Resumen de Iniciatives per a millorar l'adequació de la pràctica clínica en l'entorn hospitalari
Introduction. Improving the appropriateness of clinical practice refers to the choice of tests, treatments and other interventions that, according to scientific evidence, possess more benefits than risks, a reasonable cost-benefit ratio, and are compatible with the preferences of people and the society. This process includes identifying and eliminating low-value practices and promoting those that are more appropriate.
Objectives. 1. to describe the initiatives aimed at improving the appropriateness of clinical practice worldwide; 2. to develop methodological resources that assess and improve appropriateness in the hospital setting; and 3. to analyse the perceptions of health professionals about inappropriate or low-value practices and recommendations to reduce them.
Methods. We carried out five studies. To document initiatives of interest, we conducted a literature review. As methodological resources, we developed an open online database for consulting initiatives to improve the appropriateness of clinical practice and other information of interest. We also developed a set of indicators based on systematic reviews to assess appropriateness in two areas of the hospital setting. Finally, to achieve our third objective, we carried out two surveys and two focus groups with doctors and nurses.
Results. With the literature review we identified 22 initiatives from 10 countries, including Spain. As of July 2015, these initiatives produced 2,940 outputs in the form of recommendations and appropriateness analyses mainly from clinical practice guidelines and most commonly from scientific societies. We found great variability in the methodological rigor employed to develop these resources and to guarantee that they draw on the best evidence.
Based on our search results we created the website DianaHealth.com, which includes a database of the initiatives and their associated recommendations and appropriateness analyses.
We obtained 18 indicators applicable on delivery care from 303 systematic reviews (6%) and six indicators on peripheral arterial disease care from 149 reviews (4%).
In the surveys, we found a high agreement among doctors and nurses (83% and 96% respectively) with the recommendations for reducing low-value practices. In both groups, professionals believe that there is good adherence to these guidelines in the hospital (90% and 80%) and consider them useful (70% and 90%).
In the focus groups we identified defensive medicine, bad management of uncertainty and contradictory scientific evidence as the main barriers to reducing low-value practices. As facilitators, positive leadership and teamwork stand out.
Conclusions. The best-known initiatives for improving the appropriateness are those producing recommendations to reduce low-value practices, developed by scientific societies. Despite their important contributions, the lack of a rigorous and standardised methodology for identifying low-value practices or producing recommendations arouses concerns and jeopardises the implementation of their contributions.
Regarding the two methodological resources developed in this tehsis work, DianaHealth.com is still active and it is frequently consulted. As for the indicators based on systematic reviews, we found that the number of indicators that could be produced is limited by the lack of solid evidence on low-value practices and their implementation depends on the degree of detail, as well as the quality of clinical information.
In addition to employing scientific evidence, improving the appropriateness of clinical practice involves other aspects related to the beliefs and attitudes of healthcare professionals, the hospital environment and the dynamics of the healthcare system and society in general. These aspects should be worked on simultaneously and with the same intensity that should be devoted to ensuring that the initiatives are supported by the best scientific evidence available.
