De-implementing Low-Value Care in Cancer Care Delivery: A Systematic Review

Abstract

Background Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings, define an agenda for future research, and inform the literature about opportunities for additional work. Methods We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design; outcome(s); type of cancer, objective(s); and de-implementation interventions, determinants of the use ofthe use of de-implementation interventions, and their effectiveness. We assessed included studies’ quality using the NIH Quality Assessment Tools. Results Out of 2,793 studies, 13 met our inclusion criteria. Included studies have been published between 2003 and 2020, and the majority (n = 9) of them were conducted in the USA. They covered several cancer types including prostate cancer (n = 4), multiple cancers (n = 3), hematologic cancers (n = 3), lung cancer (n = 1), breast cancer (n = 1), and gastrointestinal cancer (n = 1). Four studies were focused on de-implementing low-value diagnostic tests, six studies focused on de-implementing low-value treatment procedures, and three studies focused on low-value screening services. Most of the de-implementation interventions (n = 11) were effective in reducing low-value care. No study assessed the determinants of the use of de-implementation interventions. Conclusions This review showed that to accelerate the reduction of low-value cancer care, instead of solely relying on diffusion new evidence and guidelines (i.e., passive de-implementation), healthcare organizations should initiate de-implementation interventions and implement strategies purposefully aimed at reducing low-value care (i.e., active de-implementation). Additionally, future research should include a broader range of variables such as patients’ perspectives and preferences, unintended effects of de-implementing low-value care, and system-level factors when studying de-implementation.

Strategies for de-implementation of low-value care—a scoping review

“…Studies investigating strategies to reduce LVC have been published in a broad range of journals, typically within specific clinical and medical care areas, from microbiological research on antimicrobial resistance to potentially inappropriate medication for the elderly [2]. Studies on strategies for de-implementation have also focused on specific LVC within fields such as nursing [25], low-value blood management techniques in primary hip and knee arthroplasty [26], pharmacological prescriptions [27], and cancer [28]. An exception is a systematic review of de-implementation strategies covering a wide range of clinical areas [29] that found promising results for clinical decision support and performance feedback, concluding that multicomponent strategies addressing both clinicians and patients had the greatest potential for reducing LVC.…”

“…An exception is a systematic review of de-implementation strategies covering a wide range of clinical areas [29] that found promising results for clinical decision support and performance feedback, concluding that multicomponent strategies addressing both clinicians and patients had the greatest potential for reducing LVC. Another review [28] focused specifically on cancer care similarly found that most de-implementation strategies were multifaceted. The most widely used strategies were audit and feedback, use of clinical champions, educating clinicians through developing and disseminating guidelines, and decisionsupport tools.…”

Strategies for de-implementation of low-value care – a scoping review

“…Studies investigating strategies to reduce LVC have been published in a broad range of journals, typically within speci c clinical and medical care areas, from microbiological research on antimicrobial resistance to potentially inappropriate medication for the elderly (9). Studies on strategies for de-implementation have also focused on speci c LVC within elds such as nursing (26), low-value blood management techniques in primary hip and knee arthroplasty (27), pharmacological prescriptions (28), and cancer (29). An exception is a systematic review of de-implementation strategies covering a wide range of clinical areas (30) that found promising results for clinical decision support and performance feedback, concluding that multicomponent strategies addressing both clinicians and patients had the greatest potential for reducing LVC.…”

“…An exception is a systematic review of de-implementation strategies covering a wide range of clinical areas (30) that found promising results for clinical decision support and performance feedback, concluding that multicomponent strategies addressing both clinicians and patients had the greatest potential for reducing LVC. Another review (29) focused speci cally on cancer care similarly found that most de-implementation strategies were multifaceted. The most widely used strategies were audit and feedback, use of clinical champions, educating clinicians through developing and disseminating guidelines, and decision-support tools.…”