Reduce Harm and Waste - Disinvestment

The approach to Reducing Harm and Waste in Realistic Medicine is to focus on value. When resources are limited, interventions are offered to those who will benefit most and who are more willing to accept risk and in these conditions it is more likely that high value healthcare is delivered. However as resources increase, interventions are offered to those less likely to benefit while the likelihood and magnitude of harm stays the same and in these conditions it is more likely that low or negative value healthcare is delivered. A personalised approach to care can help communicate these concepts for patients and help understand what benefit and risk mean for a patient’s personal situation. Personalised care can also reduce the impact of adverse events. Being Open is a best practice framework used in Scotland which creates an environment where patients and families feel supported and healthcare professionals and managers have the confidence to act appropriately. “Psychological harm to families is reduced when they experience compassionate care, their perspective is valued and when they are central to the review of care.” Being Open has also been used to prevent future harm when staff participate with the learning and improvement generated from the adverse event review reports. [The Scottish Government. Personalising Realistic Medicine: Chief Medical Officer for Scotland’s Annual Report 2017-18. Published 2019. https://www.gov.scot/publications/personalising-realistic-medicine-chief-medical-officer-scotland-annual-report-2017-2018/pages/7/]

Value can be assessed in many different ways and can include cost-effectiveness analysis, economic analysis, disinvestment, and reducing overuse and overprescribing. Below is a selection of journal articles and reports which are about disinvestment in healthcare.  If you are looking to answer a specific question please submit a literature search request at the link above.  If you would like to be alerted when new content is available here then please sign in and select Follow.  You are welcome to leave comments and suggestions below in the comments section.

BADGERYPARKER T., et al, 2020. Hospital characteristics associated with low-value care in public hospitals in New South Wales, Australia. BMC health services research, 20(1), pp. 750.
Rates of low-value care vary between hospitals in New South Wales, Australia. Understanding factors associated with this variation will help in understanding the drivers of low-value care and in planning initiatives to reduce low-value care.

BERLIN, N.L., et al, 2020. Too Much Surgery: Overcoming Barriers to Deimplementation of Low-value Surgery. Annals of Surgery, 271(6), pp. 1020-1022.

GRIMSHAW, J.M., et al, 2020. De-implementing wisely: developing the evidence base to reduce low-value care. BMJ Quality & Safety, 29(5), pp. 409-417.
"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. 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." Copyright © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

MARCOTTE, L.M., et al, 2020. Measuring low-value care: learning from the US experience measuring quality. BMJ Quality & Safety, 29(2), pp. 154-156.

NORTON, W.E. and CHAMBERS, D.A., 2020. Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Science, 15(1), pp. 2.
"De-implementing inappropriate health interventions is essential for minimizing patient harm, maximizing efficient use of resources, and improving population health. Research on de-implementation has expanded in recent years as it cuts across types of interventions, patient populations, health conditions, and delivery settings. This commentary explores unique aspects of de-implementing inappropriate interventions that differentiate it from implementing evidence-based interventions, including multi-level factors, types of action, strategies for de-implementation, outcomes, and unintended negative consequences. We highlight opportunities to continue to advance research on the de-implementation of inappropriate interventions in health care and public health."

RIETBERGEN, T., et al, 2020. Effects of de-implementation strategies aimed at reducing low-value nursing procedures: a systematic review and meta-analysis. Implementation Science, 15(1), pp. 38.
The aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20). CONCLUSIONS: The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used. TRIAL REGISTRATION: The review is registered in Prospero (CRD42018105100).

SYPES, E.E., et al, 2020. Engaging patients in de-implementation interventions to reduce low-value clinical care: a systematic review and meta-analysis. BMC Medicine, 18(1), pp. 116.
The objective of this systematic review with meta-analysis was to determine the effect of de-implementation interventions that engage patients within the patient-clinician interaction on use of low-value care. RESULTS: From 6736 unique citations, 9 RCTs and 13 quasi-experimental studies were included in the systematic review. Studies mostly originated from the USA (n = 13, 59%), targeted treatments (n = 17, 77%), and took place in primary care (n = 10, 45%). The most common intervention was patient-oriented educational material (n = 18, 82%), followed by tools for shared decision-making (n = 5, 23%). Random effects meta-analysis demonstrated that de-implementation interventions that engage patients within the patient-clinician interaction led to a significant reduction in low-value care in both RCTs (RR 0.74; 95% CI 0.66-0.84) and quasi-experimental studies (RR 0.61; 95% CI 0.43-0.87). There was significant inter-study heterogeneity; however, intervention effects were consistent across subgroups defined by low-value practice and patient-engagement strategy. CONCLUSIONS: De-implementation interventions that engage patients within the patient-clinician interaction through patient-targeted educational materials or shared decision-making tools are effective in decreasing the use of low-value care. Clinicians and policymakers should consider engaging patients within initiatives that seek to reduce low-value care. REGISTRATION: Open Science Framework (https://osf.io/6fsxm).

SYPES, E.E., et al, 2020. Understanding the public's role in reducing low-value care: a scoping review. Implementation Science, 15(1), pp. 20.
The objective of this scoping review was to systematically examine the literature describing public involvement in initatives to reduce low-value care. RESULTS: The 218 included citations were predominantly original research (n = 138, 63%), published since 2010 (n = 192, 88%), originating from North America (n = 146, 67%). Most citations focused on patient engagement within the patient-clinician interaction (n = 156, 72%), using tools that included shared decision-making (n = 66, 42%) and patient-targeted educational materials (n = 72, 46%), and reported both reductions in low-value care and improved patient perceptions regarding low-value care. Fewer citations examined public involvement in low-value care policy-making (n = 33, 15%). Among citations that examined perspectives regarding public involvement in initiatives to reduce low-value care (n = 10, 5%), there was consistent support for the utility of tools applied within the patient-clinician interaction and less consistent support for involvement in policy-making. CONCLUSIONS: Efforts examining public involvement in low-value care concentrate within the patient-clinician interaction, wherein patient-oriented educational materials and shared decision-making tools have been commonly studied and are associated with reductions in low-value care. This contrasts with inclusion of the public in low-value care policy decisions wherein tools to promote engagement are less well-developed and involvement not consistently viewed as valuable. TRIAL REGISTRATION: Open Science Framework (https://osf.io/6fsxm).

WANG, T., et al, 2020. A Framework for De-implementation in Surgery. Annals of Surgery, epub ahead of print

ESANDI M.E., et al, 2019. An evidence-based framework for identifying technologies of no or low-added value (NLVT). International Journal of Technology Assessment in Health Care, epub ahead of print
"Although identification methods have been described in the literature and tested in different contexts, the proliferation of terms and concepts used to describe this process creates considerable confusion. The proposed framework is a rigorous and flexible tool that could guide the implementation of strategies for identifying potential candidates for disinvestment."

MOES F., et al, 2019. Collective constructions of 'waste': epistemic practices for disinvestment in the context of Dutch social health insurance. BMC health services research, 19(1), pp. 633.
"Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders' reluctance to engage in what can be perceived as 'rationing'. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. "

POLISENA J., et al, 2019. Disinvestment Activities and Candidates in the Health Technology Assessment Community: An Online Survey. International Journal of Technology Assessment in Health Care, 35(3), pp. 189-194.
"Among the 362 invitees, twenty-four unique responses were received, and almost 70 percent were involved in disinvestment initiatives. The disinvestment candidates identified represented a range of health technologies. Evidence or signaling of clinical ineffectiveness or inappropriate use typically led to the nomination of disinvestment candidates. The survey results suggested that disinvestment activities are occurring in the HTA community, especially in the public sector."

BURTON, C., et al, 2019. Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence. Systematic Reviews, 8(1), pp. 194.
The aim of this evidence synthesis is to produce meaningful programme theory and practical guidance for policy makers, managers and clinicians to understand how and why de-implementation processes and procedures can work. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017081030.

MITCHELL, D., et al, 2019. Health care staff responses to disinvestment-A systematic search and qualitative thematic synthesis. Health care management review,
“Health care staff have a strong professional identity associated with autonomy in their decision making in the provision of health care services. Disinvestment from a service that health care staff can usually choose to provide threatens this identity. Engaging clinical champions to lead change, using rigorous patient outcome data, and transparent decision-making processes may assist health care staff to embrace a new identity as innovators and accept disinvestment in low-value health care.”

MITCHELL, D., et al, 2019. Understanding Health Professional Responses to Service Disinvestment: A Qualitative Study. International Journal of Health Policy & Management, 8(7), pp. 403-411.
“Clinicians and health service managers are protective of the services they deliver and can create barriers to disinvestment. Even when services are removed to ascertain their value, health professionals may continue to provide services to their patients. Measuring the impact of the disinvestment may assist staff to accept the removal of a service.“

OSORIO, D., et al, 2019. Selecting and quantifying low-value nursing care in clinical practice: A questionnaire survey.  Journal of Clinical Nursing,
“We found a great understanding of low-value care between nurses, given the high agreement to recommendations and perception of usefulness. However, several low-value practices may be present in nursing care, requiring actions to reduce them, for instance, reviewing institutional protocols and involving patients in de-implementation. Hospitals and other settings should be aware of low-value practices and take actions to identify and reduce them. A survey may be a simple and helpful way to start this process.”

SIPILA, R., et al, 2019. Highlighting the need for de-implementation - Choosing Wisely recommendations based on clinical practice guidelines. Finland  BMC Health Services Research, 19(1), pp. 638.
“Choosing Wisely recommendations can be produced systematically from existing clinical practice guidelines. The rigorous methods of evidence-based medicine ensure high-quality recommendations. We welcome the use of our processes and methods describes in this article by other guideline-producing organizations.”

Calabro, GE., Torre, G La., Waure, C de., et al (2018) Disinvestment in healthcare: an overview of HTA agencies and organisations activities at European level. BMC Health Services Research 18: 148.  Today, in a healthcare context characterized by resource scarcity and increasing service demand, “disinvestment” from low-value services and reinvestment in high-value ones is a key strategy that may be supported by HTA. The lack of evaluation of technologies in use, in particular at the end of their lifecycle, may be due to the scant availability of frameworks and guidelines for identification and assessment of obsolete technologies that was shown by our work. Although several projects were carried out in different countries, most remain constrained to the field of research. Disinvestment is a relatively new concept in HTA that could pose challenges also from a methodological point of view. To tackle these challenges, it is necessary to construct experiences at international level with the aim to develop new methodological approaches to produce and grow evidence on disinvestment policies and practices.

Chambers, JD., Salem, MN., D'Cruz, BN., et al (2018) A review of empirical analysis of disinvestment initiatives. Value Health 20(7): 909-918.  The success of disinvestment initiatives has been mixed, with fewer than half the indentified empirical studies reporting that  use of the low-value service was reduced. Our findings suggest that promotion of the disinvestment initiative among clinicians is a key component to the success of the disinvestment initiative.

Daniels, T., Williams, I., Bryan, S., Mitton, C. (2018) Involving citizens in disinvestment decisions: what do health professionals think?  Findings froma multi-method study in the English NHS. Health Economics, Policy and Law 13(2):162-188. Public involvement in disinvestment decision making in health care is widely advocated, and in some cases legally mandated. However, attempts to involve the public in other areas of health policy have been accused of tokenism and manipulation. This paper presents research into the views of local health care leaders in the English National Health Service (NHS) with regards to the involvement of citizens and local communities in disinvestment decision making. The research includes a Q study and follow-up interviews with a sample of health care clinicians and managers in senior roles in the English NHS. It finds that whilst initial responses suggest high levels of support for public involvement, further probing of attitudes and experiences shows higher levels of ambivalence and risk aversion and a far more cautious overall stance. This study has implications for the future of disinvestment activities and public involvement in health care systems faced with increased resource constraint. Recommendations are made for future research and practice.

Harris, C., Green, S. Elshaug, AG. (2017) Sustainability in Health care by Allocating Resources Effectively (SHARE) 10: operationalising disinvestment in a conceptual framework for resource allocation.  BMC Health Services Research 17: 632.  The framework can be employed at network, institutional, departmental, ward or committee level. It is proposed as an organisation-wide application, embedded within existing systems and processes, which can be responsive to needs and priorities at the level of implementation. It can be used in policy, management or clinical contexts.

Hasson, H., Nilson, P., Augustsson, H., Thiele Schwarz, U Von. (2018)  Empirical and conceptual investigation of de-implimentation of low-value care from professional and health care system perspectives: a study protocol. Implementation Science 1391): 67 This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de-implementation of low-value care. The professionals' perspectives will be highlighted, including insights into how they make decisions, handle de-implementation in daily practice, and what consequences it has on their work. Furthermore, the health care system perspective will be considered and new knowledge on how de-implementation can be understood across health care system levels will be obtained. The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve de-implementation processes at all levels of the health care system. The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.

Leigh, JP., Niven, DJ., Boyd, JM., Stelfox, HT.  Developing a framework to guide the de-adoption of low-value clinical practices in acute care medicine: a study protocol.  BMC Health Services Research 17: 54. There is a growing body of literature suggesting that the de-adoption of ineffective or harmful practices from patient care is integral to the delivery of high quality care and healthcare sustainability. The framework developed in this study will map barriers and facilitators to de-adoption to the most appropriate interventions, allowing stakeholders to effectively initiate, execute and sustain this process in an evidence-based manner.

Moore, L., Boukar, KM., Tardif, P., et al. (2017)  Low-value clinical practices in injury care: a scoping review protocol, BMJ Open 7(7): e016024. We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify research articles, reviews, recommendations and guidelines that identify at least one low-value clinical practice specific to injury populations. We will search Medline, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, websites of government agencies, professional societies and patient advocacy organisations, thesis holdings and conference proceedings. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles using a prepiloted and standardised electronic data abstraction form. Low-value clinical practices will be categorised using an extension of the Agency for Healthcare Research and Quality conceptual framework and data will be presented using narrative synthesis.

Niven, DJ., Mrklas, KJ., Holodinsky, JK., et al. (2015) Towards undestanding the de-adoption of low-value clinical practices: a scoping review.  BMC Medicine 13:255. This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.