As the costs of providing medical care continue to grow, so does the demand for physicians to provide care that is high in value. Indeed, maximizing clinical benefits to the patient, minimizing direct and indirect harms, and avoiding unnecessary high costs with the care we provide is paramount to our fiduciary responsibilities as physicians. And yet, while simple in concept, the execution of efforts to increase the value of care we provide is much more difficult. A growing body of evidence highlights successes in reducing the amount of unnecessary radiographic and laboratory testing as a means for increasing the value of care provided. However, just how generalizable the success of one institution to the health-care system is, as a whole, less certain. National campaigns such as “Choosing Wisely” offer pediatricians evidence-based ways to reduce the need for unnecessary medical care, but the outcomes have not been robustly validated. In this month’s Pediatrics, Hiscock et. al. perform a systematic review (10.1542/peds.2017-2862) to summarize the evidence describing which categories of interventions have been successful in reducing unnecessary imaging and pathology tests. Study authors performed a literature search in studies originating from developed countries over the past 20 years resulting in 64 studies for the final review. The interventions of each study were then categorized as having one or more of the following attributes: education of providers, audit of and feedback to providers, system/process-based changes, incentive/penalty schemes, and publication of an evidence-based guideline. The relative percentage reduction (RR) and absolute percentage reduction (AR) for both radiographic and pathology testing in each study was reported or calculated where applicable.
So, what worked? Of thirty-two studies reporting interventions to reduce unnecessary imaging, 61% of single interventions and 93% of multi-faceted interventions involved a system/process-based modification. This resulted in absolute changes in radiographic testing ranging from a 92% reduction to a 21% increase. Similarly, all ten studies reporting interventions to reduce pathology testing alone utilized system/process-based changes with reported relative percentage reductions ranging from 0% (no change in number of tests ordered) to 100%. Due to the high amount of heterogeneity between studies, the results were not quantitatively pooled for statistical analyses. Nonetheless, Hiscock et. al. report descriptive findings that combining system/process-based, education, and audit/feedback components were the most effective at reducing the amount of radiographic and pathology testing with a mean RR of 45% compared to one (mean RR 28.6%) or two intervention components (mean RR = 32.0%). Education-based interventions were the most effective if performed alone (mean RR = 57.9%), however authors do caution that this mean originates from a limited number of studies. While this systematic review cannot identify the best way to reduce unnecessary imaging and pathology testing, it does suggest a path towards best practices for future efforts. Namely, approaches should be multi-faceted, specifically including system/process-based, education, and audit/feedback components. Just what effect would these future interventions have on increasing the value of care we provide? That part is not so clear. See for yourself how you could best reduce the inappropriateness of testing in this month’s Pediatrics.
