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

Abstract

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.

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

“…There has been increasing exploration into the use of theory broadly in de-implementation efforts [4,13]. Recent reviews have reported that de-implementation efforts have increasingly utilized classic theories, determinant frameworks, and implementation theories to support efforts to reduce LVC [10,14]. Research is inconclusive on the value of implementation science knowledge for understanding de-implementation [4,7,8,[15][16][17].…”

“…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]. Building on previous work [14,23] this study aims to understand, (i) factors that sustain LVC, (ii) the magnitude of the problem (LVC), and (iii) factors that impact de-implementation processes. These aims are accomplished through an exploration of Choosing Wisely Interventions implemented in hospital and primary care settings.…”

Identification of barriers, enablers and interventions to inform deimplementation of low-value care in emergency medicine practice: A protocol for a mixed methods scoping review informed by the Theoretical Domains Framework

“…12 Several literature reviews have explored barriers, enablers and interventions for deimplementation of low-value care. [12][13][14][15][16][17][18][19][20][21][22] Van Dulmen et al demonstrated that situation-specific knowledge of barriers and enablers is essential for designing tailored deimplementation interventions. 12 A systematic review conducted by Wang et al concluded that addressing patient, clinician and systemlevel barriers is necessary for successful deimplementation of low-value breast cancer surgery.…”

“…14 Multifaceted interventions have the greatest potential to reduce low-value care [15][16][17][18] when interventions target tests individually, 16 involve patients in decision-making, 19 modify clinician environments, 20 address contextual factors 17 and are informed by behavioural change theories. 21 Identification of barriers and enablers as well as development of effective interventions have been highlighted as areas of deimplementation of low-value care that merit further research. 22 As part of global efforts to address low-value care, leading emergency medicine organisations have developed recommendations to reduce coagulation studies, 23 urine cultures, 24 25 blood cultures, 23 cranial CT in syncope, 26 cranial CT in head trauma, 23 cervical CT in neck trauma, 23 ankle radiographs in ankle trauma, 27 duplex lower extremity ultrasound in suspected deep vein thrombosis, 27 CT pulmonary angiography in suspected pulmonary embolism 27 and CT of the kidney-uretersbladder in suspected renal colic.…”

Implementation of clinical guidelines for osteoarthritis together (IMPACT): protocol for a participatory health research approach to implementing high value care

“…Too much focus is on end-stage joint replacement surgery and pain-relieving procedures or medications in the interim, at a significant cost to society and the individual. There is increased recognition across healthcare organisations and the field of musculoskeletal pain, that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and causes unnecessary stress and harm for patients [ 7 , 8 ]. Ireland has substantial orthopaedic waiting list times that have recently been exacerbated by COVID-19 pandemic-related cancellations.…”