Background
Methods
Study design
Study setting
Study participants & recruitment
Data collection
Data analysis
Findings
Sample characteristics
(n=17) | |||
---|---|---|---|
Location | Ontario | 12 | |
Newfoundland | 3 | ||
Saskatchewan | 1 | ||
Nova Scotia | 1 | ||
Setting | Hospital | 15 | |
Primary Care | 2 | ||
Role in CWC Intervention | Team Lead | 12 | |
Physician Champion | 2 | ||
Team Member | 3 | ||
Low-value
care
| Prescribing | Opioids | 3 |
Antibiotics | 2 | ||
PPIs | 1 | ||
Laboratory testing | 5 | ||
Pre-Operative testing | 2 | ||
Blood transfusions | 2 | ||
Imaging | 1 | ||
Catheter use | 1 |
Key findings
Theme 1: drivers of LVC
Provider factors
I think a lot of the resistance was just related to people having their own style of practice, they’ve been doing [it] a certain way for so many years … probably the strongest resistance to this project was the force of habit. [P10]
…the biggest barrier is culture, that this is the way you’ve practiced for a long time and this is the way that the population is expecting practice. It’s the combination of demand from the population and a system where it’s easier to meet the demand than push back on the demand. [P12]
There was a lot of people who were very resistant as well. So, there’s quite a bit who had got quite defensive and put their backs up. And usually, it was kind of the older physicians that I would say they were kind of set in their ways. [P17]
There was a culture of wanting to be very thorough and doing a lot of testing in order to demonstrate that you were really keeping an eye on things and being expansive in your differential diagnosis. So, there’s that aspect of wanting to impress. [P03]
Patient factors
Theme 2: the magnitude of the problem of LVC
Harm
…although x-rays have low exposure, the dose [of radiation from] a rib x-ray which requires several views of both ribs, definitely is a concern for harm. That’s the main, I would say, patient harm. [P02]
…causing an infection and that infection can spread and it can infect your orthopedic implant and that can be a pretty horrendous complication if that happens. But even short of that, just having a UTI is a problem. Patients can get disseminated sepsis from that. So that’s a big problem and then just delirium as well, from having the catheter, from having a UTI. [P16]
When urine cultures are ordered incorrectly, they [can] lead to antimicrobial overuse… because we’re doing the testing inappropriately, you’re going to get a 15 to 50% positive rate of positive bacteria, which will lead to treatment and that has no benefit. [P02]
There is still a significant portion of patients who overdose on medications like Hydromorphone or prescribed Fentanyl patches or Morphine for that matter. So, that’s still a significant problem. [P04]
…if we start overusing antibiotics the bacteria become resistance, then you’re going to have troubles down the road where people actually need these bacteria antibiotics, and the antibiotics are not going to work. They’re not going to be lifesaving. [P17]
Resources
…you’re using more [blood] products and the products are valuable products [and] are not always available. You’re using more lab time in doing the cross match and the issuing of the units, you are using more nursing time spending the time transfusing the unit. You are using more tubing system because each system has to have tube as well and you’re using the patient’s time, sitting there and receiving the transfusion. Giving an unneeded intervention is a huge waste of resources. [P15]
…it would be more harm in the sense of wasted resources on the system, more than actual patient harm I would say. Because it’s really hard to see, the idea of unnecessary testing is an important one, but because there’s very little patient harm coming from it, it’s hard to sort of make an argument for it. [P11]
…one of our challenges in MRI is we have a wait list. And so those cases should be for indications that require MRI because there’s no other diagnostic. So, we really just don’t want to be using up the time on stuff that’s not going to change management [of care]. [P09]
“We have a very high opioid overdose rate, [x] times the rest of the province and then our hospitalization and emergency department visits were also about [x] times [the] rest of the province. So, these patients, they certainly can take up a lot of resources. These patients go to walk in clinics, the emergency department multiple times a month. They’re admitted for months at a time with infectious complications from injection IV drug use, endocarditis, all these sorts of things. So, even the prevention of one or two of these patients I think has a significant impact to resources of the healthcare system. [P04]
…the cost of doing the test is quite low, maybe it’s about two bucks a test. But the quantity of testing is so high that it translates into a substantial amount of spending. [P11]
Prevalence
So, I would say about three-quarters of them were getting blood work. About two-thirds were getting ECGs and about 25% were getting chest x-rays. And these are numbers that could all essentially go to zero because we’re already talking about the population that doesn’t need them. We’re talking about low-risk patients getting low-risk surgery. [P08]
Unique influences on de-implementation processes
Theme 3: Choosing Wisely as a change influencer
Choosing Wisely was really the catalyst of de-implementation. It was an awareness. It was a lot of education here. [P05]
Theme 4: availability of data
You need to look and analyze what’s driving that change. Sometimes it’s practice. Sometimes it’s a knowledge gap sometimes, it’s an evolution of care that’s happened over time. We’re fortunate in that we can pull data very easily around what volumes are we looking at? Where are those volumes coming from? And then from that you can make some inference about why it may be high in one area versus the other and where can we tackle it? When we look at it, we’re able to not only look at volumes but also the source of those orders. [P06]
I would say this is a system level barrier in general for all quality improvement – data - and being able to track this stuff. It’s really hard… the amount of time that went into getting all that data by this painful chart review because we don’t have it at our fingertips, just because of how the systems are set up…at the end of the day then one of your limitations is the quality of that data … So, having metrics actually available for these things that are important would be a huge benefit and is a barrier always to doing this kind of work. [P16]
Theme 5: lack of targets
…but there’s so many interventions that we overdo that there’s no clear recommendation on what the target should be. So, I think it’s actually more interesting that we didn’t use a target. To show that we were still able to make a reduction without having a true target and that would be maybe more harmful than useful. [P02]
Well, the goals were obviously to reduce the amount of volume of antibiotics or the rate of antibiotics in the province. The issue with that is, we never really had a goal because we couldn’t really identify appropriateness. [P17]
…we didn’t really know what the problem was; there’s no agreed upon number. No one knows what proportions of patients actually need to be seen or what proportion of those patients actually needs a test. Those sorts of targets don’t exist. [P11]
Theme 6: hard-coded intervention strategies
…it was a very sustainable change because it was hardwired into practice and workflow as opposed to sometimes other things where you’re more reliant on people to remember or remain committed. [P06]
…so interestingly and we didn’t realize this, the vast majority of two-unit [blood] transfusions were ordered on admission as a standing order. So, it was not a deliberate choice. At the time of the transfusion, it was a pre-standing order that the physician had just entered and left there. [P03]