Discussion
In this study, we found that a managed programme with clearly defined criteria can prevent the occurrence of low-value surgery. Pre-implementation and post implementation analyses of the programme showed that it is possible to reduce unnecessary cholecystectomies and endometriosis surgeries to virtually zero at the local level, resulting in reduced costs for the health system and increased patient safety. The primary strength of our programme is that it was performed in a real-world setting and is therefore likely to be generalisable at least to other Brazilian settings.
The explicit definition of the institutional criteria for performing these surgeries, approval by the expert council and postoperative confirmation of the clinical picture described by physicians requesting the procedures may be responsible for the changes observed in the physician practice patterns in our study.
In a recent review, Colla et al13 suggested that patient education or cost sharing, pay for performance, insurer restrictions, clinical decision support (clinical pathway and point-of-care decision support), physician education or feedback and the association of these interventions may be effective in reducing low-value care. However, almost all interventions aimed to reduce the overuse of antibiotics, acid-suppressive medications, blood transfusions and diagnostic tests. However, these interventions cannot be easily adapted to perioperative workflows.
In the systematic reviews cited above, only 10% of the studies evaluated strategies aimed at the deimplementation of surgical procedures. One such study was conducted by Wong et al,14 who mailed the results of an audit on the appropriateness of this procedure to all surgeons performing carotid endarterectomies in a Canadian city, along with clinical practice guidelines on the subject and a notification that prospective surveillance of the use of this procedure was to commence. Appropriate indications for surgery increased from 22% to 49%, and inappropriate surgeries decreased from 18% to 4%.
These findings suggest that active interventions and those with multiple components, such as ours, are more successful in producing deimplementation or deadoption of low-value care,15 although the subject still requires further research.16
We were unable to identify interventions with characteristics similar to those of our programme (institutional definition of surgical appropriateness criteria, third-party analysis of medical history and imaging studies to assess inclusion in these criteria, discussion and definition of the best conduct by a council of specialists in atypical cases and postoperative confirmation of the clinical picture).
In many cases, insurers’ preauthorisation programmes lack the detailed clinical discrimination required to contraindicate low-value procedures. Therefore, <2% of surgeries are refused by payers,17 which is much lower than that observed in the present study.
The interventions that most closely resemble our programme are mandatory second-opinion policies that have proven effective. An example of this type of intervention was a randomised multicentre study carried out in 36 hospitals in Latin America that followed 149 276 deliveries and induced a reduction in hospital caesarean section rates of 7.3% (95% CI 0.2%–14.5%).18 Since 2011, our hospital has been developing a second-opinion project to perform spine surgeries for one of the health plans served by the institution. This resulted in a recommendation for conservative treatment in 55.3% of the cases, and 11.1% of the patients were not considered to have a spinal disease.19
Mandatory second-opinion policies have the disadvantage of introducing a second doctor into patient care, which can compromise the physician–patient relationship with the first professional. In our intervention, the patient is only approached after the procedure has been performed, when confirmation of the clinical condition described by the physician and the collection of PROMs are carried out. Since January 2022, the Adequacy of Care Management Program has included all spinal surgeries performed at our institution.
Less invasive interventions for medical autonomy may also be effective. In a randomised controlled trial, local opinion leader education was an effective method of encouraging a trial of labour and vaginal birth for women with previous caesarean deliveries.20 Since 2014, our hospital has carried out a programme called Adequate Childbirth, which with a multicomponent approach (creation and training of a multidisciplinary team, education of pregnant women, improvements in infrastructure and audits of delivery types) achieved an increase in the vaginal delivery rate of 27.5% and reduced neonatal intensive care unit admissions by 31.2%.21
The US healthcare system wastes $760 billion to $935 billion annually, representing 25% of total healthcare costs.22 In 2012, the American Board of Internal Medicine Foundation started a campaign called ‘Choosing Wisely’, which aimed to reduce low-value care services.23 Although the USA undertook this and other national campaigns aimed at reducing low-value care, from 2014 to 2018, the cost of healthcare among individuals for fee-for-service Medicare remained virtually unchanged.24
Local policies that limit inappropriate care, in addition to economic appeal, could improve the quality and safety of care because they minimise iatrogenic diseases caused by unnecessary interventions. From both patient and health system perspectives, programmes of this type can improve the quality and safety of care and have positive economic implications. Preventing the performance of procedures that may not be beneficial for patients can lead to cost savings for the healthcare system and reduce the occurrence of a significant number of complications.
By providing perverse incentives for the overuse of procedures, the fee-for-service model is an additional complicating factor for the success of a low-value care deimplementation programme.25 In this payment system, surgeons earn higher profits for the performance of more surgeries. This is the case for surgeons who work at our hospital but are not hired by the institution. In fact, these physicians are the hospital’s main clients, as they bring patients from their offices to undergo surgery at the institution. In this model, the financial sustainability of institutions largely depends on the clinical and surgical admissions generated by the open clinical staff. In a relationship of this type, harmony between the medical staff and the organisation greatly depends on the financial relationship between the parties. The adoption of measures that limit the performance of surgical procedures recommended by physicians from the clinical staff and consequently reduce their financial gains is a difficult task that may repel surgeons. While this reduction in physicians’ autonomy to recommend surgery is a reason for discontent, doctors and patients are attracted to hospitals with good reputations, which is generally built through the adoption of strict safety protocols. This is the case with Hospital Israelita Albert Einstein, which occupied the 34th position among the best hospitals in the world in the 2023 ranking in Newsweek. A programme such as this does not seem to be viable in many institutions, as it may induce physicians to operate on their patients in other hospitals where their practice does not suffer any kind of interference.
In a value-based payment model, providers receive adjusted reimbursements based on quality and cost efficiency. In this context, PROMs can be a very useful metric.26 Among the patients who responded to the survey, almost half of those who underwent cholecystectomy and one-fifth of those who underwent surgery for endometriosis did not seem to have improved quality of life.
Moreover, this programme was only possible because of the institutional regulations of our organisation, whose articles are validated by a simple majority of votes in an assembly held with medical staff and establishes that the physicians’ practices must be based on the best available evidence and the institution reserves the right not to carry out procedures that could jeopardise patient safety.
Since programme implementation, these interventions in endometriosis surgery and cholecystectomy have continued. Currently (May 2023), in addition to the aforementioned spinal surgeries, the programme also manages operations for nephrolithiasis and venous stent implantation in Cockett syndrome, and it is being structured to include tonsillectomy and spinal infiltration.
Our study had several limitations. For ethical reasons, the team responsible for the programme did not approach the patients before performing the surgeries to confirm the details of the surgeon’s clinical history. However, all patients with endometriosis and most patients who underwent cholecystectomy answered a questionnaire containing relevant data from the clinical history and PROMs via telephone call or electronically during the postoperative period. In only one case of endometriosis, the information differed from the medical report required to schedule the surgery. As those in our hospital, many scheduled surgeries are suspended because of issues related to the patients (ie, withdrawal) or healthcare providers (ie, non-authorisation). Whether the reduction in low-value surgeries was motivated by the approach taken by the team responsible for the programme remains uncertain. We cannot state that the surgeries cancelled after the programme’s intervention did not occur in another hospital.
