International Roundtable Report
Choosing Wisely International Roundtable
Advancing Implementation of Choosing Wisely in Practice and Science
Report from NZ participants
This meeting was an opportunity for the twenty plus countries working on Choosing Wisely initiatives to exchange ideas and learn from each other – while forwarding Choosing Wisely International.
Pre-Meeting on October 1 – MEASUREMENT
On the Monday afternoon there was a roundtable meeting lead by Sacha Bhatia & Eve Kerr with help from Jeremy Grimshaw
- To discuss measurement & evaluation activities for national campaigns
- To assess the opportunities/interest for international collaboration based on pre-work
The main themes for the research objectives were:
- Evaluating implementation strategies on specific clinical areas/ priorities
- Comparing patient and physician surveys
- Review potential funding opportunities
- Establish a work plan to advance this research collaboration
The outcome was that there would be follow-up at the main meeting to:
- Prioritize potential research focus across diagnostic, therapeutic and procedure domains
- Develop a brief (1-2 page) overview of collaborative research agenda
- Discuss a framework paper, whether this will be based on attached Canadian draft or a separate article
Days 2 and 3 – ADVANCING IMPLEMENTATION OF CHOOSING WISELY IN PRACTICE AND SCIENCE
The objectives of the roundtable were to:
- Continue to provide forum for sharing of ideas, innovations and strategies to further Choosing Wisely campaigns
- Support new countries starting Choosing Wisely campaigns
- Develop opportunities to support international research/measurement & evaluation collaboration.
The main areas of discussion were:
- Medical Education – here we learnt in NZ we have probably started to liaise with student too late in their time at university and need to engage more with the Universty hierarchy.
- Patient and Public Engagement – here a new guide with successful ideas for engagement though out the world will be published. Other countries have a different take on the 4 questions for example in England they branded them the BRAN questions (benefits, risks, alternatives and (what if I do) nothing), and Wales use “What are my options”,” What are the benefits and risks” and “What can I do to help myself”. Another phrase suggested was “What matters to you” instead of what is the matter with you
- Implementation & Scalability and Measurement and Evaluation – were major themes of the working groups and the main addresses – see below
Other discussion areas added on were:
- Equity for other populations e.g. refugees, indigenous people etc
- How to measure cultural change and the possible use of a tool from the USA.
These discussions took place in small groups with some report back to the main forum. Most groups developed background papers for their talks which are available for the NZ Choosing Wisely office.
Some of these matters will be carried forward during the year with working groups operating via teleconferences throughout the year.
Trish Greenhalgh – Choosing Wisely: Implementation Science Meets Disinvestment
Trish Greenhalgh gave an address on Implementing Choosing Wisely in practice – a focus on disinvestment which provided a clear framework on successful implementation of Choosing Wisely She talked from the premise that in treating breast cancer not everyone needs intervention though multidisciplinary teams as some cancers are “simple” or “routine” in the treatment approach and we should focus (MDT discussion) on the complicated ones who stand to benefit more, therefore look at disinvestment in some kinds of MDT in some patients. A meta-analysis had shown that using MDTs to dictate treatment was better than not (using an MDT) but that they do not change the management in 55-96% of cases. As she said multi-disciplinary committees are great for complex shared decision-making and not always necessary the most appropriate way to deal with simpler cases. So it was an issue of stopping some areas of practice, but not throwing the baby out with the bathwater. Framing this issue was critical, “instead of depriving (some patients) of MDT input, focusing the MDT on the patients for which it shows true benefit to free up resources for other care and not to delay any treatment on routine cases.
Trish will be in NZ in 2020 for the WONCA conference.
Her book “How to implement evidence-based care” – gave a framework for looking at different units of analysis e.g. the evidence, the individual, group and the team etc
Learnings from this session included:
- If trying to change behaviour in terms of the evidence make it shorter, use pictures, use stories – create a persona to explain your case. Use infographics.
- Change needs leaders with vision, people who get on, clear goals, risk taking environment
- Using social cognitive theory [Bandura]: If I see people I respect doing this. And if I also practice doing it…And if I get support to get better at it… and if I feel confident doing it….…. I will probably do it.
- Remember when seeking to implement evidence (in relation to disinvestment or otherwise) – There is no magic way of making stuff happen, know a few principles, address practicalities, try stuff out and measure carefully to see if it’s working. Her powerpoint is available from the NZ CW office.
Jeremy Grimshaw – Advancing Implementation Science & Research on Choosing Wisely
Jeremy Grimshaw, who is working with Choosing Wisely in Canada, spoke about how institutions currently address implementation issues and research on behavioural science. He said many institutions try to make changes though issuing guidance, implementing something because it seems a good idea at the time.
He noted that:
“Evidence based medicine should be complemented by evidence-based implementation”
It was also noted that in implementation sciences there is consistent evidence of failure to translate research findings into clinical practice.
- 30-40% patients do not get treatments of proven effectiveness
- 20–25% patients get “care” that is not needed or potentially harmful
This suggests that implementation of research findings is a fundamental challenge for healthcare systems to optimise care, outcomes and costs.
He then looked at implementation science and also how to get behavioural change and he had collated a chart on what techniques are effective for this. His power point is available from the NZ Choosing Wisely office.
David Tovey and Bernard Burnand (Cochrane) talked on how to Improve the Quality of the Evidence for Choosing Wisely Campaigns & Recommendations.
And in a session on Aligning Agendas with International Organisations to support Choosing Wisely there were brief speeches from Niek Klazinga (OECD), Robin Osborne (Commonwealth Fund) and Anthony Staines (ISQuA) in which there was discussion of research and funding.
The meeting is followed up by forming several cross-national groups to tackle some of the issues raised – such as “de-implementation” evaluation, equity and cultural change.