Low-value injury care in the adult orthopaedic trauma population: A systematic review

Development and usability testing of a multifaceted intervention to reduce low-value injury care

BACKGROUND

Multifaceted interventions that address barriers and facilitators have been shown to be most effective for increasing the adoption of high-value care, but there is a knowledge gap on this type of intervention for the de-implementation of low-value care. Trauma is a high-risk setting for low-value care, such as unnecessary diagnostic imaging and the use of specialized resources. The aim of our study was to develop and assess the usability of a multifaceted intervention to reduce low-value injury care.

METHODS

We used the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change tool as theoretical foundations to identify barriers and facilitators, and strategies for the reduction of low-value practices. We designed an initial prototype of the intervention using the items of the Template for Intervention Description and Replication. The prototype's usability was iteratively tested through four focus groups and four think-aloud sessions with trauma decision-makers (n = 18) from seven Level I to Level III trauma centers. We conducted an inductive analysis of the audio-recorded sessions to identify usability issues and other barriers and facilitators to refine the intervention.

RESULTS

We identified barriers and facilitators related to individual characteristics, including knowledge and beliefs about low-value practices and the de-implementation process, such as the complexity of changing practices and difficulty accessing performance feedback. Accordingly, the following intervention strategies were selected: involving governing structures and leaders, distributing audit & feedback reports on performance, and providing educational materials, de-implementation support tools and educational/facilitation visits. A total of 61 issues were identified during the usability testing, of which eight were critical, 33 were moderately important, and 18 were minor. These issues led to numerous improvements, including the addition of information on the drivers and benefits of reducing low-value practices, changes in the definition of these practices, the addition of proposed strategies to facilitate de-implementation, and the tailoring of educational/facilitation visits.

CONCLUSIONS

We designed and refined a multifaceted intervention to reduce low-value injury care using a process that increases the likelihood of its acceptability and sustainability. The next step will be to evaluate the effectiveness of implementing this intervention using a pragmatic cluster randomized controlled trial.

TRIAL REGISTRATION

This protocol has been registered on ClinicalTrials.gov (February 24th 2023, #NCT05744154, https://clinicaltrials.gov/ct2/show/NCT05744154 ).

Hybrid kyphoplasty with short-versus intermediate- and long-segment pedicle screw fixations for the management of thoracolumbar burst fractures

BACKGROUND

This study aimed to determine if the hybrid short-segment (HSS) technique is a good alternative to the intermediate-segment (IS) and long-segment (LS) techniques in pedicle screw fixations for acute thoracolumbar burst fractures (TLBFs).

METHODS

In this retrospective evaluation, we examined 43 patients who underwent surgical treatments, including one- or two-level suprajacent (U) and infrajacent (L) pedicle screw fixations, for acute single-level TLBFs with neurological deficits between the T11 and L2 levels from July 2013 to December 2019. Among these patients, 15 individuals underwent HSS (U1L1), 12 received IS (U2L1), and 16 underwent LS (U2L2) fixations. Supplemental kyphoplasty of the fractured vertebral bodies was performed exclusively in the HSS group. Our analysis focused on assessing blood loss and surgical duration. Additionally, we compared postoperative thoracolumbar kyphotic degeneration using the data on Cobb angles on lateral radiographic images acquired at three time points (preoperatively, postoperative day 1, and follow-up). The end of follow-up was defined as the most recent postoperative radiographic image or implant complication occurrence.

RESULTS

Blood loss and surgical duration were significantly lower in the HSS group than in the IS and LS groups. Additionally, the HSS group exhibited the lowest implant complication rate (2/15, 13.33%), followed by the LS (6/16, 37.5%) and IS (8/12, 66.7%) group. Implant complications occurred at a mean follow-up of 7.5 (range: 6-9), 9 (range: 5-23), and 7 (range: 1-21) months in the HSS, IS, and LS groups. Among these implant complications, revision surgeries were performed in two patients in the HSS group, two in the IS group, and one in the LS group. One patient treated by HSS with balloon kyphoplasty underwent reoperation because of symptomatic cement leakage.

CONCLUSIONS

The HSS technique reduced intraoperative blood loss, surgical duration, and postoperative implant complications, indicating it is a good alternative to the IS and LS techniques for treating acute single-level TLBFs. This technique facilitates immediate kyphosis correction and successful maintenance of the corrected alignment within 1 year. Supplemental kyphoplasty with SpineJack® devices and high-viscosity bone cements for anterior reconstruction can potentially decrease the risk of cement leakage and related issues.

Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial

BACKGROUND

While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care.

METHODS

We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios.

DISCUSSION

On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm.

TRIAL REGISTRATION

This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).