By Alisa Kim
Being prescribed antibiotics for a viral infection or getting an MRI scan for low back pain are examples of low-value care—health care practices that yield little or no benefit, or even cause harm. Yet, according to a 2017 report by the Canadian Institute of Health Information and Choosing Wisely Canada (CWC), an organization that aims to reduce unnecessary care, up to 30% of the tests, treatments and procedures associated with certain CWC campaigns are potentially of low value.
“Thirty per cent is a fairly substantial number,” says Dr. Gillian Parker, a graduate of the Health Systems Research program at IHPME. Her doctoral research, supervised by IHPME Professor Whitney Berta, was on de-implementation—the reduction or removal of low-value health care.
When asked what appeals to her about this area of study, Parker says de-implementation of low-value care has widespread impact. “It’s going to benefit the patient not to participate in or endure an unnecessary practice or procedure. From a financial perspective, it’s going to benefit the health care system because we’re going to be able to reduce waste and spend health care dollars more effectively,” she says.
Little is known about why low-value care persists and the best strategies to address it, notes Parker, whose work is advancing the field. In 2022, she published a literature review paper in Implementation Science to identify the theories and frameworks used to understand the dynamics of reducing low-value care. “One of the exciting aspects of that paper was that over 50% of the included studies were published in the last two years—showing de-implementation and reducing low-value practice is an emerging area of research,” she says.
Her PhD research culminated in a study published in January 2022, co-authored with Berta and IHPME faculty members Drs. Karen Born and Monika Kastner. It looked at initiatives to reduce low-value care that addressed Choosing Wisely Canada recommendations. The researchers found for many of the low-value practices studied, patients were not a significant driver of the low-value care, nor a barrier to reducing it. This finding was interesting, says Parker, because patients are often presented as significantly influencing low-value care in current de-implementation literature.
The study also detailed important aspects of the magnitude of the problem of low-value care, providing insights into the complexities and nuances of harm, resources and prevalence of unnecessary care. Participants in the study reported downstream harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm, not the immediate harm of performing the test or procedure.
The study also identified hard-coded interventions were a factor influencing both the reduction and maintenance of low-value care. These are interventions that are built into a system or technology. As an example, Parker points to the ordering of a set of lab tests for a sample of blood. An order set may contain 10 separate tests that are requested at the click of a button, but not all 10 tests may be needed. “That was a really interesting and novel finding for us—that technology can be two-sided,” Parker says. “Technology can support the reduction of low-value care, but it also has to be maintained, monitored and updated so that practices embedded in technology are evaluated regularly and updated when necessary.”
Her current research is taking a new but related direction looking at the development and adoption processes of molecular tests for cancer prognosis. Through a postdoctoral fellowship with IHPME Professor Fiona Miller, Parker is leading a study of these genomic tools which have the potential to affect clinical practice and patient care significantly. In the emerging field of precision medicine, little is known about the innovation processes and role of industry and regulation in the adoption of these tools. She notes after a person has breast cancer surgery, for example, further treatment like hormone therapy or chemotherapy usually follows. A certain class of breast cancer prognostic tools claim to have predictive capacity—the ability to determine which patients will benefit from post-surgery chemotherapy. “It’s important to understand the development and regulatory progress of these new and innovative tools as they have the potential to support appropriate care and reduce inappropriate care in cancer treatment,” she says.
Looking ahead, Parker says she feels her training at IHPME has well equipped her to effect and support change in the health system. “I feel like I could make a difference. IHPME definitely delivered on that point. It’s great for those who want to stay in the academic world, and also for those who want to work within the health system to improve care processes and delivery.”
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