Improving quality of care while decreasing the cost of health care is a national priority. The American College of Physicians recently launched its High-Value Care Initiative to help physicians and patients understand the benefits, harms, and costs of interventions and determine whether services provide good value. Public and private payers continue to measure underuse of high-value services (for example, preventive services, medications for chronic disease), but they are now widely using performance measures to assess use of low-value interventions (such as imaging for patients with uncomplicated low back pain) and using the results for public reporting and pay-for-performance. This paper gives an overview of performance measures that target low-value services in order to help physicians understand the strengths and limitations of these measures, provides specific examples of measures that assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.
"The published literature in this area also lacks a rigorous analysis of the contextual factors that facilitate or hinder practice . Efforts have been made to generate lists of candidates for decommissioning [5,6]. These are invariably established following application of quality and cost-effectiveness calculations relative to a comparator. "
[Show abstract][Hide abstract] ABSTRACT: Background
The need to better understand processes of removing, reducing, or replacing healthcare services that are no longer deemed essential or effective is common across publicly funded healthcare systems. This paper explores expert international opinion regarding, first, the factors and processes that shape the successful implementation of decommissioning decisions and, second, consensus as to current best practice.MethodsA three round Delphi study of 30 international experts was undertaken. In round one, participants identified factors that shape the outcome of decommissioning processes; responses were analysed using conventional content analysis. In round two, responses to 88 Likert scale statements derived from round one were analysed using measures of the degree of consensus. In round three the statements that achieved low consensus were then repeated but presented alongside the overall results from round two. The responses were re-analysed to observe whether the degree of consensus had changed. Any open comments provided during the Delphi study were analysed thematically.ResultsParticipants strongly agreed that three considerations should ideally inform decommissioning decisions: quality and patient safety, clinical effectiveness and cost-effectiveness. Although there was less consensus as to which considerations informed such decisions in practice, those that drew the most agreement were: cost/budgetary pressures, government intervention and capital costs/condition. Important factors in shaping decommissioning were: strength of executive leadership, strength of clinical leadership, quality of communications, demonstrable benefits and clarity of rationale/case for change. Amongst the 19 best practice recommendations high consensus was achieved for: establishing a strong leadership team, engaging clinical leaders from an early stage, and establishing a clear rationale for change.Conclusions
There was a stark contrast between what experts thought should determine decommissioning decisions and what does so in practice; a contrast mirrored in the distinction the participants drew between the technical and political aspects of decommissioning processes. The best practice recommendations which we grouped into three categories¿change management and implementation; evidence and information; and relationships and political dimensions¿can be seen as contemporary responses or strategies to manage the tensions that emerged between the rhetoric and reality of implementing decommissioning decisions.
[Show abstract][Hide abstract] ABSTRACT: Major policy initiatives are underway in the United States to improve the quality of medical care through attention to value, which goes beyond quality to incorporate cost-utility or cost-effectiveness. In this brief paper we provide critical reflections on the multiple and contested meanings of value in medicine in historical perspective.
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