Discussion
Our educational materials for patients did not increase the outcome of the three Choosing Wisely recommendations for internal medicine in the Netherlands. This could be due to a low adherence of the implementation, since only 19% of the subset of patients in the EDs received the patient summary leaflet. Nearly half of the small sample of patients who read the information about treatment limitations stated that the information helped them in the discussion with the physician. Therefore, we think that the patient information leaflets could still have important value in the conversations between physicians and patients.
Early results of seven Choosing Wisely recommendations showed also only minimal improvement in the USA, and structural outcome evaluations were missing.3 Four years later, reminders and patient education handouts for three Choosing Wisely recommendations was only associated with a small and unsustained increase in performance.13 Evidence about reducing low-value care is increasing, and recently, a framework was developed to reduce low-value care, which includes rigorous evaluation of Choosing Wisely implementation programmes.14 We found that 4 years after the start of the campaign, the implementation of the Choosing Wisely recommendation was already quite good in the EDs. The implementation was outstanding for the second recommendation, where only one patient received an abdominal X-rays for acute abdominal pain. Likewise, recommendation 3 was followed in 92% of all hospitalised patients. So, in these two recommendations, the low-value care was lower than our aim of 15%. However, results of an implementation study in Canada showed an increase in documented orders for treatment limitations, namely, 33% before implementation, 75% during implementation and 100% after 8 months of implementation.15 The implementation of the first recommendation was the lowest, with 20% of the patients who received a urinary catheter had no appropriate indication. Although this seems too much, earlier studies show that inappropriate use of urinary catheters is very common. For example, 28% of 649 catheters were placed without appropriate indication in the baseline period of a multifaceted intervention in 34 EDs in the USA.16 In the Netherlands, 32% of 324 catheters were inappropriate in non-surgical wards.8 So, 20% inappropriate indications for inserting a urinary catheter is not so high, which could be due to the awareness through the campaign and quality improvement projects to lower inappropriate catheter use.
We found no benefit of the patient information leaflets. The mean reason is probably due to the low adherence to the distribution of the leaflets. Further, this could be due to the already high implementation of the recommendations, since it has been shown before that improvement is larger when the baseline performance is poor,17 or due to shift changes with many different physicians in the ED. Earlier studies demonstrated that patient information leaflets can be very useful, especially for acute conditions where leaflets also improve adherence to treatment.18 A very recent controlled before–after study in two French EDs also showed that patients information leaflets improved communication between physicians and patients, and changed physicians behaviour to better care, since the number of re-consultations reduced from 32% to 18% (OR 0.46; 95% CI 0.27 to 0.77).19 In that study, 95% of the patients received an information leaflet and 86% read it. Of course, patient information leaflets will only be useful if patients receive, read and understand information. In our case, our ED seems not to be a workable setting for the implementation of patient materials by nurses or physicians due to the current work overload in EDs in the Netherlands. We do not know whether this intervention would be useful when a special quality healthcare worker would be handing out the leaflets.
Limitations
There are some limitations to be mentioned. First, although patient information leaflets were electronically distributed and paper forms were available in the EDs, most patients did not receive and read the leaflets. To implement the leaflets as part of regular care, in collaboration with the coordinating research nurse of the ED, we planned to disseminate the leaflets through the nurses in the triage room. Most patients have to wait quite some time to see a physician and for the laboratory results, and we thought that patients could use this time to read the leaflet. However, at the moment, this improvement project started the workload for nurses in the ED was a real problem, since a shortage of qualified nursing staff exists in the Netherlands.20 Therefore, the head of the ED of the first hospital stated that the workload of nurses could not be increased by handing over leaflets to patients or by being part of our quality improvement project. In addition, it was not possible to handover the leaflets to the registration/check-in secretary. Therefore, we had to disseminate the leaflets through the residents of the internal medicine instead. In the second hospital, we faced similar problems and also decided to disseminate the leaflets through residents. Residents were reminded to the leaflets through weekly small talks by the study coordinator in the first hospital; in the other hospital, the resident of the quality improvement team was daily present in the ED. For clarity, we asked some internal medicine residents about this process. Thereafter, we speculate that there were three main reasons why residents did not handover the leaflets. First, because they forgot the leaflet during the rushing moments in the ED. Second, because they thought the recommendations were not suitable for their patients. Third, since they already discussed symptoms and treatment options with their patients, they rather discussed the recommendations themselves without using the leaflet. Afterwards, we have to conclude that the project was probably not a priority for the management of the ED. The head of the ED agreed to start the project, but eventually we were unable to collaborate with the ED staff. With hindsight, we should have used different improvement cycles to increase the dissemination of the summary leaflets, with the help of some tools as, for example, a cause-and-effect diagram, a Plan-Do-Study-Act (PDSA) form, and/or run chart to let the quality improvement team reflect on the process.
The second limitation was the academic setting, with two EDs of university medical centres. Although the three recommendations are applicable in all hospitals in the Netherlands, we cannot extrapolate the results to non-university hospitals.
Next, if treatment limitations were discussed but not reported, we scored this as not reported. Although this could result in an underestimation of reported treatment limitations, this is in accordance with clinical practice. If physicians do not report treatment limitations, in practice this means that healthcare workers see this as ‘No treatment limitations’.
Further, we only focused on quantitative data since we aimed to implement the Choosing Wisely recommendations for internal medicine in two EDs. We could not include a detailed process evaluation of this quality improvement project. Further, we have no qualitative data of patients and physician experiences.
Finally, the power dynamic between patients and their physician, which is usually higher in a stressful setting as the ED, could potentially impact the results of our patient leaflets.
Strengths
This improvement project has some important strengths and implications. We did this improvement project in real practice and learnt that our ED is not the best setting to disseminate patient information leaflets, mainly due to a lack of management engagement and a shortage staff. Although the implementation of the three recommendations for internal medicine did not increase, the patients who received the information about treatment limitations reported that this helped them in the conversation with their physician. Most discussions about treatment limitations are in fact about cardiopulmonary resuscitation. However, the discussion around ‘Do not attempt cardiopulmonary resuscitation’ is difficult and often delayed. A review from 2016 found that physicians often hesitate to start this conversation due to concerns about possible distress for patients and fears of complaints.21 Furthermore, patients will not initiate the conversations themselves, even though they are willing to discuss treatment limitations,22 but our patient information leaflet could help to start this conversation. Next, this intervention is simple, low-cost and part of regular care, therefore well suited for further dissemination. To promote conversation between physicians and patients, future quality improvement projects could just use the patient information leaflet about treatment limitations instead of the summary leaflet of the three recommendations, since nearly half of the patients were helped by this leaflet. Furthermore, since the dissemination of leaflets was difficult, other non-printed formats to deliver patient information could be through multimedia, such as videos, audio records, patient-focused podcasts or web-based tools. However, no clear effect difference between print and multimedia has been demonstrated.23