7.2: Underpinning theory

Many frameworks, theories and models provide useful conceptual constructs as well as practical approaches to identify, measure and engage strategically to reduce low-value care in health and aged care systems. Using these constructs can provide benchmarks and references to optimise value and quality decision-making at specific and general health system delivery levels. From these constructs appropriate interventions for reducing low-value care can be developed (Parker et al., 2022).

A number of theoretical frameworks in health services research and management help managers and clinicians determine low-value care, such as patient characteristics and behaviour, organisational factors, and external influences on individual practice and the operation of health service delivery organisations. Donabedian’s model on healthcare quality (Donabedian, 2005), Anderson’s behavioural model of health services use (Alkhawaldeh et al., 2023) and the diffusion of innovations theory (Dearing & Cox, 2018) are useful in fact-finding and crystallisation of information to support decision-making or change management processes.

Value-based healthcare

A useful perspective and opportunity to examine the impact and value of service delivery comes from the value-based healthcare model (Lewis et al., 2023), which examines and emphasises optimal outcomes for patients relative to the costs involved in care and service delivery. This model aligns financial incentives with concepts of quality and value in the focus on patient-centred care. The concept of value-based healthcare is directed to the reduction of low-value care by providing incentives to individual providers and health organisations to deliver high-quality cost-effective services and interventions through the engagement of patients, clients and consumers in shared decision-making.

Several practical and applied frameworks for understanding and acting on the reduction or elimination of low-value care are emerging nationally and internationally. The Choosing Wisely Australia strategy (see box text) is part of an international agenda that focuses on understanding, change and reform to minimise or eliminate low-value care in day-to-day clinical practice and service delivery. Collectively, professional bodies and organisations within health services focus entirely or incorporate important components of their agendas around standards development, provision of practices service delivery guidelines and reporting and benchmarking opportunities. The Royal Australian College of Physicians EVOLVE program (see box text) helps professions to identify significant incidents of low-value care and provides guidance and frameworks to deal with them.

CHOOSING WISELY AUSTRALIA

The Choosing Wisely Australia initiative is a health profession led engagement strategy aimed at promoting and developing a national dialogue about unnecessary tests, treatments and procedures. It focuses on supporting and enabling people to make healthcare choices and decisions based on evidence, necessity and strategies to reduce harm to individuals. The initiative and its activities are supported by professional colleges in healthcare, societies, associations and agencies that are involved in many aspects of quality, risk and safety in healthcare. The Choosing Wisely initiative began in the US in 2012, and the agenda and activities are now found in a number of countries throughout the world.

The Choosing Wisely Australia website (hosted by the Australian Commission on Safety and Quality in Healthcare) provides a range of information, evidence and discussion and an opportunity for individuals or groups to engage in the concepts promoted by this initiative.

ROYAL AUSTRALIAN COLLEGE OF PHYSICIANS EVOLVE INITIATIVE

The Royal Australian College of Physicians (RACP) EVOLVE initiative aims to reduce the provision of low-value care by empowering physicians to take the lead in transforming clinical practices, thereby enhancing patient care, fostering improved decision-making and optimising resource use. EVOLVE focuses on the ‘Top 5’ clinical practices that may be overused, provide little or no benefit or could cause harm for patients. Sponsored and facilitated by RACP, EVOLVE supports and enables physicians to take a key leadership role in changing clinical behaviour to enable better decision-making and, ultimately, appropriate and proportionate use of resources in clinical care.

The EVOLVE Top 5 methodology gives clinicians and those working in low-value care identification and change a framework that has been tested and which supports the development, refinement and finalisation of identified low-value practices in healthcare to create an action agenda for improvement and change.