How 4 E’s can reduce use of ineffective care
A new JAMA Internal Medicine article suggests providers looking to increase care value should take a cue from Wheel of Fortune and buy a vowel—specifically, the “4 E’s” approach to eliminating ineffective care.
The mnemonic was coined by lead author William K. Silverstein, MD, at the University of Toronto and colleagues. It stands for Education; Embedding reminders; Empowering interprofessional health colleagues; and Enforcing stewardship.
“Professional societies curate lists of tests and treatments that physicians and patients should question, which highlight overused tests, treatments and procedures that lack benefit and are potentially harmful, to promote better healthcare value,” write the authors. “However, despite the Society of Hospital Medicine’s longstanding recommendations against use of continual electrocardiographic monitoring (telemetry), routine and repetitive bloodwork, and indwelling urinary catheters without indications, overuse among inpatients remains common.”
The proposed 4 E’s strategy is based on a hierarchy of effectiveness, suggesting that, while initial steps like education are crucial, they must be complemented by more robust measures to ensure durable change and improve healthcare value.
Education, as the foundation of the strategy, involves updating clinicians on practice standards and the potential harms associated with unnecessary procedures. For example, telemetry, recommended only for specific cardiac conditions, often leads to negative outcomes like delirium and insomnia without improving patient management or mortality rates for those without clear indications. Similarly, routine bloodwork and urinary catheter placement, often performed out of habit rather than necessity, contribute to patient discomfort, increased hospital stays and, in some cases, more severe complications.
The approach then builds on education with embedded reminders within electronic medical records and daily practices, empowering healthcare professionals to advocate for the discontinuation of unnecessary care and, finally, enforcing stewardship by integrating rules that promote high-value care into healthcare systems.
“These initiatives also save hospitals hundreds of thousands to millions of dollars, depending on size,” the authors write.
Supporting this approach was a separate just-published JAMA Internal Medicine study led by Jeffrey T. Kullgren, MD, MPH, at the University of Michigan. This utilized behavioral economics to engage clinicians and older patients in reducing low-value care. The intervention, which included clinician commitments to Choosing Wisely recommendations and patient education, showed a reduction in low-value care across three clinical situations and an increase in the deintensification of hypoglycemic medications for diabetes, highlighting the potential of targeted interventions to improve care value while preserving patient and clinician autonomy.
Evan joined TriMed in 2011, writing primarily for Health Imaging. Prior to diving into medical journalism, Evan worked for the Nine Network of Public Media in St. Louis. He also has worked in public relations and education. Evan studied journalism at the University of Missouri, with an emphasis on broadcast media.