anna kotzeva , md, mph catalan agency for healthcare quality and assessment
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ESSENCIAL Project: Appropriateness of care and discontinuation of low-value practices. Anna Kotzeva , MD, MPH Catalan Agency for Healthcare Quality and Assessment Agència de Qualitat i Avaluació Sanitàries de Catalunya ( AQuAS ). - PowerPoint PPT PresentationTRANSCRIPT
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Anna Kotzeva, MD, MPHCatalan Agency for Healthcare Quality and AssessmentAgència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS)
ESSENCIAL Project:Appropriateness of care and discontinuation of low-value practices
EFPC 5th Biannual Conference – Barcelona, 1-2 September 2014
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Healthcare Systems
(economic constraints)
Scientific community
(overdiagnosis / overtreatment alerts)
Patients & Citizens
(proactive and informed)
NEED FOR:1) Revision of routine clinical practices 2) Revision of health coverage lists3) Patient empowerment and shared DM
Background
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Different strategies towards reducing waste in healthcare
“do not do” recommendations (NICE, UK) (source: CPGs)
Choosing Wisely (ABIM Foundation&Consumer reports,USA) (source: medical specialty societies)
Choosing Wisely Canada (with the Can Med Association) (source: medical specialty societies)
Quality framework of the Australian Government (source: published evidence + key informants)
Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ 2011; 343: d4519.Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA 2012; 307: 1801-1802.Medical Benefits Reviews Task Group. Development of a quality framework for the Medicare Benefits Schedule. Discussion paper. Canberra: Australian Government Department of Health and Ageing, 2010.
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March 2013: in Catalonia is launched the ESSENCIAL Project
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VISION: ESSENCIAL Project contributes to care quality improvement
and sustainable allocation of healthcare resources in Catalonia
Aims
1. To identify low-value practices and promote their discontinuation through implementation of specific recommendations for the clinical practice
2. To encourage healthcare professionals’ involvement in the identification and in the process of change management within the system.
3. To rise awareness for avoidance of unnecessary and low-value practices in health care
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Engagement of clinicians & patients
Accountability and impact assessment
Sustainability of care
Evidence-based practice
Leading principles
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Methods
Identification of low value practices
Prioritization
and
elaboration of recommendations
Dissemination and
implementation
Impact assessment
1
Participation of health professionals and scientific community
23
4
The process is explicit and transparent, comprising 4 phases:
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Identification and prioritization
ineffective or lack evidence on their effectiveness
negative risk-benefit balance
more cost-effective alternatives exists
obsolete due to the introduction of new technologies
Context-based prioritization (local healthcare system data and policies)
Low-value practices
scientific evidence (CPGs, SRs, HTA reports)
other published low-value lists
nominations from clinical and non-clinical stakeholder groups knowledgeable of the context and the local health system performance
Information sources
Elaboration of recommendations to the clinical practice
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Multichannel communication strategy
Scientific events
Regional meetings
Clinical specialty societies
Social networks
Website
Consumers
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Involvement of the practitioners
Through scientific associations
Collaboration with healthcare centres
Direct suggestions
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Implementation and impact assessment
Dissemination
Incentives and processes
Training and skills
Opinion leaders
Implementation activities are based on Change Management model and include: *tailored communication strategies, *training, *clinical decision support systems, *provider-specific performance measures.
Impact assessment applies quantitative and qualitative methodologies
Involves three main areas:
degree of awareness of the recommendations among target health professionals (surveys)
direct impact on clinical practice, measured by the change in use rates of practices recommended as of “low-value” (database assessment)
budgetary impact attributable to the adoption of the recommendations
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Results
26recommendationsImaging for low-back pain, Pre-operatory Rx in asymptomatic patients, Duration of post-ictus rehabilitation, Imaging for simple headache, Bisphosphonates in post-menopausic women with low fracture risk, Overuse of proton-pump-inhibitors, Routine screening for breast cancer, PSA for prostate cancer screening, Cough-and-cold medications in children, Routine episiotomy, Urinary catheter in patients with stroke, Antibiotics in otitis media, Hospitalization for community-acquired pneumonia, Vitamin D in elderly, ….
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Results
recommendations Radiology: 10
Pediatrics: 6
Cardiology: 3
Neurology: 2
Public Health:4
Pneumology:2
Primary care: 17
Hospital care: 8
Rehabilitation: 1
Oncology: 3
Reumatology:2
Gynecology: 1
Nursing: 1
Surgery: 1
Urology: 1
Screening: 3
Diagnosis: 7
Treatment: 10
Prevention: 3
Follow-up: 2
Rehabilitation:1
26
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Ex 1: Imaging for low back pain
Imaging tests for low back pain during the first 6 weeks should NOT be prescribed, unless red flags are present
• 130.000 PC visits for low back pain• 30% received imaging tests• 700.000 €, corresponding to 280
knee implants
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Ex 2: Bisphosphonates in post-menopausic women with low risk of fracture
In women who have low risk of osteoporotic fractures, the treatment with bisphosphonates presents an unfavourable risk-benefit ratio
5 M€, equivalent to the annual budget of
2 Primary Care Centres
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Ex 3: PSA for prostate screening
Do not prescribe PSA determination as a screening tool for prostate cancer on a population level.
More than 321.090 PSA determinations in Catalan men
≥15 years old, 63% without history of prostate pathology
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Such type of initiatives should provide timely information, but are very time- and resource-consuming.
Multiple sources for identification of low-value practices and good knowledge of the context are needed to ensure the relevance of promoted recommendations.
Total discontinuation is rarely recommended and an accurate definition of the conditions in which the practice is considered as “low-value” needs to be elaborated.
Each recommendation requires a specific communication and implementation strategy.
Conclusions/Lessons learned so far…
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The uptake of recommendations is influenced by various context-related (organization, incentives, available resources) and professional-related (culture and mindset, predisposition towards change) factors.
The patients (knowledge, engagement, expectations) play a key role for the change in prescription models.
The success of the implementation could be improved by a priori identification of potential barriers and facilitators and by reaching broad stakeholder commitment for collaboration.
Conclusions/Lessons learned so far…