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Education as a low-value improvement intervention: often necessary but rarely sufficient
  1. Christine Soong1,
  2. Kaveh G Shojania2
  1. 1 GIM, Mount Sinai Hospital, Toronto, Ontario, Canada
  2. 2 Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
  1. Correspondence to Dr Christine Soong, GIM, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada; christine.soong{at}

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Since the launch of Choosing Wisely in the United States,1 efforts to raise awareness about avoiding low-value care have spread internationally,2 prompting numerous commentaries,3–7 descriptive studies and improvement interventions,8–10 as well as inspiring new hospital job descriptions (eg, Chief Value Officer), journal sections11 and conferences devoted to the ‘Less is More’ paradigm. Low-value clinical care refers to services or interventions that provide little to no benefit to patients in specific clinical scenarios, may cause harm and/or incur unnecessary cost.6 12 13

One example of a commonly encountered low-value practice is the continuation of proton pump inhibitors (PPIs) in patients without indication for ongoing use. Following completion of a defined period of therapy for appropriate indications (eg, peptic ulcer disease), continued use of PPIs provides little value, yet de-prescribing occurs infrequently. Moreover, this low-value use unnecessarily exposes patients to associated PPI-related adverse events such as pneumonia and Clostridioides difficile infections.14 15 Like many other areas of low-value care, PPI deprescribing is the focus of numerous quality improvement interventions.16–18

In this issue of BMJ Quality and Safety, Bruno and colleagues examined the impact of a national educational intervention aimed at reducing outpatient PPI prescriptions in Australia.19 Australia’s NPS MedicineWise (previously the National Prescribing Service) developed the study intervention released in association with Choosing Wisely Australia’s similar educational materials and alerts highlighting the importance of reducing or ceasing PPI prescribing in the absence of specific indications. The programme began with mailings to general practitioners (GPs) showing data about their own PPI prescribing compared with other GPs nationwide. The remainder of the programme consisted of educational interventions, which the authors describe as a mixture of ‘passive’ and ‘active’ components. Passive components of the intervention included online educational resources, mailed evidenced-practice summary sheets and other …

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