Lead/Presenter: Tim Hofer,
COIN - Ann Arbor
All Authors: Kerr EA (VA Center for Clinical Management Research; University of Michigan), Klamerus ML (VA Center for Clinical Management Research), Markovitz A (VA Center for Clinical Management Research; University of Michigan) Caverly T (VA Center for Clinical Management Research; University of Michigan) Sussman J (VA Center for Clinical Management Research; University of Michigan) Saini SD (VA Center for Clinical Management Research; University of Michigan) Min L (VA Center for Clinical Management Research; University of Michigan) Bernstein SJ (University of Michigan) Chou R (Oregon Health and Science University) Lohman SE (VA Center for Clinical Management Research; Wayne State University Medical School) Froehlich W (VA Center for Clinical Management Research; University of Michigan Medical School) Goodrich D (VA Center for Clinical Management Research) Skurla SE (VA Center for Clinical Management Research) Hofer TP (VA Center for Clinical Management Research; University of Michigan)
The objective was to develop a systematic approach to identify and validate recommendations for stopping or scaling back (de-intensifying) tests or treatments in primary care.
The identification of candidate recommendations for de-intensification began with a systematic scan of guidelines/recommendations developed by selected specialty societies, the USPSTF, and CW. We limited our search to common clinical areas in routine ambulatory primary care: prevention/treatment of cardiovascular disease (CVD) and diabetes (DM), screening (non-CVD), and inappropriate medication use in adults. Each candidate recommendation was reviewed by physician investigators to: 1) verify it related to de-intensification and was relevant to routine primary care; 2) assess whether it would likely improve outcomes, impact patients, and be feasible to measure. An external advisory council prioritized the resultant recommendations. The prioritized recommendations, and supporting evidence, were considered by two multidisciplinary expert panels of physicians. We adapted the RAND/UCLA Appropriateness Method of two rounds of ratings with discussion between by employing virtual group participation via an internet collaboration tool plus teleconferences. The primary rating criterion was validity (1-9; 9 = recommendation definitely based on high-quality evidence). Recommendations were classified according to the panel's median final rating and level of disagreement.
The systematic scan resulted in 947 potentially relevant recommendations. 538 were excluded by physician investigators as not meeting study criteria. 409 were grouped into 178 similar recommendations, with 37 prioritized by the advisory council. Following refinements to the recommendations, the two expert panels rated 44 de-intensification recommendations. 37 (84%) were rated as valid (median validity rating between 7-9) without substantial disagreement. Recommendations classified as appropriate included: CVD (N = 10; e.g., stop carotid artery stenosis screening in asymptomatic patients); DM (N = 4; e.g., reduce DM medications in patients at high-risk for hypoglycemia); screening (non-CVD) (N = 13, e.g., don't screen for breast cancer in women with a limited life expectancy); and medication use (N = 10; e.g., decrease benzodiazepines in older adults).
Forty-four high-priority de-intensification recommendations were identified and 37 were validated.
Recommendations for de-intensifying medical care can be systematically developed and validated using evidence curated by existing guideline efforts. These findings set the stage for planning implementation approaches to stop or scale back unnecessary services.