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Time for “top down” and systems approaches to drive better value healthcare

Introduction by Croakey: Choosing Wisely Australia launched in 2015 to promote a national dialogue on unnecessary tests, treatments and procedures, and to support people to choose healthcare that is supported by evidence.

Established by NPS MedicineWise in partnership with Australia’s health professional colleges, societies and associations, Choosing Wisely Australia challenges the way we think about healthcare, questioning the notion ‘more is always better’.

Over the past six years, the initiative has been successful in driving grassroots changes to the delivery of healthcare. But many participants at the recent Choosing Wisely Australia National meeting suggested that it is now time to complement this approach with “top down” strategies to address the system wide factors and levers driving the ongoing provision of low value care.

Croakey’s Jennifer Doggett reports on the discussions below, for the Croakey Conference News Service.


Jennifer Doggett writes:

Successful efforts to reduce low value healthcare were profiled at the recent Choosing Wisely Australia National meeting, including a program that has reduced the use of benzodiazepines in older people in Canada.

Other such efforts targeted low-value transfusion practices, while others sought to ensure telehealth consultations were directed to patients who are most likely to benefit from them.

This grassroots approach was described by Choosing Wisely Australia’s Chief Executive Officer, Katherine Burchfield, in her introduction to the event as bringing together health professionals, consumers and services with a common paradigm in order to drive a change in the culture of healthcare.

However, a number of presenters and participants suggested that the effectiveness of this approach was being limited by systemic factors working against addressing low value care.

Dr Wendy Levinson, Chair of Choosing Wisely Canada, referenced a recent article in The New England Journal of Medicine, titled ‘Ten Years of Choosing Wisely to Reduce Low-Value Care’.

The author, Dr Elizabeth Rourke, from Brigham and Women’s Hospital and Harvard Medical School in Boston, argues that the political compromises that have allowed Choosing Wisely to flourish, specifically the lack of an explicit focus on the funding mechanisms of low value care, have also rendered the initiative “toothless.”

“Choosing Wisely has allowed doctors (and medical societies) to look like they are addressing low-value care without actually being forced to make any substantive changes,” she writes.

A system issue

Levinson acknowledged that Choosing Wisely has struggled to demonstrate its impact in the Canadian health system and argued that this was partly due to the limitations of its grassroots approach to reducing low value care.

“Overuse is not just about conversations between clinicians and patients, it’s also a system issue,” she said.

Levinson suggested that the future direction for Choosing Wisely should include both a top down/systems change approach as well as grassroots action.

“The Choosing Wisely lists have been terrific but they are just a first step. Local implementation is also great and creates energy but it is insufficient to demonstrate broader change.

“We need to look at where local action can be scaled up to systems change. There are some cases where we can stop paying for low value services, for example, folate supplementation or routine vitamin D testing.

“Ordering systems for tests should also restrict certain services, such as knee arthroscopy, until specific criteria are met,” she said.

Levinson went on to clarify that Choosing Wisely could not have taken a top down approach initially as this would have been seen by clinicians as an attempt to ration services.

However, she believes that now this initiative has established enough credibility with clinicians to prevent this from occurring.

Dr Wendy Levinson presenting at #ChoosingWisely2022

Role of research

The contribution that research can make to de-implementing low value care at the service and system-wide levels was outlined by Associate Professor Denise O’Connor, from Monash University and Cabrini Health.

O’Connor discussed the findings of three systematic reviews of the models, theories and frameworks on de-implementation of low value care which she said could be used to scale up local initiatives to the system level.

She also emphasised the benefits of scaling up successful grassroots initiatives.

“Even small effects with modest changes at an individual level can have a big impact at the population level,” she said.

Associate Professor Denise O’Connor presenting at #ChoosingWisely2022

The patient journey

Participants in the breakout session, which was a discussion on how to promote alignment with the health system, also commented on the need to address systemic barriers to the de-implementation of low value care.

Dr Fiona van Leeuwen commented on how health system structures and processes can obstruct the delivery of high value care.

“The healthcare system is almost completely unaligned with the patient journey and this bothers me a lot,” she said.

She suggested that one way Choosing Wisely could address this issue is to map the patient journey through all services and treatments, including the private sector.

“Why not follow that patient journey supported by best practice and target all the spots along that journey that are ineffective, inefficient or dangerous?”

van Leeuwen also stressed the need to include the private sector when looking at reducing low value care.

“Don’t forget the patient journey includes the private system – we can’t do Choosing Wisely and ignore the role of private health, in areas like the provision of MRIs [magnetic resonance imaging].”

In the same session, Dr Emma-Leigh Synnott raised the importance of the health funding system in incentivising low value care.

“We are funded to do more under activity based funding. What constitutes good health delivery is not always guided by good clinical care decisions.

“We need to go back to understanding health economics as a driver and get better participatory democracy to empower consumers to help guide clinicians to deliver holistic healthcare,” she said.

Context matters

Professor Rachelle Buchbinder is a rheumatologist and epidemiologist and the author (with orthopaedic surgeon Dr Ian Harris) of the recently published book Hippocrasy, which argues that overdiagnosis and overtreatment are endemic in modern medicine, resulting in patient harms and an inefficient use of resources.

In her keynote address, Buchbinder also stressed the need for a systems-wide approach to reducing low value care. “We’ve done grass roots and now need to do top down as well as a coordinated approach across all levels of the health system,” she said.

Buchbinder argued that not much has changed since the release of this 2015 report from The Grattan Institute, ‘Questionable care: avoiding ineffective treatment’, and suggested that Choosing Wisely should look at broad factors affecting healthcare provision, such as the political context, regulations, financial drivers, and societal cultures.

She made some specific suggestions to address systemic levers:

  • Formal consideration of over-diagnosis and overtreatment in health technology assessments
  • Rapidly de-implement tests and treatment – tougher policy decisions to reduce influence of industry.
  • Introducing conditional funding for new treatments and technologies (which can then be removed if found to be ineffective)
  • Incentivising high value care.

Buchbinder also stressed the importance of increasing consumer involvement in research, adding that it was important to get consumers actively engaged in the research questions and presenting results of work, and not just involving them superficially.

She gave the example of a research project that included a journalist on the research team which she argued helped the research get a platform in the mainstream media.

Professor Rachelle Buchbinder presenting at #ChoosingWisely2022

The road ahead

In her closing address, Burchfield acknowledged that it was taking time for Choosing Wisely to get traction but added that “…we are doing important work with a lot of value and hope and there is lots to come”.

She agreed on the need to look at the whole system, both top down and bottom up, and stressed that this is a journey that will take time.

Burchfield also emphasised that the value of Choosing Wisely comes from being an international and voluntary initiative grounded in grassroots change with the ability to “sit alongside” and connect with systems levers.

“Choosing Wisely has the ability to connect the dots – to look not just at one system, area of care or group of consumers – and to ground our tools and resources in the science of behaviour change,” she said.

Burchfield concluded by stating that Choosing Wisely has great brand momentum and opportunities to do more, including thinking about how to connect top down with bottom up, and identify key national priorities and coordinate action across the country.

Katherine Burchfield presenting at #ChoosingWisely2022

More news

On Twitter check out the discussions: #ChoosingWisely2022

Also follow this Twitter list of participants.

Bookmark this link for the Croakey Conference News Service coverage. Also see our coverage of the 2019 and 2018 conferences.

 

 

 

 

 

 

 

 

 

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