The De-adoption of Low-value Clinical Practices in Adult Critical Care Medicine
Abstract
Low-value clinical practices are common, and potentially harmful to patients and healthcare systems, yet the optimal approach to reducing (i.e. de-adopting) these practices is unknown. This thesis reports the results of three studies conducted with the overall objective of improving knowledge related to the de-adoption of low-value clinical practices in patients admitted to adult intensive care units (ICUs), an area known to have high resource consumption. First, a scoping review of the literature was conducted to systematically identify current knowledge regarding the science of de-adoption. From 109 citations, this review identified that current terminology is heterogeneous and poorly defined, that most of the literature evaluates the outcomes of some type of de-adoption effort, and that the most common (and least successful) approach to de-adoption is to wait for it to occur following passive diffusion of published research. A framework to guide the de-adoption process is proposed. Second, another scoping review using a replication research framework was conducted to identify low-value clinical practices among patients admitted to adult ICUs. Low-value practices were those wherein new evidence (i.e. replication research) suggests that an intervention previously thought to be beneficial is ineffective or harmful (i.e. evidence reversal). This review demonstrated that the results of nearly half of original replicated citations were reversed (n = 35, 49%), with the highest proportion of reversals in practices originally found to be beneficial (n = 21, 60%). Third, an interrupted time series analysis using the APACHE clinical database and patients admitted to adult ICUs in the United States examined the effects of replication research on clinical practice for a practice with evidence reversal, namely tight glycemic control. This study found notable changes in the practice of glycemic control following a clinical trial that demonstrated the benefits of tight glycemic control, with comparatively less change following a methodologically more rigorous trial that demonstrated its harmful effects. Taken together, the results of these three studies demonstrate the urgent need for additional research to understand and promote the de-adoption of low-value clinical practices.
Description
Keywords
Epidemiology, Medicine and Surgery
Citation
Niven, D. (2015). The De-adoption of Low-value Clinical Practices in Adult Critical Care Medicine (Doctoral thesis, University of Calgary, Calgary, Canada). Retrieved from https://prism.ucalgary.ca. doi:10.11575/PRISM/28042