14 June 2018

Eva Verkerk, Marit Tanke and colleagues identified three types of unnecessary care that can help in selecting the best strategy to reduce it.

Although we strive for high-quality and valuable care, caregivers regularly provide low-value care: care without benefit for the patient. The concept of low-value care is broad and includes routine transthoracic echocardiograms for patients without symptoms, chronic use of benzodiazepines and curative treatment for patients that prefer palliative care.
Reducing low-value care makes healthcare safer for less costs, but stopping with care is hard. There is not one solution that works for all low-value care practices and contexts. Researchers of the Dutch national program ‘To do or not to do’ (www.doenoflaten.nl) identified three types of low-value care that can help in selecting the best strategy to reduce it.
The type ineffective care is medically ineffective. Inefficient care is medically effective, but is of low-value through inefficient provision or inappropriate intensity. Unwanted care is also medically appropriate for the condition it targets, but is of low-value since it does not fit the patients’ preferences. An example to illustrate this is the use of an MRI scan for a patient with a lumbal hernia. The MRI scan can be of low-value because the scan is not indicated (ineffective), because it had already been done at another hospital (inefficient), or because the patient prefers physiotherapy over an operation (unwanted).
The researchers discuss that these three types require different approaches to reduce. Ineffective care can be clearly defined, which enables automatic warnings in the ordering system, clear recommendations in guidelines or even reducing reimbursement: limit. For inefficient care, reorganizing care or facilitating cooperation are promising: lean. Unwanted care can be reduced by identifying the patients’ preferences and shared decision making: listen.
This typology provides insight in the three situations in which care is of low-value and what strategy might be helpful. The researchers hope to stimulate others to start reducing unnecessary care.

Limit, lean or listen? A typology of low-value care that gives direction in de-implementation.
Verkerk EW, Tanke MAC, Kool RB, van Dulmen SA, Westert GP.

All authors are members of theme Healthcare improvement science.

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