De-implementing Low-Value Care
An example of an implementation science research study.
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.
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
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.
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.
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 of 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.
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 patient engagement process that we developed for this study has been published here:
The evaluation of our patient engagement has been published here:
- De-implementing wisely developing the evidence base to reduce low value care
- De-Implementing Low-Value Care Project
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- Barriers to reducing imaging for low back pain in Newfoundland and Labrador
- 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
- Barriers and enablers to enhancing fidelity of training and delivery for an intervention to reduce imaging for low back pain
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- Protocol for assessing the determinants of preoperative test-ordering behaviour for low-risk surgical procedures using a theoretically driven, qualitative design
- Barriers to Reducing Unnecessary Preoperative Testing in Newfoundland and Labrador
- Barriers to reducing preoperative testing for low-risk surgical procedures A qualitative assessment guided by the Theoretical Domains Framework
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- Patient Perspectives of Upper Respiratory Tract Infections and How They Should be Managed
- Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework
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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.
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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.
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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.
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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.
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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).
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).