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Research Letter | Less Is More

Creating a List of Low-Value Health Care Activities in Swiss Primary Care FREE

Kevin Selby, MD1; Jean-Michel Gaspoz, MD, MPH2; Nicolas Rodondi, MD, MAS3; Stefan Neuner-Jehle, MD, MPH4; Arnaud Perrier, MD5; Andreas Zeller, MD6; Jacques Cornuz, MD, MPH1
[+] Author Affiliations
1Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
2Division of Primary Care Medicine, Department of Community Medicine, Primary Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
3Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
4Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
5Department of Medicine, University of Geneva, Geneva, Switzerland
6Institute of Primary Health Care, University of Basel, Basel, Switzerland
JAMA Intern Med. 2015;175(4):640-642. doi:10.1001/jamainternmed.2014.8111.
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In 2010, the idea emerged of creating lists of low-value health care activities as a way to confront rising medical costs and encourage cost-conscious care. The Good Stewardship Working Group1 and Brody2 pioneered the idea of “top 5” lists, leading to the Choosing Wisely campaign.3 Building on this momentum, there has been widespread interest in proposing additional lists.4 In 2012, the Swiss Society of General Internal Medicine committed to creating a list for Swiss ambulatory internal medicine.

A review of publications was performed using the search terms low value, disinvestment, less is more, and avoidable care. Three sets of lists were identified (1103 recommendations)3,5,6 as of March 5, 2013. Two physicians excluded recommendations that were not relevant to ambulatory internal medicine (eg, specialized medicine, pediatrics), leading to an initial list of 38 international recommendations.

An online Delphi process was then applied, using successive electronic survey instruments placed on the Survey Monkey website (www.surveymonkey.com). All committee members of the Swiss Society of General Internal Medicine and the Swiss Society of Family Medicine, along with professors from the divisions of General Internal Medicine and Family Medicine at the 5 Swiss university medical schools, were invited to participate as experts. A 7-member advisory committee was formed based on Swiss Society of General Internal Medicine members who expressed a specific interest in this subject.

In round 1, experts gave their level of agreement with the international recommendations using a 10-point Likert scale. Experts could also propose additional recommendations. After a review of publications to ensure their validity based on available evidence, 12 of 21 novel recommendations were retained.

In round 2, recommendations with intermediate scores in round 1 (average scores, 7-9) were reranked based on experts’ level of agreement, along with the 12 novel recommendations.

For round 3, recommendations with scores greater than 9 were graded based on a 3-point Likert scale in 3 areas: frequency, costs, and patient harm. Frequency was defined as how often the average general practitioner is faced with the decision to perform the test or prescribe the treatment. Costs were direct costs and not those of unanticipated adverse effects or complications. Harms were defined as potential harms from the test or treatment, including those that could be expected from the recommendation. For reasons of implementation, the final list was limited to 5 of the 10 most frequent recommendations.

Of the 59 experts contacted, 35 agreed to participate (59%; mean [SD] age, 51 [6.3] years; 27 men [77%]). A flowchart of the recommendations is shown in the Figure. Through rounds 1 and 2, a total of 50 items were ranked based on an agreement scale of 1 to 10, including the 12 novel recommendations. The mean (SD) agreement score was 8.52 (0.80) of 10. Of the 18 recommendations reviewed in round 3, the top 10, ranked by perceived frequency, are seen in the Table. The final top 5 list was made by consensus of the advisory committee, who believed there would be too much overlap if there were 2 recommendations for respiratory tract infections.

Place holder to copy figure label and caption
Figure.
Flowchart of Recommendations Through the Delphi Process

A total of 50 recommendations were ranked during the Delphi process, including 38 existing international recommendations and 12 novel recommendations from the experts. From the top 10 recommendations of the Delphi process, an expert panel chose the final top 5 list.

Graphic Jump Location
Table Graphic Jump LocationTable.  Top 10 Recommendations Based on Frequency Scorea

Our study illustrates a method to allow medical societies to create their own national lists based on existing international work.3,5,6 Our high agreement scores suggest that there is enough consensus to allow for the adaptation of such lists in other countries.

The Good Stewardship Working Group1 used a small committee for the generation and initial selection of recommendations and a larger group of 255 health care professionals for validation; we started from an initial list of international recommendations and used a panel of 35 experts for selection. We are currently conducting an implementation study among Swiss general practitioners.

Corresponding Author: Kevin Selby, MD, Department of Ambulatory Care and Community Medicine, University of Lausanne, Policlinique médicale universitaire, Rue de Bugnon 44, 1011 Lausanne, Switzerland (kevin.selby@hospvd.ch).

Published Online: February 23, 2015. doi:10.1001/jamainternmed.2014.8111.

Author Contributions: Drs Selby and Cornuz had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Selby, Gaspoz, Rodondi, Neuner-Jehle, Perrier, Cornuz.

Acquisition, analysis, or interpretation of data: Selby, Rodondi, Neuner-Jehle, Perrier, Zeller, Cornuz.

Drafting of the manuscript: Selby, Zeller, Cornuz.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Selby.

Obtained funding: Gaspoz, Cornuz.

Administrative, technical, or material support: Selby, Perrier, Cornuz.

Study supervision: Gaspoz, Rodondi, Perrier, Cornuz.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by a grant from the Swiss Society of General Internal Medicine and the Department of Ambulatory Care and Community Medicine, Lausanne University.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Christoph Meier, MD, Department of Medicine, Triemli Hospital, provided guidance throughout this project, 35 expert participants volunteered their time, and Joana Le Boudec, MD, Department of Ambulatory Care and Community Medicine, University of Lausanne, assisted with drafting the first survey instrument and reviewing international recommendations. None were financially compensated.

Good Stewardship Working Group.  The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-1390.
PubMed   |  Link to Article
Brody  H.  Medicine’s ethical responsibility for health care reform: the top five list. N Engl J Med. 2010;362(4):283-285.
PubMed   |  Link to Article
American Board of Internal Medicine. Choosing Wisely website.http://www.choosingwisely.org/. Accessed January 7, 2015.
Hurley  R.  Can doctors reduce harmful medical overuse worldwide? [published online July 3, 2014]. BMJ. doi:10.1136/bmj.g4289.
PubMed
National Institute for Health and Care Excellence. NICE 'do not do' recommendations. National Institute for Health and Care Excellence website. https://www.nice.org.uk/proxy/?sourceurl=http://www.nice.org.uk/usingguidance/donotdorecommendations/index.jsp.Accessed January 7, 2015.
Elshaug  AG, Watt  AM, Mundy  L, Willis  CD.  Over 150 potentially low-value health care practices: an Australian study. Med J Aust. 2012;197(10):556-560.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Flowchart of Recommendations Through the Delphi Process

A total of 50 recommendations were ranked during the Delphi process, including 38 existing international recommendations and 12 novel recommendations from the experts. From the top 10 recommendations of the Delphi process, an expert panel chose the final top 5 list.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Top 10 Recommendations Based on Frequency Scorea

References

Good Stewardship Working Group.  The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-1390.
PubMed   |  Link to Article
Brody  H.  Medicine’s ethical responsibility for health care reform: the top five list. N Engl J Med. 2010;362(4):283-285.
PubMed   |  Link to Article
American Board of Internal Medicine. Choosing Wisely website.http://www.choosingwisely.org/. Accessed January 7, 2015.
Hurley  R.  Can doctors reduce harmful medical overuse worldwide? [published online July 3, 2014]. BMJ. doi:10.1136/bmj.g4289.
PubMed
National Institute for Health and Care Excellence. NICE 'do not do' recommendations. National Institute for Health and Care Excellence website. https://www.nice.org.uk/proxy/?sourceurl=http://www.nice.org.uk/usingguidance/donotdorecommendations/index.jsp.Accessed January 7, 2015.
Elshaug  AG, Watt  AM, Mundy  L, Willis  CD.  Over 150 potentially low-value health care practices: an Australian study. Med J Aust. 2012;197(10):556-560.
PubMed   |  Link to Article

Correspondence

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