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Low-value clinical practices in injury care

A scoping review and expert consultation survey

Moore, Lynne PhD; Lauzier, François MD, MSc; Tardif, Pier-Alexandre MA, MSc; Boukar, Khadidja Malloum MSc; Farhat, Imen MSc; Archambault, Patrick MD, MSc; Mercier, Éric MD, MSc; Lamontagne, François MD, MSc; Chassé, Michael MD, PhD; Stelfox, Henry T. MD, PhD; Berthelot, Simon MD, MSc; Gabbe, Belinda PhD; Lecky, Fiona MD, MSc; Yanchar, Natalie MD, MSc; Champion, Howard MD; Kortbeek, John MD; Cameron, Peter MD; Bonaventure, Paule Lessard MD, MSc; Paquet, Jérôme MD; Truchon, Catherine PhD; Turgeon, Alexis F. MD, MSc on behalf of the Canadian Traumatic brain injury Research Consortium

Journal of Trauma and Acute Care Surgery: June 2019 - Volume 86 - Issue 6 - p 983–993
doi: 10.1097/TA.0000000000002246
EAST Journal Club

BACKGROUND Tests and treatments that are not supported by evidence and could expose patients to unnecessary harm, referred to here as low-value clinical practices, consume up to 30% of health care resources. Choosing Wisely and other organizations have published lists of clinical practices to be avoided. However, few apply to injury and most are based uniquely on expert consensus. We aimed to identify low-value clinical practices in acute injury care.

METHODS We conducted a scoping review targeting articles, reviews and guidelines that identified low-value clinical practices specific to injury populations. Thirty-six experts rated clinical practices on a five-point Likert scale from clearly low value to clearly beneficial. Clinical practices reported as low value by at least one level I, II, or III study and considered clearly or potentially low-value by at least 75% of experts were retained as candidates for low-value injury care.

RESULTS Of 50,695 citations, 815 studies were included and led to the identification of 150 clinical practices. Of these, 63 were considered candidates for low-value injury care; 33 in the emergency room, 9 in trauma surgery, 15 in the intensive care unit, and 5 in orthopedics. We also identified 87 “gray zone” practices, which did not meet our criteria for low-value care.

CONCLUSION We identified 63 low-value clinical practices in acute injury care that are supported by empirical evidence and expert opinion. Conditional on future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 “gray zone” practices, which may be interesting targets for value-based decision-making. Our study represents an important step toward the deimplementation of low-value clinical practices in injury care.

LEVEL OF EVIDENCE Systematic Review, Level IV.

From the Department of Social and Preventative Medicine (L.M., K.M.B., I.F.), Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine (L.M., F.Lauzier, P.-A.T., K.M.B., I.M., E.M., S.B., P.L.B., A.F.T.), Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Department of Anesthesiology and Critical Care Medicine (F.Lauzier, A.F.T.), Population Health and Optimal Health Practices Research Unit (P.A.), Transfert des Connaissances et Évaluation des Technologies et Modes d'Intervention en Santé, Centre de Recherche du CHU de Québec, Université Laval (Hôpital St François d'Assise), Université Laval; Department of Medicine (F.Lamontagne), Université de Sherbrooke, Sherbrooke; Department of Medicine (M.C.), Université de Montréal, Montréal, Québec; Departments of Critical Care Medicine (H.T.S.), Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; School of Public Health and Preventive Medicine (B.G.), Monash University, Melbourne, Australia; Emergency Medicine (F.Lecky), University of Sheffield, Sheffield; Trauma Audit and Research Network, United Kingdom; Department of Surgery (N.Y.), Dalhousie University, Halifax, Nova Scotia; Department of Surgery (H.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery (J.K.), University of Calgary, Calgary, Alberta, Canada; The Alfred Hospital (P.C.), Monash University, Melbourne, Australia; Division of Neurosurgery, Department of Surgery (P.L.B., J.P.), Université Laval; Institut National D'Excellence en Santé et en Services Sociaux (C.T.), Québec, Canada.

Address for reprints: Lynne Moore, CHU de Québec Research Center (Enfant-Jésus Hospital), Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, 1401, 18e rue, local H-012a, Québec, Canada G1J 1Z4; email:

The results of this study were presented at the 77th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery and 4th World Trauma Congress, September 26th-29th, 2018 in San Diego, California.

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© 2019 Lippincott Williams & Wilkins, Inc.