Active change interventions to de-implement low-value healthcare practices: a scoping review protocol

Parker, Gillian; Rappon, Tim; Berta, Whitney

doi:10.1136/bmjopen-2018-027370

Cited by 8 publications

(9 citation statements)

References 31 publications

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“…Many of the included studies not only explicitly report that a lack of knowledge or education is a key barrier to reducing low-value care but also acknowledge that knowledge is necessary, but not sufficient to effect change. This finding aligns with recent work on the effect of passive versus active change interventions which suggest that passive interventions, such as education sessions or the publication of guidelines or “do not do” lists alone, do not appear to be effective to change healthcare provider behavior to reduce low-value care [ 10 , 27 , 97 – 101 ]. A 2015 study of early trends for seven Choosing Wisely recommendations concluded that the recommendations alone were not enough to produce significant changes in practice and that active interventions, such as financial incentives, data feedback, and systems-level interventions increase the effectiveness of practice change [ 100 ].…”

Section: Discussionsupporting

confidence: 84%

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

et al. 2022

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Background There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care. Methods We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review. Results Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently. Conclusions This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

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Section: Discussionsupporting

confidence: 84%

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

et al. 2022

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“…To date, de-implementation research has focused primarily on identifying the problem of LVC. A more in-depth and nuanced understanding of the context in which LVC is practiced and in which de-implementation occurs can increase the effectiveness of efforts to reduce harm to patients and improve the use of resources, ultimately improving the overall health of populations [4,18,22]. In addition, there has been a call for qualitative research to explore the complexities of de-implementation and how determinants differ depending on the type of LVC [1,5].…”

Section: Introductionmentioning

confidence: 99%

Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely Interventions across Canadian hospitals

Parker

Kastner

Born

et al. 2022

BMC Health Serv Res

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Background Choosing Wisely (CW) is an international movement comprised of campaigns in more than 20 countries to reduce low-value care (LVC). De-implementation, the reduction or removal of a healthcare practice that offers little to no benefit or causes harm, is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations. Methods Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis. Findings Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not ‘patient facing’; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, providing insight into the complexities and nuances of harm, resources and prevalence. Harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions. Conclusions This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

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“…Although the problem of overuse has been recognised in research and policy domains for several decades, until recently many efforts to tackle it have been relatively 'passive'. [128][129][130] These have included the publication of guidelines or educational materials, 130 health technology reassessment outputs such as NICE's do-not-do lists, 131,132 evolution in prescribing patterns, 128 and other evidence of a practice's ineffectiveness or harm. 129 Some of these approaches have had a significant impact on practice.…”

Section: Tackling Overuse Through Different Approaches To Carementioning

confidence: 99%

“…133 But in this section we focus mainly on what some have described as 'active strategies to change practices'. 130 These more active strategies go beyond awareness-raising, the dissemination of tools and guidelines, and educational or decision support. They involve the types of intervention that are commonly understood as quality improvementusually incorporating defined mechanisms, theories of change, and outcome measures.…”

Section: Tackling Overuse Through Different Approaches To Carementioning

confidence: 99%

Reducing Overuse

Cupit

Tarrant

Armstrong

2023

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Overuse has become a major issue of healthcare quality, safety, and sustainability around the world. In this Element, the authors discuss concepts, terminology, and the history of concerns. They show how interventions to address overuse target multiple drivers. They highlight successes and promising approaches, but also challenges in generating and using evidence about overuse. They emphasise that different stakeholder perceptions of value must be recognised. System-level efforts to restrict access to services have created tensions between stakeholder groups and stimulated politicised debates about rationing. They argue for clear articulation of priorities, problem definition, mechanisms for interventions, and areas of uncertainty. Policy-makers should prioritise transparency, be alert to inequalities as they seek to reduce overuse, and consider how to balance controlling use with enabling clinicians to respond to individual circumstances. The complexity of the drivers and possible solutions to overuse require the use of multiple research methods, including social science studies. This title is also available as Open Access on Cambridge Core.

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Active change interventions to de-implement low-value healthcare practices: a scoping review protocol

Cited by 8 publications

References 31 publications

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely Interventions across Canadian hospitals

Reducing Overuse

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