Clinical impact of Choosing Wisely Canada hepatology recommendations: an interrupted time-series analysis using data from GEMINI

Abstract

Introduction: Choosing Wisely Canada (CWC) Hepatology published recommendations in 2017 aiming to reduce low-value care and testing, including serum ammonia tests for hepatic encephalopathy (HE) and transfusion of blood products for minor invasive procedures. We explored the impact of these recommendations in reducing rates of low-value testing and care.

Methods: We included all medicine inpatients from 23 hospitals in Ontario, Canada from the GEMINI database between April 2015 and March 2022. Weekly rates of low-value care were measured before and after the CWC Hepatology recommendations (19 July 2017). Interrupted time-series regression models were used to assess time trends for rates of low-value care. Subgroup analysis was completed on hospitalisations under hepatology or gastroenterology services.

Results: Of 59 155 patients identified with liver disease, 17 906 developed HE and 11 676 cirrhosis patients underwent minor invasive procedures. In the HE cohort, there was no immediate change in the rate of ammonia tests with recommendations, but the overall rate decreased by 0.002 tests per hospitalisation per week (95% CI -0.00413 to -0.000009). With recommendations, we observed an increase in the rate of 0.242 (95% CI 0.010 to 0.474 transfusions/hospitalisation), but no significant difference in the rate change nor in the rate of platelet and vitamin K transfusions. There was no significant change in the rate of platelet and vitamin K transfusions. Hospitalisations under hepatology or gastroenterology services also did not have a change in rates of low-value care overall, except for ammonia tests where the rate decreased by 0.012 tests (95% CI -0.0177 to -0.00626 tests/hospitalisation) per week after recommendations.

Conclusions: The CWC recommendations were associated with a reduction in the rate of serum ammonia tests, but not with transfusion of blood products. Thus, there remains an opportunity to reduce low-value care and application of clinical guidelines.

Keywords: Evidence-based medicine; Interrupted Time Series Analysis; Unnecessary Procedures.

Figure 1. Time trends in serum ammonia tests, fresh frozen plasma transfusions, platelet transfusions and vitamin K infusions. The red dashed line represents the introduction of the intervention (CWC Hepatology recommendations). The orange dashed line represents the underlying trend of the rate before intervention and after intervention (counterfactual) with the assumption that the level and trend of the rate would not be altered if there was no intervention. The blue dashed line represents the trend of the rate after intervention (factual). The difference in level between the orange and blue dashed lines represents the immediate impact of the intervention on the rate, and the difference in slope represents the ongoing impact of intervention. CWC, Choosing Wisely Canada.