De-adoption of Low-value Technologies: Importance and Challenges

Daniel Niven MD, MSc, PhD, FRCPC Departments of Critical Care Medicine & Community Health Sciences O’Brien Institute for Public Health Cumming School of Medicine, University of Calgary Calgary, Alberta, Canada

Disclosures

• I have no conflicts of interest to disclose

Objectives

• To define and review the importance of de-adoption and its link to providing evidence-based care

• To review practical challenges with de-adoption of low-value technologies

De-adoption: Definition and Importance

De-adoption is Part of Evidence-Based Medicine

Clinical Practice

New practice (e.g. Lytics for STEMI)

Practice Update (e.g TNK > tPA for

STEMI)

De-adopt current practice

(e.g. PVC suppression)

Discover

Replace

Reverse

Research Evidence

De-adoption = discontinuing practices that research shows to be ineffective or harmful (low-value)

Crit Care Med 2011;39:1613

De-adoption is Important Because: Low-value Care Potentially Harms Patients

NEJM 1991;324:781

NNH = 21 (death)

De-adoption is Important Because: Low-value Care Harms Health Systems

Factor Cost (Per ICU admission)

p

Total Cost Low-value Care $1,003 <0.0001

Components <0.0001

Pharmacy $205

Radiology $229

Laboratory $273

Blood banking $211

Echocardiography $86

AJRCCM 2006:174:1206

BMC Med 2015;13:255

Identify & Prioritize* Low-value

Clinical Practices

Assess barriers & facilitators to de-adoption

Evaluate de-adoption process

and outcomes

Adapt knowledge to local context

Sustain de-adoption

Select, tailor, implement de-adoption intervention

Identify, review & select de-adoption

knowledge

Synthesis Framework for Facilitating De-adoption

Stakeholder engagement

BMC Med 2015;13:255

De-adoption Challenge #1 How to Identify Candidate Low-value Practices

Hypothetical Distribution of Practices: Effect vs Strength of Evidence

Strength of Evidence

Effe

ct o

f Pra

ctic

e ✔ ADOPTION

DE-ADOPTION X

More research?

More research?

Ineffective OR Harmful

Effective

• Began with ABIM in US in 2012

• Canadian initiative began 2014

• Now more than 15 international programs

• Countless societies and ‘do not do’ statements

• Significant investments to create lists

NEJM 2014;370(7):589-592

• Expert opinion followed by search for evidence…

• Identification of practices not in full control of that specialty

• Identification of practices that may have already been ‘de-adopted’

Reproducibility of Clinical Research

Original Study

Beneficial Adoption

Clinical Practice

Reproduction Attempt

Beneficial

Ineffective/Harmful

Consistent Effects

Inconsistent Effect

✔

De-adoption X

Niven et al. Under peer review

Reproducibility of Scientific Evidence in Critical Care: A Scoping Review

Electronic Database Searches

Scoping Review Methodology

Reproducibility Analyses

- RCTs, SRs, SR-MAs - Dx/Rx practices in adult ICUs - NEJM, JAMA, Lancet, BMJ,

Ann Intern Med - AJRCCM, Intensive Care

Med, Chest, Crit Care Med, Crit Care

Included Articles N = 337

Unique Practices N = 172

Practices without a Reproduction

Attempt N = 100

Practices with a Reproduction

Attempt N = 72

Critical Care Best Practices Should NOT DO (Reproducible Harm)

Niven et al. Under peer review

• Hydroxyethyl starch for fluid resuscitation

• Tight glycemic control

Critical Care Best Practices Consider NOT Doing (Reproducible Lack of Efficacy)

Niven et al. Under peer review

De-adoption Challenge #2 Changing Clinical Practice

JAMA IM 2015; 175: 801-09

De-adoption Requires Active Behavioural Change Intervention

JAMA IM 2015; 175: 801-09

No Significant De-adoption of Tight Glycemic Control or its Harmful Effects

Tight Glycemic Control Hypoglycemia

effect sizes were

marginal clinical significance is

uncertain additional

interventions are necessary for

wider implementation of Choosing

Wisely recommendations.”

JAMA IM 2015;175(12):1913-1920

Take Home Points • De-adoption of low-value clinical practices is one aspect of

the knowledge translation process that is critical to delivering high-quality, evidence-based clinical care

• Objective identification of low-value practices is necessary to engage relevant stakeholders

• There is an urgent need to understand and promote the de-adoption of ineffective and harmful clinical practices