Routine preoperative assessment for cataract surgery is a source of frustration for primary care providers.

BACKGROUND: Cataract surgery is one of the most common surgical procedures performed in older adults in the United States and is generally considered to be extremely low-risk. As of 2019, routine preoperative evaluation within 30 days of surgery is no longer mandated by the United States of America (USA) Centers for Medicare & Medicaid Services (CMS) for ambulatory surgery centers, but it is unclear how primary care providers perceive this change. METHODS: We performed a qualitative analysis of semi-structured interviews with six primary care providers to explore primary care providers' perspectives on routine preoperative assessment for cataract surgery. RESULTS: Primary care providers commented on the large number of referrals they receive for preoperative assessment before cataract procedures. The analysis revealed an overarching sentiment of resentment over the time, effort, and resources expended on these assessments. Themes included the lack of awareness of the updated regulations that no longer require a history and physical to be completed within 30 days and the perception of a universal lack of medical necessity to perform preoperative assessment for cataract surgery. Providers also commented on the strain on limited resources and the burden on patients. The relationship between specialties and professional roles emerged as another important theme. CONCLUSIONS: Referrals for preoperative clearance for cataract surgery continue to burden providers, patients, and the health system, and represent an opportunity to streamline care in this patient population.

Prevalence, trends, and outcomes of same-day discharge following elective percutaneous coronary intervention: a retrospective observational cohort study using routinely-collected health data.

AIMS: To identify the prevalence, trends, and outcomes of same-day discharge following elective percutaneous coronary intervention among six public hospitals in one Australian State. METHODS AND RESULTS: A retrospective observational research design was used. A total of 4387 cases were obtained from the State Cardiac Outcomes Registry and National Hospital Cost Data Collection. The two datasets were linked using identifiable data items. Patients were those who had elective percutaneous coronary intervention between December 2012 and December 2019 either discharged the same day of the procedure or the next day. Data were analysed using descriptive and inferential statistics. The overall same-day discharge prevalence was 6.5%, with a trend increasing from 0.2% in 2013 to 9.0% in 2019. The prevalence varied at the individual hospital level. Two hospitals did not perform same-day discharge during the study period. The remaining hospitals demonstrated variability in same-day discharge prevalence, with the highest from one hospital being 28.2% in 2019. Almost all same-day discharge patients experienced no complications during or following percutaneous coronary intervention within 24 hours. Compared to next-day discharge, same-day discharge reduced the length of stay by 18 hours and conferred an average of $3695 cost-savings per patient. CONCLUSIONS: There was limited implementation of same-day discharge in the six public hospitals contributing data to this study. Improvement in the same-day discharge rate could result in better hospital resource utilisation and reduce low-value care. Hence, strategies to implement and promote same-day discharge are warranted.

Value-Based Radiology in Canada: Reducing Low-Value Care and Improving System Efficiency.

Radiology departments are increasingly tasked with managing growing demands on services including long waitlists for scanning and interventional procedures, human health resource shortages, equipment needs, and challenges incorporating advanced imaging solutions. The burden of system inefficiencies and the overuse of "low-value" imaging causes downstream impact on patients at the individual level, the economy and healthcare system at the societal level, and planetary health at an overarching level. Low value imaging includes those performed for an inappropriate clinical indication, with little to no value to the management of the patient, and resulting in healthcare resource waste; it is estimated that up to a quarter of advanced imaging studies in Canada meet this criterion. Strategies to reduce low-value imaging include the development and use of referral guidelines, use of appropriateness criteria, optimization of existing protocols, and integration of clinical decision support tools into the ordering provider's workflow. Additional means of optimizing system efficiency such as centralized intake models, improved access to electronic medical records and outside imaging, enhanced communication with patients and referrers, and the utilization of artificial intelligence will further increase the value of radiology provided to patients and care providers.

Association of a Novel Electronic Form for Preoperative Cardiac Risk Assessment With Reduction in Cardiac Consultations and Testing: Retrospective Cohort Study.

BACKGROUND: Preoperative cardiac risk assessment is an integral part of preoperative evaluation; however, there is significant variation among providers, leading to inappropriate referrals for cardiology consultation or excessive low-value cardiac testing. We implemented a novel electronic medical record (EMR) form in our preoperative clinics to decrease variation. OBJECTIVE: This study aimed to investigate the impact of the EMR form on the preoperative utilization of cardiology consultation and cardiac diagnostic testing (echocardiograms, stress tests, and cardiac catheterization) and evaluate postoperative outcomes. METHODS: A retrospective cohort study was conducted. Patients who underwent outpatient preoperative evaluation prior to an elective surgery over 2 years were divided into 2 cohorts: from July 1, 2021, to June 30, 2022 (pre-EMR form implementation), and from July 1, 2022, to June 30, 2023 (post-EMR form implementation). Demographics, comorbidities, resource utilization, and surgical characteristics were analyzed. Propensity score matching was used to adjust for differences between the 2 cohorts. The primary outcomes were the utilization of preoperative cardiology consultation, cardiac testing, and 30-day postoperative major adverse cardiac events (MACE). RESULTS: A total of 25,484 patients met the inclusion criteria. Propensity score matching yielded 11,645 well-matched pairs. The post-EMR form, matched cohort had lower cardiology consultation (pre-EMR form: n=2698, 23.2% vs post-EMR form: n=2088, 17.9%; P<.001) and echocardiogram (pre-EMR form: n=808, 6.9% vs post-EMR form: n=591, 5.1%; P<.001) utilization. There were no significant differences in the 30-day postoperative outcomes, including MACE (all P>.05). While patients with "possible indications" for cardiology consultation had higher MACE rates, the consultations did not reduce MACE risk. Most algorithm end points, except for active cardiac conditions, had MACE rates <1%. CONCLUSIONS: In this cohort study, preoperative cardiac risk assessment using a novel EMR form was associated with a significant decrease in cardiology consultation and testing utilization, with no adverse impact on postoperative outcomes. Adopting this approach may assist perioperative medicine clinicians and anesthesiologists in efficiently decreasing unnecessary preoperative resource utilization without compromising patient safety or quality of care.

How do experts determine where to intervene on test ordering? An interview study.

OBJECTIVES: Lab testing is a high-volume activity that is often overused, leading to wasted resources and inappropriate care. Improving test ordering practices in tertiary care involves deciding where to focus scarce intervention resources, but clear guidance on how to optimize these resources is lacking. We aimed to explore context-sensitive factors and processes that inform individual decisions about laboratory stewardship interventions by speaking to key interest holders in this area. METHODS: We conducted semi-structured interviews with test-ordering intervention development experts and authors of test-ordering guidance documents to explore five broad topics: 1) processes used to prioritize tests for intervention; 2) factors considered when deciding which tests to target; 3) measurement of these factors; 4) interventions selected; 5) suggestions for a framework to support these decisions. Transcripts were double coded using directed-content and thematic analysis. RESULTS: We interviewed 14 intervention development experts. Experts noted they frequently consider test volume, test value, and patient care when deciding on a test to target. Experts indicated that quantifying many relevant factors was challenging. Processes to support these decisions often involved examining local data, obtaining buy-in, and relying on an existing guideline. Suggestions for building a framework emphasized the importance of collaboration, consideration of context and resources, and starting with "easy wins" to gain support and experience. CONCLUSIONS: Our study provides insight into the factors and processes experts consider when deciding which tests to target for intervention and can inform the development of a framework to guide the selection of tests for intervention and guideline development.

Effectiveness of de-implementation of low-value healthcare practices: an overview of systematic reviews.

BACKGROUND: Reducing low-value care (LVC) is crucial to improve the quality of patient care while increasing the efficient use of scarce healthcare resources. Recently, strategies to de-implement LVC have been mapped against the Expert Recommendation for Implementing Change (ERIC) compilation of strategies. However, such strategies' effectiveness across different healthcare practices has not been addressed. This overview of systematic reviews aimed to investigate the effectiveness of de-implementation initiatives and specific ERIC strategy clusters. METHODS: We searched MEDLINE (Ovid), Epistemonikos.org and Scopus (Elsevier) from 1 January 2010 to 17 April 2023 and used additional search strategies to identify relevant systematic reviews (SRs). Two reviewers independently screened abstracts and full texts against a priori-defined criteria, assessed the SR quality and extracted pre-specified data. We created harvest plots to display the results. RESULTS: Of 46 included SRs, 27 focused on drug treatments, such as antibiotics or opioids, twelve on laboratory tests or diagnostic imaging and seven on other healthcare practices. In categorising de-implementation strategies, SR authors applied different techniques: creating self-developed strategies (n = 12), focussing on specific de-implementation strategies (n = 14) and using published taxonomies (n = 12). Overall, 15 SRs provided evidence for the effectiveness of de-implementation interventions to reduce antibiotic and opioid utilisation. Reduced utilisation, albeit inconsistently significant, was documented in the use of antipsychotics and benzodiazepines, as well as in laboratory tests and diagnostic imaging. Strategies within the adapt and tailor to context, develop stakeholder interrelationships, and change infrastructure and workflow ERIC clusters led to a consistent reduction in LVC practices. CONCLUSION: De-implementation initiatives were effective in reducing medication usage, and inconsistent significant reductions were observed for LVC laboratory tests and imaging. Notably, de-implementation clusters such as change infrastructure and workflow and develop stakeholder interrelationships emerged as the most encouraging avenues. Additionally, we provided suggestions to enhance SR quality, emphasising adherence to guidelines for synthesising complex interventions, prioritising appropriateness of care outcomes, documenting the development process of de-implementation initiatives and ensuring consistent reporting of applied de-implementation strategies. REGISTRATION: OSF Open Science Framework 5ruzw.

Barriers and facilitators for reducing low-value home-based nursing care: A qualitative exploratory study among homecare professionals.

AIM: To explore barriers and facilitators for reducing low-value home-based nursing care. DESIGN: Qualitative exploratory study. METHOD: Seven focus group interviews and two individual interviews were conducted with homecare professionals, managers and quality improvement staff members within seven homecare organizations. Data were deductively analysed using the Tailored Implementation for Chronic Diseases checklist. RESULTS: Barriers perceived by homecare professionals included lack of knowledge and skills, such as using care aids, interactions between healthcare professionals and general practitioners creating expectations among clients. Facilitators perceived included reflecting on provided care together with colleagues, clearly communicating agreements and expectations towards clients. Additionally, clients' and relatives' behaviour could potentially hinder reduction. In contrast, clients' motivation to be independent and involving relatives can promote reduction. Lastly, non-reimbursement and additional costs of care aids were perceived as barriers. Support from organization and management for the reduction of care was considered as facilitator. CONCLUSION: Understanding barriers and facilitators experienced by homecare professionals in reducing low-value home-based nursing care is crucial. Enhancing knowledge and skills, fostering cross-professional collaboration, involving relatives and motivating clients' self-care can facilitate reduction of low-value home-based nursing care. Implications for profession and patient care: De-implementing low-value home-based nursing care offers opportunities for more appropriate care and inclusion of clients on waitlists. IMPACT: Addressing barriers with tailored strategies can successfully de-implement low-value home-based nursing care. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research checklist was used. No patient or public contribution.

Unravelling Low-Value Care Decision-Making: Residents' Perspectives on the Influence of Contextual Factors.

BACKGROUND: Several initiatives have been developed to target low-value care (ie, waste) in decision-making with varying success. As such, decision-making is a complex process and context's influence on decisions concerning low-value care is limitedly explored. Hence, a more detailed understanding of residents' decision-making is needed to reduce future low-value care. This study explores which contextual factors residents experience to influence their decision-making concerning low-value care. METHODS: We employed nominal group technique (NGT) to select four low-value care vignettes. Prompted by these vignettes, we conducted individual interviews with residents. We analyzed the qualitative data thematically using an inductive-deductive approach, guided by Bronfenbrenner's social-ecological framework. This framework provided guidance to "context" in terms of sociopolitical, environmental, organizational, interpersonal, and individual levels. RESULTS: In 2022, we interviewed 19 residents from a Dutch university medical center. We identified 33 contextual factors influencing residents' decision-making, either encouraging or discouraging low-value care. The contextual factors resided in the following levels with corresponding categories: (1) environmental and sociopolitical: society, professional medical association, and governance; (2) organizational: facility characteristics, social infrastructure, and work infrastructure; (3) interpersonal: resident-patient, resident-supervising physician, and resident-others; and (4) individual: personal attributes and work structure. CONCLUSION: This paper describes 33 contextual factors influencing residents' decision-making concerning low-value care. Residents are particularly influenced by factors related to interactions with patients and supervisors. Furthermore, organizational factors and the broader environment set margins within which residents make decisions. While acknowledging that a multi(faceted)-intervention approach targeting all contextual factors to discourage low-value care delivery may be warranted, improving communication skills in the resident-patient dynamics to recognize and explain low-value care seems a particular point of interest over which residents can exercise an influence themselves.

Specifying behavioural and strategy components of de-implementation efforts targeting low-value prescribing practices in secondary health care.

BACKGROUND: /Aims De-implementation, including the removal or reduction of unnecessary or inappropriate prescribing, is crucial to ensure patients receive appropriate evidence-based health care. The utilization of de-implementation efforts is contingent on the quality of strategy reporting. To further understand effective ways to de-implement medical practices, specification of behavioural targets and components of de-implementation strategies are required. This paper aims to critically analyse how well the behavioural targets and strategy components, in studies that focused on de-implementing unnecessary or inappropriate prescribing in secondary healthcare settings, were reported. METHODS: A supplementary analysis of studies included in a recently published review of de-implementation studies was conducted. Article text was coded verbatim to two established specification frameworks. Behavioural components were coded deductively to the five elements of the Action, Actor, Context, Target, Time (AACTT) framework. Strategy components were mapped to the nine elements of the Proctor's 'measuring implementation strategies' framework. RESULTS: The behavioural components of low-value prescribing, as coded to the AACTT framework, were generally specified well. However, the Actor and Time components were often vague or not well reported. Specification of strategy components, as coded to the Proctor framework, were less well reported. Proctor's Actor, Action target: specifying targets, Dose and Justification elements were not well reported or varied in the amount of detail offered. We also offer suggestions of additional specifications to make, such as the 'interactions' participants have with a strategy. CONCLUSION: Specification of behavioural targets and components of de-implementation strategies for prescribing practices can be accommodated by the AACTT and Proctor frameworks when used in conjunction. These essential details are required to understand, replicate and successfully de-implement unnecessary or inappropriate prescribing. In general, standardisation in the reporting quality of these components is required to replicate any de-implementation efforts. TRIAL REGISTRATION: Not registered.

Success factors for interventions to reduce low-value imaging. Six crucial lessons learned from a practical case study in Norway.

BACKGROUND: Substantial overuse of health care services is identified and intensified efforts are incited to reduce low-value services in general and in imaging in particular. OBJECTIVE: To report crucial success factors for developing and implementing interventions to reduce specific low-value imaging examinations based on a case study in Norway. MATERIALS AND METHODS: Mixed methods design including one systematic review, one scoping review, implementation science, qualitative interviews, content analysis of stakeholders' input, and stakeholder deliberations. RESULTS: The description and analysis of an intervention to reduce low-value imaging in Norway identifies six general success factors: 1) Acknowledging complexity: advanced knowledge synthesis, competence of the context, and broad and strong stakeholder involvement is crucial to manage de-implementation complexity. 2) Clear consensus-based criteria for selecting low-value imaging procedures are key. 3) Having a clear target group is critical. 4) Stakeholder engagement is essential to ascertain intervention relevance and compliance. 5) Active and well-motivated intervention collaborators is imperative. 6) Paying close attention to the mechanisms of low-value imaging and the barriers to reduce it is decisive. CONCLUSION: Reducing low-value imaging is crucial to increase the quality, safety, efficiency, and sustainability of the health services. Reducing low-value imaging is a complex task and paying attention to specific practical success factors is key.

Use and Cost of Low-Value Services Among Veterans Dually Enrolled in VA and Medicare.

BACKGROUND: Over half of veterans enrolled in the Veterans Health Administration (VA) are also enrolled in Medicare, potentially increasing their opportunity to receive low-value health services within and outside VA. OBJECTIVES: To characterize the use and cost of low-value services delivered to dually enrolled veterans from VA and Medicare. DESIGN: Retrospective cross-sectional. PARTICIPANTS: Veterans enrolled in VA and fee-for-service Medicare (FY 2017-2018). MAIN MEASURES: We used VA and Medicare administrative data to identify 29 low-value services across 6 established domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing, and surgery. We determined the count of low-value services per 100 veterans delivered in VA and Medicare in FY 2018 overall, by domain, and by individual service. We applied standardized estimates to determine each service's cost. KEY RESULTS: Among 1.6 million dually enrolled veterans, the mean age was 73, 97% were men, and 77% were non-Hispanic White. Overall, 63.2 low-value services per 100 veterans were delivered, affecting 32% of veterans; 22.9 services per 100 veterans were delivered in VA and 40.3 services per 100 veterans were delivered in Medicare. The total cost was $226.3 million (M), of which $62.6 M was spent in VA and $163.7 M in Medicare. The most common low-value service was prostate-specific antigen testing at 17.3 per 100 veterans (VA 55.9%, Medicare 44.1%). The costliest low-value service was percutaneous coronary intervention (VA $10.1 M, Medicare $32.8 M). CONCLUSIONS: Nearly 1 in 3 dually enrolled veterans received a low-value service in FY18, with twice as many low-value services delivered in Medicare vs VA. Interventions to reduce low-value services for veterans should consider their substantial use of such services in Medicare.

Mapping the Environmental Co-Benefits of Reducing Low-Value Care: A Scoping Review and Bibliometric Analysis.

Reducing low-value care (LVC) and improving healthcare's climate readiness are critical factors for improving the sustainability of health systems. Care practices that have been deemed low or no-value generate carbon emissions, waste and pollution without improving patient or population health. There is nascent, but growing, research and evaluation to inform practice change focused on the environmental co-benefits of reducing LVC. The objective of this study was to develop foundational knowledge of this field through a scoping review and bibliometric analysis. We searched four databases, Medline, Embase, Scopus and CINAHL, and followed established scoping review and bibliometric analysis methodology to collect and analyze the data. A total of 145 publications met the inclusion criteria and were published between 2013 and July 2023, with over 80% published since 2020. Empirical studies comprised 21%, while commentary or opinions comprised 51% of publications. The majority focused on healthcare generally (27%), laboratory testing (14%), and medications (14%). Empirical publications covered a broad range of environmental issues with general and practice-specific 'Greenhouse gas (GHG) emissions', 'waste management' and 'resource use' as most common topics. Reducing practice-specific 'GHG emissions' was the most commonly reported environmental outcome. The bibliometric analysis revealed nine international collaboration networks producing work on eight key healthcare areas. The nineteen 'top' authors were primarily from the US, Australia and Canada.

Estimating oncologist variability in prescribing systemic cancer therapies to patients in the last 30 days of life.

INTRODUCTION: Clinical guidelines and quality improvement initiatives have identified reducing the use of end-of-life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation. RESULTS: Patients' median age at the time of death was 74 years (interquartile range, 69-79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end-of-life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end-of-life cancer therapy (OR, 4.42; 95% CI, 4.00-4.89). CONCLUSIONS: Oncologists show substantial variation in end-of-life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision-making can reduce overuse of end-of-life cancer therapies.

Gender Disparities in Adverse Events Resulting From Low-Value Practices in Family Practice in Spain: A Retrospective Cohort Study.

Objectives: This study aimed to evaluate gender-based disparities in preventable adverse events due to low-value practices (LVPs) in primary care. Methods: A retrospective cohort study in Alicante, Spain. Results: A total of 1,516 patient records were examined, finding that older individuals and women experienced more LVP-related events. Female patients faced a higher volume of such events than males with the same health issue. Interaction analysis revealed patients treated by male physicians had more severe events, while those attended by females experienced milder ones. Adverse events were more frequent in LVPs associated with gender-based reasons. Conclusion: These results highlight the need for tailored healthcare professional awareness programs on overuse's impact on safety. Addressing outcome differences between male and female patients should inform awareness campaigns.

Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization.

BACKGROUND: Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada. METHODS: We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes. DISCUSSION: The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work. TRIAL REGISTRATION: This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic. CLINICALTRIALS: gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.

Assessing MRI referrals' appropriateness for low back pain post a radiology-initiated intervention.

INTRODUCTION: This study evaluated a pilot intervention to reduce low-value Magnetic Resonance Imaging (MRI) referrals for Low Back Pain (LBP). METHODS: This before-after intervention study analysed MRI referrals for LBP at two private imaging centres in Norway. MRI referrals for LBP obtained before and after an intervention of information campaigns and sending a return letter to clinicians for declined referrals were evaluated on information, quality, and justification rates. Four radiologists and two radiographers assessed the referrals. A point system was used to calculate referral quality. Each referral was given a score 'good' when rated above 5.5 and 'poor' below 2.5. Justification was based on assessors categorised rating as justified, unjustified or need more information. Stata Statistical Software (Release 18) was used for analysis. A mixed model analysed variations of the referrals pre- and post-intervention. A p-value of <.05 in variations was considered statistically significant. RESULTS: A total n = 300 patients' referrals (150 referrals pre- and post-intervention) were collected and assessed. Post-intervention, 68% of referrals were justified, up from 63% pre-intervention. The assessment showed a 4% decrease in referrals with poor scores and a 2% increase in those rated as good or intermediate quality post-intervention. These changes were not statistically significant. CONCLUSION: It is important to state that it was not possible in our study to identify the subgroup of referrals that are known to be from clinicians who had received a return letter, although the information campaign targeted all referrers. Despite the limitations our findings suggest that providing reasons for declined referrals can serve as an educational tool for clinicians and contribute to the reduction of low value MRI for LBP. IMPLICATIONS FOR PRACTICE: Radiology department initiatives that raise awareness and offer referral criteria guidance to clinicians can serve as valuable educational tools, and further emphasize the importance of providing comprehensive information in MRI referrals for LBP.

Reducing low-value imaging-A qualitative evaluation of a pilot intervention in Norway.

RATIONAL: Low-value radiological imaging threatens patient safety and efficient use of limited health resources. It is important to evaluate measures for reducing low-value utilisation, to learn and to improve. Accordingly, the objective of this study was to qualitatively evaluate a pilot intervention for reducing low-value imaging in Norway. METHODS: Semi-structured interviews were conducted aimed at describing stakeholders' experience with a multicomponent pilot intervention consisting of a standardised procedure for referral assessment, a standardised return letter, and information about the value and possible risks of magnetic resonance imaging-examinations to the public. Data were analysed in line with qualitative content analysis with a deductive approach. RESULTS: Seven healthcare providers were interviewed, including two radiologists, two radiographers, one manual therapist, one practice consultant and one general practitioner. Data analysis yielded four categories: (1) information and reception, (2) referral- and assessment processes, (3) suggestions for improvement and facilitation and (4) outcomes of the pilot intervention. CONCLUSIONS: The pilot intervention was deemed acceptable, feasible, engaging and relevant. Specific training in the use of the new procedure was suggested to improve the intervention. The simple design, as well as the positive acceptance demonstrated and the few resources needed, make the pilot intervention and methodology highly relevant for other settings or when aiming to reduce the number of other low-value radiology examinations.

Identification of low-value practices susceptible to gender bias in primary care setting.

BACKGROUND: Data on overuse of diagnostic and therapeutic resources underline their contribution to the decline in healthcare quality. The application of "Do Not Do" recommendations, in interaction with gender biases in primary care, remains to be fully understood. Therefore, this study aims to identify which low-value practices (LVPs) causing adverse events are susceptible to be applied in primary care setting with different frequency between men and women. METHODS: A consensus study was conducted between November 1, 2021, and July 4, 2022, in the primary care setting of the Valencian Community, Spain. Thirty-three of the 61 (54.1%) health professionals from clinical and research settings invited, completed the questionnaire. Participants were recruited by snowball sampling through two scientific societies, meeting specific inclusion criteria: over 10 years of professional experience and a minimum of 7 years focused on health studies from a gender perspective. An initial round using a questionnaire comprising 40 LVPs to assess consensus on their frequency in primary care, potential to cause serious adverse events, and different frequency between men and women possibly due to gender bias. A second round-questionnaire was administered to confirm the final selection of LVPs. RESULTS: This study identified nineteen LVPs potentially linked to serious adverse events with varying frequencies between men and women in primary care. Among the most gender-biased and harmful LVPs were the use of benzodiazepines for insomnia, delirium, and agitation in the elderly, and the use of hypnotics without a previous etiological diagnosis. CONCLUSIONS: Identifying specific practices with potential gender biases, mainly in mental health for the elderly, contributes to healthcare promotion and bridges the gap in gender inequalities. TRIAL REGISTRATION: NCT05233852, registered on 10 February 2022.

Multi-layered structure and physicochemical properties of reconstituted meat-based products from minced fish by physical extrusion: Impact of extrusion strength.

Multi-layered structure of reconstituted meat-based products from minced fish was formed by physical extrusion, followed by an investigation into the impact of extrusion strength on structural and physicochemical properties before and after frying. Under an appropriate pressure (3-9 kPa), the air within minced fish underwent enrichment and rearrangement to form a stratified phase, promoting the formation of multi-layered structure during frying. Conversely, the lower pressure (≤1.5 kPa) was insufficient for phase separation and directional rearrangement, while the higher pressure (≥15 kPa) would cause the stratified phase to flow out of food system. Moreover, by directly increasing water mobility and meat compactness, physical extrusion indirectly caused more water loss and stronger ionic bonds during frying, which was positively correlated with multi-layered structure. However, an excessive pressure caused an increase in random coil and hydrophobic interactions during frying, which was negatively correlated with multi-layered structure. In conclusion, appropriate physical extrusion strength promoted the formation of multi-layered structure.