The National Health Service is already under immense pressure to meet an ever-growing demand following a decade of austerity, the challenges of caring for a growing and ageing population, and pressure exerted on resources by the Covid-19 pandemic. Furthermore, advances in the medical sciences have led to the growth of new high-cost technologies (e.g., practices, medicines, devices, procedures, systems) which without a reduction in existing technologies or increase in resources, exerts unsustainable pressure on budgets [1-3]. New evidence relating to existing technologies can sometimes raise questions about the benefits of continued provision – either in general, or for groups of patients. Examples may include scenarios where evidence emerges that the technology is harmful or of limited benefit to a sub-group of patients, or an alternative technology becomes available that provides greater effectiveness/cost-effectiveness. It is important to ensure that these technologies continue to be provided to patients who are expected to benefit, but it may be possible to stop or reduce the technology use in people that are not expected to benefit [4].

 Stopping or reducing a technology that is currently available is referred to as 'de-adoption' [2]. In recent years, there has been increased global attention on de-adoption as a potential means to optimise healthcare [5]. There is now a significant amount of research related to the identification and prioritisation of technologies that could be candidates for de-adoption [6, 7], and growing interest in the implementation of initiatives to facilitate this (e.g. only funding the technology for patients who fulfil criteria) [8-10]. However, achieving this can be challenging due to common professional patterns and perceived (or actual) patient/public expectations [11]. More research is needed to identify the factors that support and hinder de-adoption initiatives and to investigate the implications of reducing the use of technologies from relevant stakeholders’ perspectives.

 The Evidence Based Intervention (EBI) Programme was introduced by NHS England and Improvement and came into effect on 1 April 2019 [12]. The programme requires regional commissioning bodies to stop or reduce the activity of interventions in scenarios where evidence indicates limited or no benefit (for some or all patients). The first list of 17 procedures identified was published in April 2019. The procedures are split into two categories: four procedures were in ‘category 1’ which meant that they should not be routinely provided. The remaining 13 procedures were ‘category 2’, which meant that they should only be considered when specific clinical criteria are met.

The overall aim of my PhD is to investigate patients’ understanding and experiences of NHS care for symptoms that could potentially be managed with three case-study procedures from the EBI programme. The case studies have been chosen based on their differing levels of available evidence from randomised controlled trials (e.g., published evidence versus ongoing trials). This factor was chosen as the literature indicates that evidence of a health technology’s effectiveness (or ineffectiveness) may influence de-adoption success and acceptability [13].

To address my aim, I will:

• Conduct qualitative interviews with patients who are potential candidates for the case-study procedures.
• Capture audio-recordings of their clinical consultations with healthcare professionals in which the patient’s eligibility for the case study procedures is going to be assessed.

Interviews with patients will allow me to explore their expectations, interpretations, and satisfaction about the care provided throughout their clinical pathway, stemming from initial healthcare seeking (e.g., consulting General Practice), to their latest consultation with healthcare professionals at the time of interview. I will also encourage patients to share their interpretations and general views surrounding access to NHS care. Audio-recordings of consultations will allow me to capture actual (rather than reported) clinical practice, with a focus on how treatment options are discussed with patients. Understanding the impact of the EBI programme from patients’ perspectives is timely and warranted given the need to develop approaches to optimise beneficial, evidence-based healthcare, and respond to the needs of patients.

 

References

1.         Harris, C., et al., Sustainability in Health care by allocating resources effectively (SHARE) 1: introducing a series of papers reporting an investigation of disinvestment in a local healthcare setting. BMC Health Services Research, 2017. 17(1): p. 323.

2.         Niven, D.J., et al., Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC medicine, 2015. 13(1): p. 255.

3.         Prasad, V., A. Cifu, and J.P.A. Ioannidis, Reversals of Established Medical Practices Evidence to Abandon Ship. Jama-Journal of the American Medical Association, 2012. 307(1): p. 37-38.

4.         Garner, S., et al., Reducing ineffective practice: challenges in identifying low-value health care using Cochrane systematic reviews. Journal of Health Services Research & Policy, 2013. 18(1): p. 6-12.

5.         Mafi, J.N. and M. Parchman, Low-value care: an intractable global problem with no quick fix. BMJ Quality & Safety, 2018. 27(5): p. 333-336.

6.         Elshaug, A.G., et al., Over 150 potentially low-value health care practices: an Australian study. Medical Journal of Australia, 2012. 197(10): p. 556-560.

7.         Esandi, M.E., et al., An evidence-based framework for identifying technologies of no or low-added value (NLVT). International Journal of Technology Assessment in Health Care., 2019.

8.         Levinson, W., et al., 'Choosing Wisely': a growing international campaign. BMJ Quality & Safety, 2015. 24(2): p. 167-74.

9.         Harris, C., et al., Sustainability in Health care by Allocating Resources Effectively (SHARE) 6: investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting. BMC Health Services Research, 2017. 17: p. 1-30.

10.       Dowling, S., et al., A Patient-focused Information Design Intervention to Support the Minor Traumatic Brain Injuries (mTBI) Choosing Wisely Canada Recommendation. Cureus, 2019. 11(10): p. e5877.

11.       Montini, T. and I.D. Graham, "Entrenched practices and other biases": unpacking the historical, economic, professional, and social resistance to de-implementation. Implementation Science, 2015. 10(1): p. 24-24.

12.       NHS England. Evidence-Based Interventions: Guidance for CCGs. 2019  [cited 2020 2.10.2020]; Available from: https://www.england.nhs.uk/wp-content/uploads/2018/11/ebi-statutory-guidance-v2.pdf.

13.       Prasad, V., V. Gall, and A. Cifu, The frequency of medical reversal. Arch Intern Med, 2011. 171(18): p. 1675-6.