The basic tenet to let go of things, and to declutter one’s surroundings, is fundamental to an organising method coined KonMari. Within healthcare systems, there is the opportunity to streamline the number of available interventions, to eliminate or let go of less effective ones.
Yet, it is not yet a wide-ranging norm to let go when we bring new things into our lives, whether it be our homes or our healthcare systems. De-investment or de-adoption of low-value care is a necessity, however, if we are to reduce the resources that are being expended on marginally or ineffective care. This is critically important in light of the demographic shift and the mounting needs for preventative and curative treatments for a mounting older population.
The extent of the problem of low value or unnecessary healthcare interventions is estimated to be as high as 30%. 1,2,3 This includes tests, treatments and procedures that have no or little clinical benefit and in some instances may even be harmful.
Conventional wisdom may look to physicians and other healthcare professionals to take the lead in determining low-value interventions. However, as we work to normalise patient involvement in medicines R&D, their role should extend to the discussion of de-adoption of health interventions.
Another key aspect of de-investment is the prioritisation of services, allowing for the elimination of less effective interventions, with the expressed interest to make way for innovative, efficacious and safe new interventions. The de-adoption process allows for the redeployment of resources. Patients have an important role in ensuring resources are reapplied on interventions to satisfy patients’ unmet needs.
The cultural move toward de-adoption is dependent on a few factors; awareness of the case for why it is important to optimally manage resources, the accumulation of evidence regarding quality of interventions, and pathways for patients and healthcare professionals to jointly engage in decision making on care.
Indeed, several initiatives have cropped up to help achieve these goals. One programme currently established in 20 countries including the UK, France and Germany, is the Choosing Wisely initiative. Educational materials are available, as well as an app that provides the evidence base to support healthcare choices.
Despite this, a real concern persists that de-adoption will not lead to re-deployment, but merely to decrease healthcare expenditure. The net result would then be no gain for patients’ health and no true advantage or advancement for healthcare systems.
While conversations are taking place amongst policymakers and in the hallways of payers’ organisations, the patients’ voice is not prominent in this dialogue. However, the value from a patient perspective is obviously a key component in the assessment of the value of healthcare interventions. The work being done on value assessments has the opportunity to include de-adoption as a component of these frameworks. Patient perspectives are key to the design of such formulas. The National Health Council in the US, an umbrella organisation made up of more than 125 national health-related organisations and businesses whose aim is to provide a united voice for patients, their family, and caregivers, has done considerable work in articulating the critical rationale for inclusion of patient perspectives in value rubrics.
With respect to pharmacological interventions, patients’ role in the medicines R&D process continues to grow and expand, and there is significant interest in further involving patients in early HTA proceedings. A natural extension is to involve patients in the de-adoption of medicines. There are studies to point to the willingness of patients to engage in de-adoption of medicines.4
A symbiotic link exists between engaging patients in the de-adoption process and giving voice to their perspectives in determining the valuation of new medicines. If we wish to create more value within the health system, at a time when budgets are not keeping pace with the rise of morbidity, de-adoption of low-value interventions can pave the way for making room for innovation. The hinge pin is the engagement of patients in both of these processes.
- Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013;173:823–5.
- Institute of Medicine (US) Roundtable on evidence-based medicine. In: Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: lowering costs and improving outcomes: Workshop series summary. Washington (DC): National Academies Press (US); 2010.
- Kirkham KR, Wijeysundera DN, Pendrith C, Ng R, Tu JV, Laupacis A, et al. Preoperative testing before low-risk surgical procedures. CMAJ 2015. CMAJ. 2015;187(11):E349–58.
4. SilversteinW, Lass E, Born K, Morinville A, Levinson W, Tannenbaum C., A survey of primary care patients’ readiness to engage in the de‑adoption practices recommended by Choosing Wisely Canadaal. BMC Res Notes (2016)