over the last decade revealing a similar trend. National Basketball Association players use heat maps and wearable devices to improve shooting accuracy. National Hockey League teams optimise line performance using entropy mapping. Moreover, professional soccer teams develop novel metrics to...
Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.
The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.
Preventing central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) remains challenging in intensive care units (ICUs).Objective
The Agency for Healthcare Research and Quality Safety Program for ICUs aimed to reduce CLABSI and CAUTI in units with elevated rates.Methods
Invited hospitals had at least one adult ICU with elevated CLABSI or CAUTI rates, defined by a positive cumulative attributable difference metric (CAD >0) in the Centers for Disease Control and Prevention’s Targeted Assessment for Prevention strategy. This externally facilitated programme implemented by a national project team and state hospital associations included on-demand video modules and live webinars reviewing a two-tiered approach for implementing key technical and socioadaptive factors to prevent catheter infections, using principles and tools based on the Comprehensive Unit-based Safety Program. CLABSI, CAUTI and catheter use data were collected (preintervention 13 months, intervention 12 months). Multilevel negative binomial models assessed changes in catheter-associated infection rates and catheter use.Results
Of 366 recruited ICUs from 220 hospitals in 16 states and Puerto Rico for two cohorts, 280 ICUs completed the programme including infection outcome reporting; 274 ICUs had complete outcome data for analyses. Statistically significant reductions in adjusted infection rates were not observed (CLABSI incidence rate ratio (IRR)=0.75, 95% CI 0.52 to 1.08, p=0.13; CAUTI IRR=0.79, 95% CI 0.59 to 1.06, p=0.12). Adjusted central line utilisation (IRR=0.97, 95% CI 0.93 to 1.00, p=0.09) and adjusted urinary catheter utilisation were unchanged (IRR=0.98, 95% CI 0.95 to 1.01, p=0.14).Conclusion
This multistate programme targeted ICUs with elevated catheter infection rates, but yielded no statistically significant reduction in CLABSI, CAUTI or catheter utilisation in the first two of six planned cohorts. Improvements in the interventions based on lessons learnt from these initial cohorts are being applied to subsequent cohorts.