How to Reduce Overuse in Healthcare

Tijn Kool, MD PhD, is Full Professor Appropriate Care at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Andrea M. Patey, PhD, is Senior Research Associate in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada. Simone van Dulmen, PhD, is Senior Researcher in Appropriate and Sustainable Healthcare at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Jeremy M. Grimshaw, MBChB, PhD, Senior Scientist in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.

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