De-implementation of low-value care: Less is more

De-implementation is the process to reduce low-value care, such as overuse and waste, and must result in less patients harm and lower costs. Several programs, e.g. Choosing Wisely, are initiated to address low-value care. However, four years after the start of the Choosing Wisely Netherlands campaign, only 32% of physicians and residents of internal medicine were aware of it. Nevertheless, half of the recommendations are implemented sufficiently in clinical practice, and especially in recommendations that need a multidisciplinary approach, room for improvement is present. Unfortunately, the introduction of a patient information leaflet did not increase the implementation of the Choosing Wisely recommendations, because dissemination was poor.
Next, inappropriate use of catheters, both intravenous and urinary, is a persistent example of low-value care. Peripheral venous catheters and urinary catheters are two of the most frequently used medical devices worldwide. These catheters are frequently inserted as part of routine care and considered safe by healthcare workers, while serious complications and patient burden occur. We found that inappropriate use of catheters is more common in medical patients compared to surgical patients. In medical patients, our de-implementation strategy reduced inappropriate use of peripheral venous catheters and urinary catheters in seven hospitals in the Netherlands.
Another example of low-value care is overdiagnosis and overtreatment of asymptomatic bacteriuria. We found that 24% of urine cultures and 56% of microscopic analysis were unnecessary performed in medical patients. Therefore, we will introduce a de-implementation strategy to reduce overdiagnosis and overtreatment of asymptomatic bacteriuria.