What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies

Abstract

Background: Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear. Purpose: To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies. Methods: Analysis of 121 RCTs (1990–2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored. Results: Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%–42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied. Conclusions and Implications: Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.

Trends in low-value GP care during the COVID-19 pandemic: a retrospective cohort study

“…This notion could provide an explanation as to why we observed that in case of opioids (almost) no change in prescription rates was observed, while the rates of the other types of care did show to change (and the number and distribution of patients remained the same over the period examined). Furthermore, the observation that the COVID-19 restrictions differentially affected low-value GP care provision supports the idea that deïmplementation of low-value care requires tailored interventions [ 55 , 56 ]. A recently published review showed that among the existing studies examining the impact of deïmplementation strategies showed that strategies targeting healthcare providers, patients or organizational context are often more effective [ 55 ].…”

“…Furthermore, the observation that the COVID-19 restrictions differentially affected low-value GP care provision supports the idea that deïmplementation of low-value care requires tailored interventions [ 55 , 56 ]. A recently published review showed that among the existing studies examining the impact of deïmplementation strategies showed that strategies targeting healthcare providers, patients or organizational context are often more effective [ 55 ]. Suggesting that the provision of low-value care is often the result of an interplay of factors existing on multiple levels.…”

Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort

“…The use of abdominal and pelvic drain(s) will continue to exist in a minority (for example, <20 per cent) of selected patients (low rectal anastomoses, immunocompromised and/or frail patients, heavily contaminated or dirty procedures, excessive blood loss and/or intraoperative complications). However, the routine placement is not supported 43 , and a progressive de-implementation strategy should be actively sought at organizational and surgeon levels 44 .…”

Intervention for reducing the overuse of upper endoscopy in patients <45 years: a protocol for a stepwise intervention programme

“…Heus et al recently published a review exploring 121 randomised clinical trials evaluating various deimplementation strategies. 16 While the authors report that 'Most deimplementation strategies achieved a considerable reduction of low-value care', they also note that they 'found no signs that a particular type or number of interventions works best for deimplementation'.…”

“…All these tools have a common trait—they are based on the assumption that knowledge of areas of unwarranted variation in healthcare automatically will lead to a reduction in unwarranted variation—and recommendations regarding how to reduce this variation are not very prominent. Heus et al recently published a review exploring 121 randomised clinical trials evaluating various deimplementation strategies 16. While the authors report that ‘Most deimplementation strategies achieved a considerable reduction of low-value care’, they also note that they ‘found no signs that a particular type or number of interventions works best for deimplementation’.…”