There is growing interest in identifying overuse - care that exposes patients to services that are not beneficial or may cause harm and which may take scarce resources away from those who would benefit from them. A more focused target is promoting de-intensification when good quality practice calls for decreasing the intensity or frequency of medical services that are part of a patient's ongoing management. Increasingly, we recognize that care is too frequent or too intensive in cases where the marginal benefit is absent or there is potential for harm. Identifying, measuring, and facilitating appropriate de-intensification to complement the many measures promoting appropriate intensification is critical to restoring balance to our efforts to improve care quality.
1. To identify and validate clinical indications for de-intensification in primary care;
2. To assess prevalence and reliability of measures of de-intensification in VA;
3. To develop multi-component strategies to disseminate and implement de-intensification measures
To achieve Aim 1, clinical indications for de-intensification in primary care will be obtained using the following two approaches: 1) an environmental scan (i.e., review) of current recommendations/ guidelines to identify those that pertain to de-intensification; 2) a solicitation of candidate de-intensification indications from healthcare experts. Following the above, a rapid evidence synthesis (RES) of existing evidence supporting candidate de-intensification indications will be performed for prioritized indications. Concurrent with the RES, analyses will be initiated to estimate the opportunity for de-intensification in VA. Two expert panels, following a modified Delphi panel protocol, will then rate each of the potential indications on validity, improvement opportunity, and feasibility of implementation.
Approximately 14-18 measures of de-intensification, rated highly in Aim 1, will be constructed in Aim 2 using existing automated data sources and/or data from a medical record review. Analyses will be conducted to examine prevalence, variance, and reliability of measuring de-intensification in VA.
Providers and patients will be engaged in deliberation and design thinking sessions, in Aim 3, to develop strategies for disseminating and implementing the identified de-intensification measures.
Project investigators: 1) reviewed current, high-quality recommendations identified by staff as primary-care related, routine-based, and de-intensification focused; 2) selected over 400 that were likely valid, feasible to measure, and important in VA; 3) grouped similar recommendations, yielding 150 primary recommendations; and 4) collaboratively prioritized 46 for review by the project's Advisory Council. The Council subsequently prioritized the recommendations. Investigators drafted a proposed de-intensification measure for those that were prioritized; 26 were then validated by expert panels. As result of the panels, and with input from our Advisory Council, we selected 14 for measure development.
This will be the first study to explicitly identify, validate, and measure indications for de-intensification of medical services in primary care; thus, adding balance to existing incentives and norms to always do more. A more balanced approach will improve quality of care for Veterans by decreasing unnecessary and potentially harmful care while maintaining incentives to extend evidence-based treatments to those who will benefit. This is even more important now as we move toward a community care model for Veterans' care.
- Kerr EA, Klamerus ML, Markovitz AA, Sussman JB, Bernstein SJ, Caverly TJ, Chou R, Min L, Saini SD, Lohman SE, Skurla SE, Goodrich DE, Froehlich W, Hofer TP. Identifying Recommendations for Stopping or Scaling Back Unnecessary Routine Services in Primary Care. JAMA internal medicine. 2020 Sep 14.
- Aubert CE, Kerr EA, Maratt JK, Klamerus ML, Hofer TP. Outcome Measures for Interventions to Reduce Inappropriate Chronic Drugs: A Narrative Review. Journal of the American Geriatrics Society. 2020 Oct 1; 68(10):2390-2398.
- Klamerus ML, Damschroder LJ, Sparks JB, Skurla SE, Kerr EA, Hofer TP, Caverly TJ. Developing Strategies to Reduce Unnecessary Services in Primary Care: Protocol for User-Centered Design Charrettes. JMIR research protocols. 2019 Nov 26; 8(11):e15618.
- Markovitz AA, Hofer TP, Froehlich W, Lohman SE, Caverly TJ, Sussman JB, Kerr EA. An Examination of Deintensification Recommendations in Clinical Practice Guidelines: Stepping Up or Scaling Back? JAMA internal medicine. 2018 Mar 1; 178(3):414-416.
- Kerr EA, Kullgren JT, Saini SD. Choosing Wisely: How To Fulfill The Promise In The Next 5 Years. Health affairs (Project Hope). 2017 Nov 1; 36(11):2012-2018.
- Kerr EA, Hofer TP. Deintensification of Routine Medical Services: The Next Frontier for Improving Care Quality. JAMA internal medicine. 2016 Jul 1; 176(7):978-80.
Treatment - Implementation, Technology Development and Assessment
Clinical Performance Measures, Guideline Development and Implementation, Implementation, Quality Indicators