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Unter Low Value Care werden Leistungen verstanden, die im individuellen Kontext (a) den Patienten wenig oder keinen Nutzen bringen, (b) potenziell Schaden verursachen, (c) unnötige Kosten verursachen und/oder (d) im Vergleich zur Anwendung alternativer Leistungen bzw. der Anwendung bei einer alternativen Patientengruppe die knappen Ressourcen des Gesundheitswesens nicht nutzenorientiert eingesetzt werden. Die systematische Identifikation und Quantifizierung von Low Value Care ist herausfordernd. Abrechnungsdaten wurden hierzu bisher nicht genutzt. Die vorliegende Studie setzt sich zum Ziel, Teile des Versorgungspfads zweier exemplarischer Leistungsbereiche auf Low Value Care mithilfe von anonymisierten Versichertendaten zu untersuchen. Aufgrund ihrer Bedeutung für das Gesundheitswesen und den Leidensdruck der Patienten wurden zwei chronische Krankheiten gewählt: chronisch-obstruktive Lungenerkrankung (COPD) und die koronare Herzkrankheit (KHK). Bei COPD wurde die Medikamentenadhärenz der Patienten untersucht und festgestellt, dass eine regelgemässe Einnahme der Medikamente das Risiko einer Exazerbation inkl. Hospitalisierung um mehr als 50% senken kann. Bei KHK hat sich gezeigt, dass zur initialen Diagnostik ein weit grösserer Anteil an Patienten zuerst eine Koronar-CT anstelle einer invasiven Koronarangiografie (Herzkatheteruntersuchung) mit gleichem Diagnoseergebnis erhalten könnte. Hierdurch könnten ca. CHF 4.5 bis 5.5 Mio. pro Jahr für die Groupe Mutuel Versicherten eingespart werden. Aus den Ergebnissen der Studie lässt sich ableiten: (1) Low Value Care kann anhand von anonymisierten Abrechnungsdaten identifiziert und quantifiziert werden, (2) Low Value Care bei COPD könnte durch strukturierte Behandlungsprogramme und digitale Gesundheitsanwendungen verringert werden und (3) qualitätsorientierte Vergütungsanreize könnten bewirken, dass knappe Ressourcen zielgerichtet und effizient eingesetzt werden. Darüber hinaus hat sich gezeigt, dass eine umfangreichere Datenbasis, insb. Diagnoseinformationen, die Möglichkeiten und Ausssagecraftder Analysen substanziell verstärken würde.

Unter Low Value Care werden Leistungen verstanden, die im individuellen Kontext (a) den Patienten wenig oder keinen Nutzen bringen, (b) potenziell Schaden verursachen, (c) unnötige Kosten verursachen und/oder (d) im Vergleich zur Anwendung alternativer Leistungen bzw. der Anwendung bei einer alternativen Patientengruppe die knappen Ressourcen des Gesundheitswesens nicht nutzenorientiert eingesetzt werden. Die systematische Identifikation und Quantifizierung von Low Value Care ist herausfordernd. Abrechnungsdaten wurden hierzu bisher nicht genutzt. Die vorliegende Studie setzt sich zum Ziel, Teile des Versorgungspfads zweier exemplarischer Leistungsbereiche auf Low Value Care mithilfe von anonymisierten Versichertendaten zu untersuchen. Aufgrund ihrer Bedeutung für das Gesundheitswesen und den Leidensdruck der Patienten wurden zwei chronische Krankheiten gewählt: chronisch-obstruktive Lungenerkrankung (COPD) und die koronare Herzkrankheit (KHK). Bei COPD wurde die Medikamentenadhärenz der Patienten untersucht und festgestellt, dass eine regelgemässe Einnahme der Medikamente das Risiko einer Exazerbation inkl. Hospitalisierung um mehr als 50% senken kann. Bei KHK hat sich gezeigt, dass zur initialen Diagnostik ein weit grösserer Anteil an Patienten zuerst eine KoronarCT anstelle einer invasiven Koronarangiografie (Herzkatheteruntersuchung) mit gleichem Diagnoseergebnis erhalten könnte. Hierdurch könnten ca. CHF 4.5 bis 5.5 Mio. pro Jahr für die Groupe Mutuel Versicherten eingespart werden. Aus den Ergebnissen der Studie lässt sich ableiten: (1) Low Value Care kann anhand von anonymisierten Abrechnungsdaten identifiziert und quantifiziert werden, (2) Low Value Care bei COPD könnte durch strukturierte Behandlungsprogramme und digitale Gesundheitsanwendungen verringert werden und (3) qualitätsorientierte Vergütungsanreize könnten bewirken, dass knappe Ressourcen zielgerichtet und effizient eingesetzt werden. Darüber hinaus hat sich gezeigt, dass eine umfangreichere Datenbasis, insb. Diagnoseinformationen, die Möglichkeiten und Aussagekraft der Analysen substanziell verstärken würde.

This study systematically maps empirical research on physicians' views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English-language publications in health, legal and multi-disciplinary databases. The extraction frame-work covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions.79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investiga-tion. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels.Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care.(c) 2021 Elsevier B.V. All rights reserved.

In 2018 heeft Leading the Change het Talma Instituut verzocht een programmatische aanpak te ontwikkelen om zorgprofessionals te faciliteren bij de implementatie van zorgevaluaties op basis van een vooronderzoek. Uitgangspunten daarbij waren het versterken van de leercultuur en het verminderen van drempels voor implementatie. Op basis van een vooronderzoek omvat de voorgestelde aanpak versnelling implementatie door: (1) Ontwikkelen van spiegelinformatie op basis van bestaande, lande¬lijke datasets (EPD en declaratie data), zodat zorgprofessionals inzichtelijk krijgen hoe ze zich gedragen ten opzichte van anderen, een prikkel krijgen om hun gedrag waar nodig aan te passen, en voortgang van implementatie kunnen inzien; (2) Systematische analyse van (financiële) impact door verandering van gangbare behandeling voor patiënt, professional en zorgverlener, zodat eventuele drempels voor implementatie transparant worden en kunnen worden geadresseerd; (3) Formuleren van escalatiemogelijkheden die bijdragen aan de implementatie van zorgevaluaties, met aangrijpingspunten in de verschillende fasen vanaf het opstellen van een ken¬nisagenda voor nader onderzoek tot en met een aanpassing van de vergoeding van zorg. In het rapport zijn de resultaten samengevat. In deze rapportage is per onderdeel in detail doel, aanpak, resultaten en toepassingsmogelijkheden uitgewerkt. De rapportage bevat verwijzingen naar deelrapportages die gedurende het project zijn opgesteld.

In 2018 heeft Leading the Change het Talma Instituut verzocht een programmatische aanpak te ontwikkelen om zorgprofessionals te faciliteren bij de implementatie van zorgevaluaties op basis van een vooronderzoek. Uitgangspunten daarbij waren het versterken van de leercultuur en het verminderen van drempels voor implementatie. Op basis van een vooronderzoek omvat de voorgestelde aanpak versnelling implementatie door: (1) Ontwikkelen van spiegelinformatie op basis van bestaande, lande¬lijke datasets (EPD en declaratie data), zodat zorgprofessionals inzichtelijk krijgen hoe ze zich gedragen ten opzichte van anderen, een prikkel krijgen om hun gedrag waar nodig aan te passen, en voortgang van implementatie kunnen inzien; (2) Systematische analyse van (financiële) impact door verandering van gangbare behandeling voor patiënt, professional en zorgverlener, zodat eventuele drempels voor implementatie transparant worden en kunnen worden geadresseerd; (3) Formuleren van escalatiemogelijkheden die bijdragen aan de implementatie van zorgevaluaties, met aangrijpingspunten in de verschillende fasen vanaf het opstellen van een ken¬nisagenda voor nader onderzoek tot en met een aanpassing van de vergoeding van zorg. In het rapport zijn de resultaten samengevat. In deze rapportage is per onderdeel in detail doel, aanpak, resultaten en toepassingsmogelijkheden uitgewerkt. De rapportage bevat verwijzingen naar deelrapportages die gedurende het project zijn opgesteld.

In 2018 heeft Leading the Change het Talma Instituut verzocht een programmatische aanpak te ontwikkelen om zorgprofessionals te faciliteren bij de implementatie van zorgevaluaties op basis van een vooronderzoek. Uitgangspunten daarbij waren het versterken van de leercultuur en het verminderen van drempels voor implementatie. Op basis van een vooronderzoek omvat de voorgestelde aanpak versnelling implementatie door: (1) Ontwikkelen van spiegelinformatie op basis van bestaande, lande¬lijke datasets (EPD en declaratie data), zodat zorgprofessionals inzichtelijk krijgen hoe ze zich gedragen ten opzichte van anderen, een prikkel krijgen om hun gedrag waar nodig aan te passen, en voortgang van implementatie kunnen inzien; (2) Systematische analyse van (financiële) impact door verandering van gangbare behandeling voor patiënt, professional en zorgverlener, zodat eventuele drempels voor implementatie transparant worden en kunnen worden geadresseerd; (3) Formuleren van escalatiemogelijkheden die bijdragen aan de implementatie van zorgevaluaties, met aangrijpingspunten in de verschillende fasen vanaf het opstellen van een ken¬nisagenda voor nader onderzoek tot en met een aanpassing van de vergoeding van zorg. In het rapport zijn de resultaten samengevat. In deze rapportage is per onderdeel in detail doel, aanpak, resultaten en toepassingsmogelijkheden uitgewerkt. De rapportage bevat verwijzingen naar deelrapportages die gedurende het project zijn opgesteld.

In 2018 heeft Leading the Change het Talma Instituut verzocht een programmatische aanpak te ontwikkelen om zorgprofessionals te faciliteren bij de implementatie van zorgevaluaties op basis van een vooronderzoek. Uitgangspunten daarbij waren het versterken van de leercultuur en het verminderen van drempels voor implementatie. Op basis van een vooronderzoek omvat de voorgestelde aanpak versnelling implementatie door: (1) Ontwikkelen van spiegelinformatie op basis van bestaande, lande¬lijke datasets (EPD en declaratie data), zodat zorgprofessionals inzichtelijk krijgen hoe ze zich gedragen ten opzichte van anderen, een prikkel krijgen om hun gedrag waar nodig aan te passen, en voortgang van implementatie kunnen inzien; (2) Systematische analyse van (financiële) impact door verandering van gangbare behandeling voor patiënt, professional en zorgverlener, zodat eventuele drempels voor implementatie transparant worden en kunnen worden geadresseerd; (3) Formuleren van escalatiemogelijkheden die bijdragen aan de implementatie van zorgevaluaties, met aangrijpingspunten in de verschillende fasen vanaf het opstellen van een ken¬nisagenda voor nader onderzoek tot en met een aanpassing van de vergoeding van zorg. In het rapport zijn de resultaten samengevat. In deze rapportage is per onderdeel in detail doel, aanpak, resultaten en toepassingsmogelijkheden uitgewerkt. De rapportage bevat verwijzingen naar deelrapportages die gedurende het project zijn opgesteld.

Background Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour. Methods A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change. Results All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences. Conclusions The findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care.

Background: The outbreak of the COVID-19 pandemic led to a decrease in primary health care in-person visits and a simultaneous increase in virtual encounters. Objective: To quantify the change in the total volume of primary care visits and mix of visit types during the two years of the pandemic in Israel. Design: Cross-sectional study. Participants: All primary care visits by members of the largest healthcare organization in Israel, during three one-year periods: the pre-COVID-19 year (March 2019–February 2020), the first year of COVID-19 (March 2020–February 2021), and the second year of COVID-19 (March 2021–February 2022). Main measures: Total volume of primary care visits and mix of visit types. Results: More than 112 million primary care visits were included in the study. The total visit rate per 1000 members did not change significantly between the pre-COVID year (19) and the first COVID year (19.8), but was 21% higher in the second COVID-19 year (23). The rate of in-person visits per 1000 members decreased from 12.0 in the pre-COVID year to 7.7 in the first COVID year and then increased to 9.6 in the second. The rate of phone visits and asynchronous communication increased from 0.7 and 6.3, respectively, in the pre-COVID year, to 4.1 and 8, respectively, in the first COVID year, and remained unchanged in the second. There was substantial variation across age groups and sectors in the adoption of virtual platforms. Conclusions: The rapid introduction of virtual encounters in primary care tended to displace in-person visits in the first year of the pandemic, but they appear to have been additive in the second. This transition should be monitored, with the goal of ensuring appropriate planning efforts and resource allocation to deal with the potential added burden on medical staff. Efforts should be invested in encouraging the use of virtual platforms in patient groups that currently underutilize it, such as minorities.

This study systematically maps empirical research on physicians' views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English-language publications in health, legal and multi-disciplinary databases. The extraction frame-work covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions. 79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investiga-tion. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels. Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care. (c) 2021 Elsevier B.V. All rights reserved.

Background The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder. Methods The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost–benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS. Results The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed. Conclusions The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program’s messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.

This thesis described the stepwise development and execution of a de-implementation strategy to reduce the use of the low-value blood salvage techniques and preoperative treatment with erythropoietin in primary elective hip and knee arthroplasty. The implementation model of Grol was used to develop de-implementation goals, to identify barriers that hinder de-implementation, to develop a de-implementation strategy and to execute and evaluate the developed de-implementation strategy. The intention of de-implementing low-value patient blood-management techniques was to reduce costs and improve the quality of healthcare. However, this thesis showed that a tailored de-implementation strategy is not necessarily successful. When evaluating the effects we found that in the group of hospitals that were exposed to the de-implementation strategy the reduction in blood salvage techniques and erythropoietin was comparable to the control group hospitals. We did found that the reduction in blood salvage techniques was associated with the increased use of local analgesic infiltration and the use of tranexamic acid, an antifibrinolytic drug to prevent excessive blood loss. We found that the substitution of low-value care might contribute to de-implementation of this low-value care. In future de-implementation efforts this can be used to improve the results.

Background: Calciferol (vitamin D) is an essential nutrient that can be synthesized in the skin upon exposure to ultraviolet-B (UVB) light, or obtained through dietary and supplement sources. Traditionally known for its role in bone metabolism, vitamin D is currently described as a pleiotropic hormone with genomic and non-genomic roles in most body tissues. Clinical practice guidelines related to vitamin D are inconsistent and controversial. The purpose of this dissertation was to describe current patterns of vitamin D-related clinical care in a variety of settings, and to evaluate the impact of vitamin D supplements on the health and performance of collegiate athletes, a group with high prevalence of low vitamin D (LVD). Methods: This dissertation consists of five studies: 1) a scoping review of the health services literature related to clinical management of vitamin D; 2) a retrospective analysis of clinical care following non-indicated vitamin D testing using electronic health record (EHR) data from a regional health system; 3) a survey study to assess vitamin D-related practices among National Collegiate Athletic Association (NCAA) Division I programs; 4) an open clinical trial to evaluate the efficacy of a specific vitamin D supplement protocol in treating collegiate basketball athletes with LVD; and 5) a randomized, double-blind clinical trial to determine health and performance effects of vitamin D supplements in collegiate swimmers participating in fall season training. Results: Substantial inconsistency in vitamin D-related care was observed throughout the first three studies. Exponential increases in vitamin D testing and treatment, and associated costs, were identified in the U.S. and several other countries. A high proportion of this care was considered non-indicated (i.e., counter to professional guidelines). A lower rate of non-indicated vitamin D-related services was conducted within the health system we studied, but a cascade of low value services followed non-indicated vitamin D testing. Vitamin D testing was regularly performed by more than 65% of NCAA programs. In basketball athletes, 10 weeks of daily vitamin D3 supplements (5000 or 10,000 IU based on initial vitamin D status) improved serum 25-hydroxyvitamin D [25(OH)D], the common biomarker of vitamin D status. In swimmers, a vitamin D supplement protocol (5,000 IU vitamin D3 daily for 12 weeks) was efficacious in attenuating a seasonal decline in 25(OH)D compared with placebo. Swimmers taking vitamin D supplements also showed greater improvements in strength, power, and fat free mass. In both athlete studies, taking vitamin D supplements was associated with higher free testosterone concentration. Conclusions: The provision of evidence-based care related to vitamin D is complicated by contradictory clinical practice guidelines, resulting in inconsistent and sometimes, non-indicated care. Focused research on specific populations at high-risk for LVD can inform best practices. Our results suggest that taking vitamin D supplements is an efficacious strategy for athletes to improve 25(OH)D, especially when UVB exposure is low, and to enhance strength and power in collegiate swimmers. Ph.D. Vitamin D is known as the “sunshine vitamin” since it can be synthesized by the human body when exposed to specific wavelengths of ultraviolet-B (UVB) light. Some foods and dietary supplements also contain vitamin D. A relationship between vitamin D and bone health is well-established, but emerging research has also associated vitamin D status with a number of different diseases and health problems, including cancer, cardiovascular disease, autoimmune conditions, and depression. Unfortunately, this research is currently inconclusive, and healthcare providers’ professional guidelines related to vitamin D are highly variable. Thus, providing evidence-based care related to vitamin D is complicated. This dissertation consists of a series of three research studies that describe healthcare providers’ vitamin D-related care considering the uncertain landscape, and two research studies that explore the role of vitamin D in collegiate athletes. We chose athletes since a high proportion of them have deficient or insufficient vitamin D status, and because some research has shown that this low vitamin D status affects athletic performance. Results of these studies showed that vitamin D-related health services such as blood testing have increased dramatically over the past 15 years, as have costs associated with these services. Opportunities to improve consistency and quality of care were observed in multiple settings. In the athlete studies, a high rate of vitamin D deficiency and insufficiency was observed among basketball athletes, and we identified vitamin D supplement treatment protocol effective in improving vitamin D status. In addition, swimmers who took vitamin D supplements performed better on strength and conditioning tests than those who took placebo supplements. A favorable relationship between testosterone concentrations and vitamin D status was shown in both basketball athletes and swimmers. Continuing to conduct research focused on specific populations can help healthcare providers develop consistent, high quality, evidence-based care related to vitamin D.

Background Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial. Methods/design This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies. Discussion Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring. Trial registration ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.

Background: Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR). Methods: An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC). Results: The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] “do not do” recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely “Top 5” lists) were identified. Using appropriate coding systems for BC’s administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment. Conclusions: This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level.

The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies do not recommend population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. To assess patterns of physicians’ management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and the gray literature. Thirty-eight records met inclusion criteria and were summarized in an evidence table. Thirteen studies published between 2006 and 2015 across seven countries showed a consistent increase in vitamin D lab tests and related costs. Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term. Variability and controversy were pervasive in many aspects of vitamin D management, shining a light on physicians’ practices in the face of uncertainty. Future research is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations. Published version

The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies do not recommend population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. To assess patterns of physicians’ management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and the gray literature. Thirty-eight records met inclusion criteria and were summarized in an evidence table. Thirteen studies published between 2006 and 2015 across seven countries showed a consistent increase in vitamin D lab tests and related costs. Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term. Variability and controversy were pervasive in many aspects of vitamin D management, shining a light on physicians’ practices in the face of uncertainty. Future research is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations.

Health services overuse has been acknowledged as a relevant policy issue. In this study, we assessed the informative value of research on the quality of cancer care, exploring to what extent it is actually concerned with care overuse, thus providing policy-makers with sound estimates of overuse prevalence. We searched Medline for European studies, reporting information on the rate of use of diagnostic or therapeutic procedures/interventions in breast, colorectal, lung and prostate cancer patients, published in English between 2006 and 2016. Individual studies were classified with regards to their orientation towards overuse according to the quality metrics adopted in assessing rates of use of procedures and interventions. Out of 1882 papers identified, 100 accounting for 94 studies met our eligibility criteria, most of them on breast (n = 38) and colorectal (n = 30) cancer. Of these, 46 (49%) studies relied on process indicators allowing a direct measure of under- or overuse, the latter being addressed in 22 (24%) studies. Search for overuse in patterns of care did not increase over time, with overuse being measured in 24% of the studies published before 2010, and in only 13% of those published in 2015–2016. Information on its prevalence was available only for a relatively limited number of procedures/interventions. Overall, estimates of overuse tended to be higher for diagnostic procedures (median prevalence across all studies, 24%) than for drugs, surgical procedures or radiotherapy (median overuse prevalence always lower than 10%). Despite its increasing policy relevance, overuse is still an often overlooked issue in current European research on the quality of care for cancer patients. Electronic supplementary material The online version of this article (10.1186/s12961-018-0287-z) contains supplementary material, which is available to authorized users.

"Less is more" in medicine is an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health. It is indeed necessary to eliminate unnecessary and costly practices by streamlining care without rationing. However, several barriers and challenges for the implementation of less is more medicine have been identified in Switzerland, where overuse is rooted in our culture and demanded by a society that requests certainty at almost any cost. Patients' high expectations, physician behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement less is more recommendations. These include financial incentives, patient education, physician behavior change with data feedback, communication training and systems interventions. A quality-oriented approach can be an intellectual challenge but also a real opportunity to promote sustainable medicine.