Project Identifies and Validates Recommendations to Stop or Scale Back Unnecessary Routine Services in Primary Care
BACKGROUND:
The increased attention to the overuse of healthcare services, such as through the initiation of the Choosing Wisely campaign, has highlighted the need to avoid unnecessary one-time diagnostic procedures or treatments at the beginning of discrete episodes of care (e.g., avoiding imaging of low back pain). However, much of healthcare involves routine or continuing use of medical services for chronic conditions or prevention, and guidelines continue to focus on intensification instead of deintensification. Investigators in this study conducted a focused review of existing guidelines and recommendations – concentrating primarily on those published between 2011 and 2016 – to identify potential deintensification recommendations related to routine primary care. Investigators reconfigured about 50 high-priority recommendations by explicitly defining and specifying the deintensification action and appropriate target population. Two virtual multi-disciplinary panels were convened, involving 25 physicians from VA and U.S. academic institutions with expertise in relevant clinical areas, to review the evidence and assess the validity of the recommendations.
FINDINGS:
- Starting from a set of 86 guidelines, Choosing Wisely recommendations, and National Quality Forum measures, investigators identified 409 recommendations – corresponding to 178 unique indications – that represented opportunities to stop or scale back routine services in primary care.
- After prioritization, specification, and expert panel revisions, the panel rated 37 of 44 deintensification recommendations as valid – and 32 of 44 as both valid and an important improvement opportunity (i.e., likely to affect many patients or substantially impact a smaller number of patients).
IMPLICATIONS:
- This study builds on previous guidelines and lists of recommendations by making explicit when and for whom ongoing medical services should be stopped or scaled back. The approach used in this study in the first to systematically identify, specify, and validate actionable and measurable recommendations for deintensification in routine primary care. Next steps should include assessing how often we fail to de-intensify when indicated, tracking intended and unintended outcomes of deintensification efforts, developing patient-centered and policy solutions for deintensification, and testing and evaluating theory-based approaches for change.
LIMITATIONS:
- There was no patient representation on the expert panel, and the recommendations did not focus on the process of patient decision-making. However, subsequent panels of patients and frontline clinicians reviewed select recommendations and recommended implementation approaches.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 15-131: Kerr and Hofer, PIs). Drs. Kerr and Hofer are part of HSR&D’s Center for Clinical Management Research (CCMR) in Ann Arbor, MI.
Kerr E, Klamerus M, Markovitz A, et al. Identifying Recommendations for Stopping or Scaling Back Unnecessary Routine Services in Primary Care. JAMA Internal Medicine. September 14, 2020; Epub ahead of print.
