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

Abstract

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.

Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands?

“… 11 Parker and colleagues identified several challenges and facilitators for leaders of de-implementation projects, such as the availability of data and harm reduction. 12 We confirmed their findings and identified more lessons regarding both the barriers and facilitating factors, and the promising components of a de-implementation project.…”

“…Several of these barriers and facilitators, such as the clinicians’ move away from harmful care and their fear of missing a diagnosis, could be connected to the clinicians’ motivation to provide the best care for their patients. Two recent studies confirm the importance of harm reduction as a motivator 12 28. Another connecting theme seems to be the effort that goes into providing less care and communicating this with patients.…”

“…Two recent studies confirm the importance of harm reduction as a motivator. 12 28 Another connecting theme seems to be the effort that goes into providing less care and communicating this with patients. Patient expectations and a lack of time to turn these around are frequently reported barriers to reducing low-value care.…”

“…11 An interview study among Choosing Wisely team members found that harm reduction is a significant motivator to reduce low-value care and that data collection could be challenging. 12 Further in-depth knowledge and experience of de-implementation, including its impact and the barriers and facilitating factors involved, is needed to determine what is necessary for successful de-implementation. 13 In 2015, we started a nationwide programme in the Netherlands, comprising eight multicentre de-implementation projects that we prospectively monitored and evaluated.…”

“…Another study evaluated eight de-implementation projects in a hospital and found that support from the hospital board was a key to their success 11. An interview study among Choosing Wisely team members found that harm reduction is a significant motivator to reduce low-value care and that data collection could be challenging 12. Further in-depth knowledge and experience of de-implementation, including its impact and the barriers and facilitating factors involved, is needed to determine what is necessary for successful de-implementation 13…”