The recent series of blog posts, De-implementation of Low Value Care Services, by authors from AcademyHealth’s Research Community on Low-Value Care explores the concept of de-implementation as a normal, routine part of the ever-evolving research and care delivery. The series is essential reading for clinicians and researchers working in learning health systems as the authors of the blog posts identify specific perspectives, unintended consequences, where progress shows promise, and where progress continues to be slow.

As a Delivery System Science Fellow (DSSF), I became aware of the ubiquity of low-value care practices through quality improvement work and observation of clinical practices across departments within a large health system. One key learning from my DSSF experience is that de-implementing low-value care is critical to improving outcomes for patients as it provides space and enthusiasm among staff for introducing evidence-based practices. Additionally, clinicians and frontline staff must be partners in the de-implementation process since they know the low-value care encountered daily.

Unintended Consequences of Constant Health System Change

Health system leaders and managers often feel pressure to improve performance on metrics, especially after a specific care delivery problem is identified. Because of this urgency, they often make changes to several related processes at once --leading to risk and conflict as they converge at the point of care. Staff feel they must constantly adapt their work and add “more” to their daily responsibilities without any additional time or energy to get the work completed. For staff and clinicians, many are already experiencing burnout that is expected to increase due to COVID-19.These seemingly never-ending cycles of change can lead to change fatigue.

Change fatigue results in passive, often unnoticed behaviors. These can include frontline staff apathy, ambivalence, and low levels of engagement. These behaviors may reduce the effectiveness of change initiatives contributing to greater change failure within a health system. De-implementation of potential low-value care practices, on the other hand, can energize staff and generate opportunities for targeted, evidence-based, and patient-centered solutions. For those fatigued by constant change, eliminating low-value care practices from their workload may lead to relief and ultimately, higher staff engagement.

Identify, Measure, Report, then Use the Four R’s of Low-Value Care

One challenge in reducing low-value care is marginal benefit, wherein identified care is wasteful or inefficient in some instances, but not others. Clinical nuance and marginal benefit have to be weighed by patients and their clinicians, as suggested in AcademyHealth’s previous blog posts.

The Choosing Wisely campaign and the Task Force on Low Value Care have provided examples of services considered low value based on assessments of benefit, harm, and total spending. The Center for Value-Based Insurance Design has provided simple steps for health systems to follow, including: identify low-value care opportunities; measure when and under what circumstances this care is being practiced; report what has been learned about that low value care opportunity; and eliminate low-value care where appropriate. Finally, tailored strategies for de-implementation exist based on multi-level factors, outcomes, and unintended negative consequences. Four different types of action (the four R’s: remove, replace, reduce, restrict) have been suggested to de-implement inappropriate care.

While these resources have provided a foundation for addressing low-value care, progress in this area has been slow. Indeed, this community must find methods to promote widespread, evolving change to reduce low-value care practices at the organizational level. Rather than focusing exclusively on practices identified by the Choosing Wisely campaign or The Taskforce, de-implementation of low-value care can be applied more broadly to staff and clinician care processes.

Leverage Staff and Clinician Knowledge to Free Up Energy for Evidence-Based Care

To effectively identify low-value care, it is critical that we give a voice to staff and clinicians. Top-down approaches to change initiatives can result in clinicians and staff feeling alienated or disillusioned. These stakeholders have intimate knowledge and experience with care processes and are able to identify unnecessary or wasteful care most in need of de-implementation. Interventions which address the clinician’s role, as well as the patient’s role, in overuse may have the greatest potential to reduce low value care

A virtuous cycle of de-implementation provides a framework to reduce staff workload and creates space for targeted, evidence-based and patient-centered care. Although change remains a constant in health care, the change associated with de-implementation of low value-care not only aligns with health care professionals’ inherent desire to do the right thing, but also provides an opportunity to act.   

Audrey Johnson headshot
Member, Researcher

Audrey Johnson, P.T., D.P.T.

Fellow - Kaiser Permanente Northwest Center for Health Research

Dr. Johnson graduated from the University of Kentucky Physical Therapy program with her Master's degree in 200... Read Bio

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