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September 14, 2020

Identifying Recommendations for Stopping or Scaling Back Unnecessary Routine Services in Primary Care

Author Affiliations
  • 1Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
  • 2Department of Internal Medicine, University of Michigan, Ann Arbor
  • 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 4Medical student, University of Michigan Medical School, Ann Arbor
  • 5Department of Learning Health Sciences, University of Michigan, Ann Arbor
  • 6Pacific Northwest Evidence-Based Practice Center, Oregon Health & Science University, Portland
  • 7Division of General Medicine and Geriatrics, Oregon Health & Science University, Portland
  • 8Medical student, Wayne State University, School of Medicine, Detroit, Michigan
  • 9Veterans Affairs Quality Enhancement Research Initiative Center for Evaluation and Implementation Research, Ann Arbor, Michigan
JAMA Intern Med. Published online September 14, 2020. doi:10.1001/jamainternmed.2020.4001
Key Points

Question  Can a systematic, transparent, and reproducible approach be developed to identify, specify, and validate deintensification recommendations associated with routine adult primary care?

Findings  One hundred seventy-eight recommendations that represented unique opportunities to stop or scale back routine services were identified from a set of established guidelines, measures, and Choosing Wisely recommendations; of these, 37 recommendations were prioritized, specified, and assessed in 2 modified virtual Delphi expert panels. Panelists reviewed the evidence and suggested modifications, resulting in 44 recommendations being rated; overall, 37 recommendations were valid.

Meaning  The approach outlined can be used as a model for identifying, specifying, and validating deintensification recommendations that can be implemented and tracked in clinical practice.

Abstract

Importance  Much of health care involves established, routine use of medical services for chronic conditions or prevention. Stopping these services when the evidence changes or if the benefits no longer outweigh the risks is essential. Yet, most guidelines focus on escalating care and provide few explicit recommendations to stop or scale back (ie, deintensify) treatment and testing.

Objective  To develop a systematic, transparent, and reproducible approach for identifying, specifying, and validating deintensification recommendations associated with routine adult primary care.

Design, Setting, and Participants  A focused review of existing guidelines and recommendations was completed to identify and prioritize potential deintensification indications. Then, 2 modified virtual Delphi expert panels examined the synthesized evidence, suggested ways that the candidate recommendations could be improved, and assessed the validity of the recommendations using the RAND/UCLA Appropriateness Method. Twenty-five physicians from Veterans Affairs and US academic institutions with knowledge in relevant clinical areas (eg, geriatrics, primary care, women’s health, cardiology, and endocrinology) served as panel members.

Main Outcomes and Measures  Validity of the recommendations, defined as high-quality evidence that deintensification is likely to improve patient outcomes, evidence that intense testing and/or treatment could cause harm in some patients, absence of evidence on the benefit of continued or repeated intense treatment or testing, and evidence that deintensification is consistent with high-quality care.

Results  A total of 409 individual recommendations were identified representing 178 unique opportunities to stop or scale back routine services (eg, stopping population-based screening for vitamin D deficiency and decreasing concurrent use of opioids and benzodiazepines). Thirty-seven recommendations were prioritized and forwarded to the expert panels. Panelists reviewed the evidence and suggested modifications, resulting in 44 recommendations being rated. Overall, 37 recommendations (84%) were considered to be valid, as assessed by the RAND/UCLA Appropriateness Method.

Conclusions and Relevance  In this study, a total of 178 unique opportunities to deintensify routine primary care services were identified, and 37 of these were validated as high-priority deintensification recommendations. To date, this is the first study to develop a model for identifying, specifying, and validating deintensification recommendations that can be implemented and tracked in clinical practice.

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