Identifying and prioritizing do-not-do recommendations in Dutch general practice

Jako Burgers, Simone Van Dulmen, Tijn Kool

Keywords: Family practice, Netherlands, Clinical practice guidelines, Low-value care, De-implementation

Background:

Low-value care provides minimal or no benefit for the patient, wastes resources, and can cause harm. Efforts have been undertaken worldwide to identify these low-value care practices. The Dutch College of General Practitioners (GPs) runs a longstanding guideline programme including do-not-do recommendations.

Research questions:

To identify and to prioritize do-not-do recommendations for implementation to reduce low-value care.

Method:

We used a mixed method design in Dutch primary care. First, we identified do-not-do recommendations through a systematic assessment of 92 Dutch guidelines for GPs, resulting in 385 do-not-do recommendations. Second, we selected 146 recommendations addressing high prevalent conditions. Third, a random sample of 5000 Dutch GPs was invited for an online survey to prioritize recommendations based on the prevalence of the condition and low-value care practice, potential harm, and potential cost reduction on a scale from 1 to 5/6. Total scores could range from 4 to 22. Recommendations with a median score > 12 were included. In total, 440 GPs completed the survey.

Results:

The selection process led to a list of 30 prioritised recommendations. These covered drug treatments (n = 12), diagnostics (n = 10), referral to other healthcare professions (n = 5), and non-drug treatment (n = 3). Examples are not to prescribe antibiotics in children with acute otitis media, not to request imaging in patients with non-specific low back pain, not to refer to a (orthopedic) surgeon for an epicondylitis, and not to treat warts longer than 3 months with cryotherapy.

Conclusions:

The list of 30 high-priority do-not-do recommendations can be used to raise awareness of low-value care among GPs and to facilitate quality improvement projects. As the recommendations are supported with the latest evidence from international studies, GPs and policy makers in other countries can use the list for validating the list in their context and designing strategies to reduce low-value care.

Points for discussion:

Method for selecting and prioritising do-not-do recommendations from guidelines

Country and health system context sensitivity for accepting or rejecting do-not-do recommendations

De-implementation strategies to reduce low-value care