Background
Value has been defined as the ratio of quality outcomes to cost. Perfect value would represent infinitely beneficial outcomes associated with minimal costs. Of interest to the present study are interventions where outcomes are minimal, and costs may be high as they may provide an opportunity for disinvestment, improving the overall value of care whilst providing efficiency gains.
Methods
A Scoping Narrative Review was performed in order to understand incumbent approaches towards dealing with low value care. International lessons from different processes were identified and encompassed into a conceptual logic orientated framework for de-adoption. To identify low value care in surgery a Systematic review of peer reviewed high-level literature was performed to identify candidate interventions for de-adoption. Subsequently a granular assessment of the behaviour of passive de-adoption was performed through a retrospective longitudinal observational study based upon administrative hospital data.
Results
A comprehensive conceptual model that takes an integrated approach to de-adoption was assembled from lessons learnt when dealing with low value care previously. It identified three stages in the de-adoption cycle which are necessary for success: identification, implementation and re-evaluation. Each process should be performed at multiple planes: national (macro), local (meso) and provider / patient (micro) levels in order to have a holistic effect. The identification of low value interventions may be from exploring peer reviewed literature, as demonstrated from the systematic review or exploring geographical variation of care. Said review identified 71 low value procedures, of which 5 interventions which carried the highest economic burden were postulated to cost the health system £135 million per annum. Subsequent granular review identified that passive levers have not resulted in de-adoption of a surgical low value interventions – e.g. delayed cholecystectomy. This is due to the presence of exnovator providers whom are concurrently de-adopting innovative interventions as other providers are adopting them.
Conclusions
Low value care represents a significant burden in the current health service. This thesis has evaluated its incidence and economic burden in general surgery. Service transformation is necessary and may be achieved through the holistic integrated approach recommended here. Policy makers have already sought this novel information and encompassed it into national policy, with the objective of achieving higher value care through effective de-adoption.