Some proposals to reduce the things we do without reason

Nacho Vallejo

Reducing unnecessary tests and treatments in our organisations can be a complicated task, especially in its implementation. To facilitate its development, and in line with the previous reflection on the search for things we do without reason, we have new references that can serve as support.

Canadian Choosing Wisely's Diving into Overuse in Hospitals campaign aims to sensitise institutions to participate in this analysis by making changes (small or large) to reduce this excessive use. On their website, professionals have access to a large number of resources such as a "starter kit", webinars and other exciting supports.

Along these same lines, the Journal of Hospital Medicine began in 2015 a series of articles on things we do without reason. Some recent examples of these practices are the hospitalisation of patients with low-risk chest pain, the isolated use of thickened liquids in the treatment of hospitalised adults with dysphagia, or the use of insulin as mono-therapy for glycaemia control in this setting. Each article describes the commonly used reason for the test, treatment or clinical practice. It reflects on why it does not add value and highlights under what circumstances it can be valuable. Finally, what conclusions can we draw from the evidence and reflections provided? This series is not intended to be a standard of clinical practice, but is based on the need to generate debate, research, and the search for motivated agents among hospital professionals and patients, and reminds us that the review of low-value practices is the responsibility of everybody. To stimulate the incorporation and identification of new areas for improvement and encourage debate on social networks, they propose the following hashtag, #TWDFNR and they offer the following email twdfnr@hospitalmedicine.org where we can also send our contributions.

Lastly, The High-Value Practice Academic Alliance, another North American initiative that emerged in 2016, framed in value-based healthcare, incorporates the development of clinical practice guidelines to reduce unnecessary diagnostic tests and treatments. Some appeared in the "Less is more" section of the JAMA, such as the use of cardiac biomarkers, that of daily analytical extractions in hospitalised patients, the use of antibiotics in asymptomatic bacteriuria, the reduction of unnecessary transfusions and elimination of inappropriate constant monitoring by telemetry. On its website, it gives access to these guides already prepared and to another inspiring group of recommendations in development.

Reflection is open and not only in the hospital environment. Steps in this direction are also introduced from primary care. The identification of organisational and bureaucratic aspects that contribute little value to people's care, an issue discussed earlier in this blog, may also be a benefit for patients and greater satisfaction for professionals.

The process to identify these practices can indeed take time and requires the participation of multiple stakeholders. Still, it is an interesting opportunity to mobilise and train professionals, to pause, ask questions and lead the improvement of quality and safety in people's care and, ultimately, why not to reduce the economic cost of some of our actions.