De-implementing Low-Value Care
De-implementing Low-Value Care
An example of an implementation science research study.
Background: Choosing Wisely Canada has made over 450 recommendations about tests and treatments that should be avoided in certain clinical situations. However, many of these tests and treatments still occur because changing health care processes is not an easy task. Implementation science aims to understand the underlying reasons for health care processes and to develop and test potential solutions to improve them.
Aim: This project links Choosing Wisely Canada, patients, and health system partners in three provinces (Alberta, Ontario and Newfoundland) with leading Canadian implementation scientists to develop and test solutions for two important topics:
- Imaging scans that are not needed for patients with low-risk back pain
- Pre-operative tests that are not needed for patients having low-risk surgery
- Antibiotics that are not needed for upper respiratory tract infections
Previously Completed Work: We have done preliminary studies to make sure we fully understand the different reasons for unnecessary care and are now developing targeted solutions using insights from behavioural and system science that support both health professionals and patients to make informed decisions about whether these tests are needed.
Ongoing Work: We will test these practice changes in studies. Some health organizations (either family practices for low back pain imaging or hospitals for pre-operative testing) will receive the suggested intervention and some will not. All organizations will receive the intervention to use as they wish at the end of the study.
We will determine who gets the practice change intervention at the organization level by flipping a coin, also called randomization, to ensure that health organizations have the same chance to receive or not receive the intervention.
We are working with the Canadian Institute for Health Information and other partners to use the data already routinely collected to measure whether the intervention worked. Whether the intervention works or not, we will engage our partners and networks to share what we have learned across Canada and worldwide.
Ethics: Our study has been revised and approved by the Ottawa Health Science Network Research Ethics Board (20180746-01H) and at each local hospital and/or academic institution as required.
An essential part of this study is to engage patients throughout the study process. The patients on our team are full team members, and are involved however they wish to be, from receiving regular updates all the way to conducting data collection and analysis.
A first step that the Patient Partnership Council took was to develop some helpful patient engagement tips for all members of our team.
The Do's and Don'ts of Patient Partnership in Research
An infographic on the do's and don't of Patient Partnership in Research
Operationalizing a Patient Engagement Plan-Health Expectations 2022
The patient engagement process that we developed for this study.
Patient Engagement Evaluation
The evaluation of our patient engagement.
-
D’Arcy Duquette is actively engaged in patient engagement in Alberta as an integral member of the Surgical and Critical Care Strategic Clinical Network and currently serves as the co-chair of the Citizen Advisory Team at South Health Campus. He has been a part of numerous other patient engagement initiatives including chairing the Patient and Family Advisory Committee with the Health Quality Council of Alberta and is a graduate from the Patient and Community Engagement Researcher (PaCER) training program. Since retiring from the Canadian Pacific Railway as a Senior Director of Network Strategy, D’Arcy has committed to using his experience as a patient with cancer to ensure the safety and high quality of healthcare services for all Canadians.
On January 26th, 2023, D’Arcy received the prestigious Queen Elizabeth II Platinum Jubilee Medal in recognition of his exceptional contributions to community and healthcare advocacy.
-
Vanessa has personal and professional interests in genetics and is a volunteer on the Translational Genomics Scientific Advisory Committee in St. John’s Newfoundland among other patient engagement initiatives.
Having held a variety of nursing positions throughout her career, including Manager, Instructor and now, a Family Practice Nurse Navigator, Vanessa’s diverse experiences are an asset to her role in patient engagement. Working in rural Newfoundland has given her a unique perspective on the challenges of delivering cost-effective, high-quality healthcare to the population.
-
Kim has played an active role as a patient partner in core committees and working groups within the Strategic Clinical Networks for Alberta Health Services. Notably, she serves as a patient researcher for the Re-Purposing the Ordering of Routine Laboratory Tests (RePORT) study and the Alberta Rheumatology Learning Health System initiative. She holds positions on the Alberta Implementation Science Collaborative Steering Committee and the Artificial Intelligence for Patient Health (AI4PH) Community Advisor Board.
Previously working in the oil and gas sector with a degree in communications and english, Kim recently graduated from the Patient and Community Engagement Research (PaCER) program in Alberta. She works hard to help reduce waste in healthcare, empower patients to take an active role in their own care, and foster interprovincial collaboration aimed at enhancing the efficiency of healthcare systems.
-
Brian is the Patient Lead for Quality of Care/Choosing Wisely Newfoundland and Labrador. As an active member of the SUPPORT NL Public and Patient Advisory Council, he has been involved in numerous research projects and activities at the provincial level. His principal research interests lie in the reduction of low value tests and treatments with a view of reassigning resources within the healthcare system.
Brian obtained his Doctorate in Education from the University of Toronto. After retiring from Student Affairs and Services at Memorial University he worked for several years as a consultant in the private sector in the areas of strategic development and corporate identity. Brian brings structure and excellent communication strategies to the teams that he works with. He feels that maintaining and sustaining the Canadian Healthcare system can only be accomplished through respectful, informed interaction among all components and partners of the system. In particular, he feels that patient engagement and active, meaningful participation in their care are the right and responsibility of all patients.
-
Fay has spent most of her professional career supporting the health of communities and clients through public health initiatives focusing on the social determinants of health. Much of this work involved active participation of communities and their partners to address health and wellness issues.
Fay graduated from Dalhousie University with a Bachelor of Nursing and followed this up with a Masters Degree in Health Administration – Community Health and Epidemiology from The University of Toronto. During her career, she has worked in many areas of rural and urban public health and community services, finishing her full-time work as VP for Community and Acute Care Services with Eastern Health. Fay has also worked as an independent Public Health Consultant with a focus on engaging communities in Healthy Built Environment research, community health assessment and building sustainability within rural communities.
Fay possesses a strong belief that health promotion and protection must be a visible component within our health system, that good upstream work will contribute to improved population health, and that a collaborative and engagement approach will both strengthen our health system and contribute to positive health outcomes.
-
Barbara Sklar brings remarkable commitment to patient engagement as she began patient advocacy work at North York General Hospital in 2012, after a long career as a Registered Nurse/Educator. She currently serves on the Patient Advisory Board at the World Health Organization, and Choosing Wisely Canada, is a member of ‘Patients for Patient Safety Canada’ and is active on many research and health-related research initiatives. She is a strong advocate for inclusion of patients’ voices with the goal of improving healthcare access and outcomes for all.
-
Gloria has been an active contributor as a patient advisor within Alberta Health Services for over 10 years, dedicating herself to diverse teams and committees including the patient transitions work group. Notably, Gloria has undergone specialized training as a Patient and Community Engagement Researcher (PaCER) and had a role as a collaborating patient voice in a Ph.D. project centred around crafting a comprehensive framework for enhancing patient engagement throughout healthcare decision-making processes.
As a retired registered nurse, and municipal politician, Gloria has knowledge, experience and a strong passion for positive healthcare system change while ensuring that patient perspectives and voices remain at the forefront of healthcare decision-making.
-
Holly Etchegary, PhD is an Associate Professor in the Faculty of Medicine at Memorial University, St. John’s, Newfoundland and Labrador. A social scientist by training, her multifaceted expertise encompasses behavior change theory, health decision-making, and a versatile proficiency in both qualitative and quantitative research methodologies, most recently patient oriented research.
In her capacity as the Patient Engagement Faculty Lead for the NL Support Unit, Holly maintains a strong network of connections with various Support Units spanning the nation. Her involvement in the project is marked by an enthusiastic dedication to all aspects of patient engagement, which encompasses strategic planning and the development of training initiatives. Additionally, as a co-investigator, she plays an instrumental role in spearheading data collection and analysis endeavors, while actively contributing to knowledge translation initiatives. Holly’s commitment to the project underscores her unwavering dedication to advancing patient engagement and enhancing the overall landscape of healthcare outcomes.
-
Stefanie Linklater is a Research Program Manager in the Centre for Implementation Research at the Ottawa Hospital Research Institute (OHRI) and has been at the OHRI since 2011. Stefanie holds an Honors Bachelor of Science in Biopharmaceutical Science and a Master of Science in Cellular and Molecular Medicine, both from the University of Ottawa. As Patient Engagement Coordinator for this study she leads the Patient Partnership Council and facilitates all patient involved work.
-
Infographics:
- Barriers to reducing imaging for low back pain in Newfoundland and Labrador
- Barriers and enablers to enhancing fidelity of training and delivery for an intervention to reduce imaging for low back pain
Published Work:
- Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care a qualitative assessment guided by the Theoretical Domains Framework
- Patient education materials for nonspecific low back pain and sciatica a protocol for a systematic review and meta-analysis
- Patient education materials for non-specific low back pain and sciatica A systematic review and meta-analysis
- A qualitative study exploring perceived barriers and enablers to fidelity of training and delivery for an intervention to reduce non-indicated imaging for low back pain
- Exploring perceived barriers and enablers to fidelity of training and delivery of an intervention to reduce imaging for low back pain a qualitative interview study protocol
- Exploring factors influencing chiropractors’ adherence to radiographic guidelines for low back pain using the Theoretical Domains Framework
- What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging
-
Infographics:
Published Work:
- Barriers to reducing preoperative testing for low-risk surgical procedures A qualitative assessment guided by the Theoretical Domains Framework
- Beyond guideline knowledge a theory-based qualitative study of low-value preoperative testing
- Protocol for assessing the determinants of preoperative test-ordering behaviour for low-risk surgical procedures using a theoretically driven, qualitative design
-
Infographics:
Published Work:
-
Dr. Jeremy Grimshaw is trained as a family physician prior to undertaking a PhD in health services research at the University of Aberdeen. His research focuses on the evaluation of interventions to disseminate and implement evidence-based practice. Dr. Grimshaw is a Senior Scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, a Full Professor in the Department of Medicine, University of Ottawa and a Tier 1 Canada Research Chair in Health Knowledge Transfer and Uptake. He is a Fellow of the Canadian Academy of Health Sciences and a Corresponding Fellow of the Royal College of Edinburgh. He was formerly the Director of Cochrane Canada and the Co-coordinating Editor of the Cochrane Effective Practice and Organisation of Care group. He is the President of the Board of the Campbell Collaboration.
-
Dr. Andrea Patey is a Senior Clinical Research Associate within the Centre for Implementation Research at the Ottawa Hospital Research Institute and an Assistant Professor (Adjunct) at Queen’s University in Kingston. She holds a PhD in Health Psychology from City, University of London. Her interests in Knowledge Translation and Implementation Research include the application of psychology theories and methods to explain and change health professional behaviours across a range of clinical settings. Andrea’s interest in behaviour change focuses specifically around whether de-implementation differs from implementation and if interventions to address each should be designed targeting the possible differences. The broad objectives of her research are to promote the use of theory and rigorous methods to improve the delivery of evidence-based healthcare through the development and evaluation of complex behaviour change interventions.
-
Dr. Amanda Hall is an Assistant Professor at the Primary Healthcare Research Unit (PHRU), Memorial University of Newfoundland. She is also the Knowledge Translation Academic Advisor for Newfoundland and Labrador’s SPOR Primary and Integrated Health Care Innovation Network. She holds a PhD in Medicine from the University of Sydney (in conjunction with the George Institute for Global Health) which focused on the effects of exercise on musculoskeletal pain. Her post-doctoral work at the University College of Dublin and the University of Oxford focused on methods for implementing evidence-based guidelines into practice – primarily related to chronic musculoskeletal pain. Amanda leads a program of research that intersects musculoskeletal health, implementation science, and knowledge translation. Her work is largely concentrated on improving the management of low back pain and arthritis using biopsychosocial interventions and by improving uptake of evidence-based guidelines and building robust partnerships with knowledge users to narrow the evidence-practice gap.
-
Dr. Shannon Ruzycki is a general internist in Calgary, Alberta and Assistant Professor in the Cummings School of Medicine at the University of Calgary. She is also the Associate Director of Physician Wellness and Vitality in the Department of Medicine and a physician collaborator for Well Doc Alberta. Dr. Ruzycki research focuses on perioperative quality improvement and equity, diversity, and inclusion in the medical workplace.
-
Dr. Kyle Kirkham is an anesthesiologist and lecturer at the University of Toronto in the Faculty of Medicine. Dr. Kirkham’s clinical focus is preventing pain and optimizing less invasive approaches to anesthesia and surgery as a tool for helping patients leave hospital earlier and with improved recoveries. He is the director of the Anesthesia Preadmission Clinic at Women’s College Hospital where patients are counselled and prepared for their upcoming surgeries. Dr. Kirkham’s research focus examines the preparation that patients receive for outpatient surgery and finds ways to ensure that patients receive the testing they need while supporting a sustainable and evidence-based health care system.
This research is funded by the Canadian Institutes for Health Research, Strategy for Patient Oriented Research Innovative Clinical Trial Grant (MYG-158642).
We would also like to thank and acknowledge the funding partners that have contributed matched funding to support this study.
- Alberta Health Services
- Alberta Innovates
- Alberta Medical Association
- Canadian Institute for Health Information
- Choosing Wisely Canada
- Dr. Proton Rahman
- LifeLabs
- Memorial University of Newfoundland
- Newfoundland & Labrador Chiropractic Association
- Newfoundland & Labrador Chiropractic Board
- Ontario Health – Quality
- Ottawa Hospital Research Institute
- Ottawa Methods Centre
- University Health Network
- Women’s College Hospital Institute for Health System Solutions & Virtual Care
- Workers’ Compensation Board – Alberta
For more information about this research study, please contact our National Research Lead Andrea Patey (apatey@ohri.ca) or Research Program Manager Stefanie Linklater (slinklater@ohri.ca).