Integrative framework for measuring overuse (using low back pain as an example)
| Goal | ||||
|---|---|---|---|---|
| Example | Data source | Specific measure example | Action items | Additional data needed for robust measurement |
| Change physician attitudes to clinical practice | ||||
| Assessment of provider awareness/attitudes of Choosing Wisely recommendation on low back pain imaging | Provider survey | Validated physician survey on Choosing Wisely awareness and attitudes | Understanding of provider awareness/understanding of Choosing Wisely recommendation | Data from a representative sample of physicians to avoid non-response bias |
| Tailor provider education on low back pain imaging | ||||
| Provider attitudes data assist in intervention design and assess impact | Linked responses from same physicians to track changes in attitudes over time | |||
| Assessment of provider satisfaction with care provided for low back pain | Provider interviews | Semi-structured interviews | Monitor for unintended consequences (eg, clinician–patient trust, provider satisfaction) | |
| Foster patient engagement and acceptance | ||||
| Determine patient perceptions regarding care for low back pain | Patient-reported experience measures | Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey (with expanded questions for low-value care) | Provide patient input in developing interventions to reduce low-value care | Measures from patients in areas not exposed to Choosing Wisely to assess campaign impact and monitor for unintended consequences |
| Monitor for unintended consequences (eg, patient dissatisfaction, clinician–patient trust) | ||||
| Assist providers in designing care plans for individual patients | ||||
| Assessment of patient-reported outcomes such as pain, function, work loss | Patient-reported outcome measures | Oswestry Low Back Pain Disability Questionnaire (OSW) | Data to assist in developing decision aids/care pathways to reduce low-value care | Linked experience and outcome measures to assess the relationship between patient care experience and outcomes |
| Monitor for unintended consequences | ||||
| Change key clinical practices | ||||
| Determine practice-specific rates of imaging for uncomplicated low back pain | Clinical data | Rate of CT/MRI excluding red flags (ie, history of cancer) | Feedback to providers on ordering behaviour—identification of outliers | Data from other practices to provide context of rate and similar practices not exposed to Choosing Wisely to assess impact of local interventions |
| Validation of administrative data on true degree of overuse | ||||
| Data to administrators to implement local interventions to reduce low-value care | ||||
| Assessment of impact on local Choosing Wisely efforts | Clinical data from all points of access to healthcare system (eg, walk-in clinics, ER visits) | |||
| Determine practice-specific rates of high-value imaging for low back pain | Clinical data | Rate of indicated CT/MRI (red flags) | Monitor for unintended consequences (eg, underuse of high-value services) | |
| Promote alignment with the healthcare system | ||||
| Determine regional rates of imaging for uncomplicated low back pain imaging (CT/MRI scans) | Administrative data | Rate of CT/MRI utilisation per 1000 population | Data to policy makers to inform policy development (i.e, payment reforms) | Utilisation rates from areas not exposed to Choosing Wisely to assess campaign effects |
| Feedback to regions/institutions on regional variation | ||||
| Assessment of impact of regional Choosing Wisely initiatives | Detailed clinical information (eg, symptoms, risk factors, disease severity, physician intent to treat) for exclusions | |||
| International comparisons | ||||
| Determine regional rates of alternate imaging for uncomplicated low back pain imaging | Administrative data | Rate of X-ray utilisation per 1000 population | Monitor for unintended consequences (eg, increased use of alternate procedures) | |