What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

Abstract

ObjectivesLow-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide.DesignA mixed-methods scoping review was conducted using the Arksey and O’Malley framework.Data sourcesMedline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.Eligibility criteriaPrimary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied.Data extraction and synthesisStudy selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment.ResultsThe search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care.ConclusionHigh-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

Editorial: Navigating low‐value care in regional, rural and remote Australia

“…The challenges of providing care in this time-, space-, staff-and information-constrained setting can lead to LVC. 9 Similar to metropolitan settings, we have identified that approximately a third of urine cultures, coagulation studies, blood cultures and cranial CT scans conducted within the TUH-ED setting, may be seen as low value. 10,11 Recent semi-structured interviews with TUH-ED clinicians identified LVC is fuelled by perceptions of efficiency further compounded by clinician beliefs about consequences and capabilities of care provision (unpublished data).…”

“…Amidst a national context of emergency department overcrowding 7,8 the Townsville University Hospital Emergency Department (TUH‐ED) cared for 99 748 people in 2024. The challenges of providing care in this time‐, space‐, staff‐ and information‐constrained setting can lead to LVC 9 . Similar to metropolitan settings, we have identified that approximately a third of urine cultures, coagulation studies, blood cultures and cranial CT scans conducted within the TUH‐ED setting, may be seen as low value 10,11 .…”