Determinants for the use and de-implementation of low-value care in health care: a scoping review

Abstract

Background A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC. Aim The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care. Methods A scoping review was performed based on the framework by Arksey and O’Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group. Results In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research. Conclusion The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals’ fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC. Registration The review has not been registered.

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

“…Participants reported numerous factors which supported or hindered the de-implementation processes. Many of these factors were similar to those reported in the implementation literature [5,8], but the impact of factors such as the in uence of Choosing Wisely campaigns, availability of data, lack of targets, and hard-coded interventions are unique to de-implementation. Overwhelmingly, participants reported on the impact of Choosing Wisely on education, awareness, and support for efforts to reduce LVC.…”

A Mixed-Methods Study of Multi-Level Factors Influencing Mammography Overuse: Implications for De-implementation.

“…28,38,39 Intention has shown to be a strong predictor of mammography screening cessation 40 and should be examined in light of factors that act as barriers and facilitators of mammography screening. 41 In our study, insights from qualitative interviews with older women suggest that screening intention is reinforced by multiple factors, such as having a direct connection to breast cancer (i.e., family history or knowing someone close to their age with breast cancer), receiving a provider recommendation/referral, and a system-generated letter reminder for annual screening. In addition, ndings from provider interviews add to the existing literature that primary care providers may be reluctant to discuss reducing mammography screening for older women out of fear of medical malpractice, discomfort discussing sensitive topics, and to avoid confusion from con icting recommendations around screening.…”

“…It is well documented that system-level factors or characteristics including practice size, type, resources, sta ng, organizational culture, and cost in uence cancer screening but less attention has focused on the care delivery process. 1,41 Our ndings suggest that there is no standardized process or approach to mammography screening in our setting resulting in variation in mammography screening practices (i.e., referrals, scheduling appointment, guideline implementation) across providers and increased opportunities for older women to obtain a mammogram. While some practice variation may be justi ed when based on older women's health and preferences, as our ndings support, variation resulting from con icting guideline recommendations 45 , lack of care continuity 46 , lack of communication 47 or teamwork 48 between providers can contribute to healthcare overuse.…”

“…While some practice variation may be justi ed when based on older women's health and preferences, as our ndings support, variation resulting from con icting guideline recommendations 45 , lack of care continuity 46 , lack of communication 47 or teamwork 48 between providers can contribute to healthcare overuse. 1,41,49 De-implementation science frameworks acknowledge the need to examine practice variation and the overall care delivery process early on in the process of identifying and prioritizing low-value practices. 50 However, few acknowledge practice variation or the larger care delivery process as a factor or determinant contributing to overuse, despite studies linking the care delivery process to overuse.…”

“…50 However, few acknowledge practice variation or the larger care delivery process as a factor or determinant contributing to overuse, despite studies linking the care delivery process to overuse. 41 Particularly for long-standing and embedded practices, such as mammography screening, more empirical work in this area is needed to better understand the role of the care delivery process early on in the de-implementation process, as well as a determinant of overuse to inform the development of system-level strategies to reduce variation.…”