Identification and de‐implementation of low‐value emergency care

Value-based healthcare prioritises evidence-based practices that are effective, efficient, equitable, and beneficial for patients.1 Unscientific, ineffective, inefficient and inequitable care has little value and harms patients.2 Low-value care, encompassing tests, treatments, procedures, referrals, admissions, discharges, and retrievals, constitutes up to 30% of emergency care.3 Prevalence of low-value care may vary between settings (urban/regional/rural/remote) because value is context-dependent. Despite de-implementation endeavours over the past decade, low-value care persists in emergency medicine practice.3 Identification of targets and drivers of low-value emergency care is essential before pursuing de-implementation.4 This article discusses strategies for identification and de-implementation of low-value emergency care. Identifying low-value care targets for de-implementation requires clinician engagement. This can be encouraged by framing low-value care as a patient safety issue with the potential for physical, psychological, social and financial harm.5 Clinician engagement enables a consensus definition of low-value care within a specific context, which is a prerequisite for identification, and informs evidence-based selection of low-value emergency care targets.3, 6 Targets must be prioritised for de-implementation based on local factors such as prevalence and available resources.4 For example, an initiative to de-implement low value care in infant bronchiolitis could begin with identification of elements of care considered low value, including use of adrenaline, beta-2 agonists, glucocorticoids, antibiotics, or routine chest X-rays and viral testing, in comparison to best available evidence: the Australian Bronchiolitis Guideline. Local data on prevalence of each of these interventions would then allow prioritisation of low-value care targets and inform allocation of resources for de-implementation. Drivers of low-value care include efficiency, resources, culture, complexity, consequences, and abilities. The pursuit of efficiency in an overcrowded, access-blocked, understaffed environment with limited space for patient assessment is a key driver of low-value emergency care. Performance of ‘routine’, ‘baseline’ or ‘just-in-case’ diagnostic tests not guided by thorough patient assessment and shared decision making contributes to low-value care. Complexity of decision-making in the diagnostically uncertain and cognitively overloaded ED setting increases the probability of low-value care. Fear of negative consequences (missed pathology, complaint, lawsuit, reputational damage), patient expectations, and clinician inexperience are other drivers of low-value emergency care (unpublished data). De-implementation of low-value care requires emergency clinician behavioural change, which can be achieved by empowering clinicians to deftly navigate the drivers of low-value care. Navigation is a process of overcoming the drivers through de-implementation strategies. Adequate patient assessment is essential for patient-centred decision-making about value-based care. Ongoing advocacy for adoption of evidence-based solutions to access block can help overcome the environmental drivers of low-value care (efficiency, complexity) by facilitating adequate patient assessment. Appropriate patient assessment yields a pre-test probability that enhances the value of diagnostic tests.7 For instance, thorough assessment of patients with chest pain can guide judicious selection of one or more (or none) of the following diagnostic tests: ECG, troponin, D-dimer, CXR, CT Pulmonary Angiography, CT Aortogram. Challenging the perceived efficiency and highlighting the patient harm of low-value care could be powerful enablers of de-implementation. Education and training in the selection of the right diagnostic tests for the right patient at the right time (diagnostic stewardship) can nurture value-based diagnostic testing skills.6 Training in uncertainty tolerance can empower emergency clinicians to accept uncertainty as the norm, rather than the exception. Evidence-based diagnostic test guidelines can support inexperienced clinicians to embrace value-based care. Role modelling by senior clinicians can inspire trainees to develop skills in value-based decision making. Kind leadership can support EDs to manage the complex challenges of de-implementation and transition to a value-based care culture. Poor clinician-patient communication and absence of patient-centred decision making contribute to low-value care.8 Effective communication and informed choice, rather than defensive practice, could therefore enable better emergency clinician-patient partnerships and promote value-based care.9 Strategies described above need to be operationalised through de-implementation interventions. Effective interventions involve one or more of the following components: stakeholder engagement, nudge, audit/feedback, education, training and clinical champions (Table 1).10 Multicomponent interventions are more likely to be effective than single component interventions.10 The design and delivery of individual components, rather than the number of components, determines the effectiveness of multicomponent interventions.10 Interventions need careful calibration to the low-value care target of interest to manage the perceived risk/benefit ratio of de-implementation.10 For instance, de-implementation of low-value urine cultures is likely to be perceived to have lower risk than de-implementation of low-value CT Pulmonary Angiograms. Other approaches to maximise the chances of successful de-implementation include use of behavioural change theories, co-design with key stakeholders, adequate resources, integration into workflow and organisational leadership support.10 Value-based emergency care augments patient safety. Clinician and community engagement is critical to de-implement low-value care in emergency medicine practice. While multicomponent de-implementation interventions informed by theory are most effective, the most important thing is to start. Talk to your colleagues and identify a low-value care target. Use evidence to develop an intervention, but keep the local context in mind and adapt your strategy accordingly.