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Anna Kotzeva , MD, MPH Catalan Agency for Healthcare Quality and Assessment

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 ).

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Anna Kotzeva , MD, MPH Catalan Agency for Healthcare Quality and Assessment

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  1. 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) EFPC 5th BiannualConference – Barcelona, 1-2 September 2014

  2. Background Scientific community (overdiagnosis / overtreatment alerts) Healthcare Systems (economic constraints) NEED FOR: 1) Revision of routine clinical practices 2) Revision of health coverage lists 3) Patient empowerment and shared DM Patients & Citizens (proactive and informed)

  3. Different strategies towards reducing waste in healthcare • “do not do” recommendations (NICE, UK) • (source: CPGs) • Choosing Wisely (ABIM Foundation&Consumerreports,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.

  4. March 2013: in Catalonia is launched the ESSENCIAL Project

  5. Aims • To identify low-value practices and promote their discontinuation through implementation of specific recommendations for the clinical practice • To encourage healthcare professionals’ involvement in the identification and in the process of change management within the system. • To rise awareness for avoidance of unnecessary and low-value practices in health care VISION: ESSENCIAL Project contributes to care quality improvement and sustainable allocation of healthcare resources in Catalonia

  6. Leading principles Evidence-based practice Engagement of clinicians & patients Sustainability of care Accountability and impact assessment

  7. Methods The process is explicit and transparent, comprising 4 phases: 1 Identification of low value practices 2 Prioritization and elaboration of recommendations 3 Dissemination and implementation 4 Impact assessment Participation of health professionals and scientific community

  8. Identification and prioritization Low-value practices Information sources • ineffective or lack evidence on their effectiveness • negative risk-benefit balance • more cost-effective alternatives exists • obsolete due to the introduction of new technologies • 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 • Context-based prioritization • (local healthcare system data and policies) • Elaboration of recommendations to the clinical practice

  9. Multichannel communication strategy Website Scientific events Social networks Consumers Regional meetings Clinical specialty societies

  10. Involvement of the practitioners • Through scientific associations • Collaboration with healthcare centres • Direct suggestions

  11. Implementation and impact assessment • Implementation activities are based on Change Management model and include: *tailored communication strategies, *training, *clinical decision support systems, *provider-specific performance measures. Dissemination Opinion leaders • 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 Incentives and processes Training and skills

  12. Results 26 recommendations Imaging 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, ….

  13. Results 26 recommendations • 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 • Radiology: 10 • Pediatrics: 6 • Cardiology: 3 • Neurology: 2 • Public Health:4 • Pneumology:2 • Primary care: 17 • Hospital care: 8 • Rehabilitation: 1

  14. 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

  15. 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

  16. 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

  17. Conclusions/Lessons learned so far… • 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.

  18. Conclusions/Lessons learned so far… • 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.

  19. Thank you! akotzeva@gencat.cat http://essencialsalut.gencat.cat

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