Centre hospitalier universitaire de Québec (QC)

  • Martin Coulombe, Adjoint au directeur, Direction de l'évaluation, de la qualité, de l'ingénierie, de la performance et de la prévention des infections, Centre hospitalier universitaire de Québec, Québec, Québec (Assistant to the Director, Department of Evaluation, Quality, Engineering, Performance and Infection Prevention)
  • Daniel La Roche, Directeur de l'évaluation, de la qualité, de l'ingénierie, de la performance et de la prévention des infections, Centre hospitalier universitaire de Québec, Québec, Québec (Director, Department of Evaluation, Quality, Engineering, Performance and Infection Prevention)
  • Marc Rhainds, Cogestionnaire médical et scientifique, Unité d'évaluation des technologies et des modes d'intervention en santé, Centre hospitalier universitaire de Québec, Québec, Québec (Co-Manager, Medical and Scientific Affairs, Health Technology and Intervention Methods Evaluation Unit)

Approche stratégique de réallocation des ressources basée sur la pertinence des interventions

A Strategic Approach to Resource Reallocation Based on Appropriateness of Care Interventions

During the 1990s, some authors estimated that 30 to 40 percent of patients did not receive evidence-based care and that 20 to 25 percent of patients received unnecessary or potentially harmful treatments. According to recent studies, these cases account for up to 30 percent of total health care expenditures. The eradication of over-diagnosing and over-treatment at all levels of the health care system could lead to annual savings of approximately five billion dollars for the government of Quebec alone. Apart from understandable concerns for the safety of patients, sub-optimal clinical practices include procedures that should not be administered and which have an impact on health care system costs. This situation calls for a fundamental review of the optimization of clinical practices with a view to improving the efficiency and the performance of the health care system as a whole.

This intervention project (IP) aims to develop an approach focused on the appropriateness, quality and safety of clinical procedures and is based on the implementation of disinvestment and reallocation cycles. We tested three approaches to identify procedures that could be called into question: review of evidence, consideration of recommendations found in systematic reviews and expert consultation. We found that hospital IT systems did not yield relevant data, which is sufficiently detailed, to undertake a thorough review of evidence. The two other approaches we tested have both enabled us to identify priority work. These procedures represent a potential for recurring disinvestment of more than $4M, or upwards of $200 000 for our organization. They will be used as pilot projects. The last deliverable of our IP will consist in submitting a clinical investment policy to our board of directors  that will provide a framework for the review and withdrawal of procedures as well as for the introduction of new evidence-based technologies.

Some observed enablers are strong leadership and support at the senior leadership level, a clear vision, the involvement of stakeholders, effective communication, an existing culture of evaluation, an approach based on clinical goodwill and the reallocation of savings to the departments or services that generated them. The main barriers we have encountered thus far have been the lack of dedicated resources and the limitations of existing IT systems. 

We believe that by applying a disinvestment and reallocation approach at the organizational level, savings could potentially amount to 5 percent of procedure-related expenditures. Given that annual expenditures for medication and supplies required for care and diagnostic procedures account for approximately $155M, the savings potential for the CHU de Québec could therefore, in theory, amount to nearly $7.75 M annually. In addition, there are potential further savings related to the methods of delivery of these procedures, which could not be assessed.

The implementation of an approach similar to the one developed by this IP could be spread to other teaching hospitals and smaller institutions alike, as well as on a regional or provincial level.